S2E18: Delivering Difficult News

Harjit: She doesn't know. Baby, won't you come my way? Got something I got to say.

Margaux: I just realized that . . .

Harjit: First time, I'll start by saying this.

Margaux: Excuse me, mic adjustment.

Harjit: You ruined my song.

Margaux: Oh my gosh, you guys. I love you.

Harjit: You love me, but I have ADHD.

Margaux: Ah, you do. So, everyone, welcome to Bundle Of Hers, yet another episode with me, Margaux, Leen, and Harjit in the studio.

Harjit: I feel like Leen doesn't want to make a statement.

Margaux: She can get around to it. So today, I want to talk about some experiences I had on my surgery clerkship this past week in giving bad news to patients. This particular patient had a small bowel obstruction. And when we took him into the operating room, it was evident that there were tumors and what you call . . . or it was a tumor that was blocking his intestines. And then there was also what you call mesenteric lymphadenopathy. So, basically, all the lymph nodes around his intestines were inflamed, which is pretty classic for lymphoma.

So we took a biopsy and sent it into pathology. The next day told the patient that, you know, "This is what we saw, and we're waiting for the pathology, but you may have cancer."

The thing that I thought was really difficult about this interaction was the patient didn't speak English and required a translator. And so I think inherently you lose a lot, because when you're talking through a translator, you're trying to keep things quick and simple. But when you're delivering something like, "You may have a really bad cancer," I don't think that always comes through well enough in a translator.

Took a couple of days for the pathology to come back. It did come back. It was lymphoma. And so, when I pre-rounded, when I went to see him before we saw him as a team, he asked, "Are the test results back?" You know, in that moment as a med student, it's not your responsibility to give the bad news, even though I had looked and saw that it was back. I just said, "I don't know right now." And sometimes, you have to say that. It's really awkward because you know the bad news and this patient here should be entitled to that. But you as a medical student can't give that to them.

So then on rounds, I told the resident, "Yeah, it came back positive, and part of the plan is to consult oncology. And I think we should do that with the Spanish interpreter and make sure everyone's here and make it nice." And he was like, "Yeah. Okay."

The resident goes in and just in broken Spanish says, "Oh, by the way, you have cancer, and the oncologist will come back to talk to you later today." And I was like, "Oh my God." And so that to me was like really kind of shaking. I don't know. It was really kind of upsetting.

And then, we left the room and I was like, "This is so incomplete, such a bad way to give that sort of news." Yes, we have the test results, so we'll give it to him, but there's a time and a right way to do it. And I don't know how that patient reacted because then we're on to the next patient. And it kind of stuck with me for the rest of the day.

But I don't know. What do you guys think about that case? And have you had any other experiences with delivering news poorly?

Harjit: I think one thing that I'm learning this year, along with all the medicine and stuff, is really picking out things that I want to do and don't want to do. You know? I feel like sometimes it's just like, "Oh, we need to give this news because it's part of the plan," but not really think about the delivery or when the environment is right.

A lot of times, in medicine, I realized things are very "let's get these things done so we can move on to the next thing." But I think that we miss opportunities to really impact a patient. Yes, we maybe couldn't do anything in the fact of the matter that, you know, the person has cancer, but just making that blow a little bit simpler or even more understandable, because we don't even know what they understood or didn't understand from that, right? I think that's very powerful.

I'm actually on my neurology service, and one thing that I've noticed this week, maybe because I'm on the wards, but in neurology, the diagnoses that people usually get, it usually can't get fixed all the way. And I think it's because, in general, the neurological system is super complex. There's still more research that needs to be conducted in that area, just like every other area, but that one specifically, and we're still getting answers, or we don't have answers to things.

So, because of that, our ward is full of people who are constantly getting bad news every single day. And I actually want to share a separate experience. We had a patient that also had a certain type of cancer, but it was metastatic, basically meaning that it was going to go into their entire body.

And I put it in the plan, like, "This person has this. These are the things that we need to do for it to confirm that it's the right one," because it was still a possible diagnosis. And it's a conversation that we need to have with the family.

My resident asked me in the morning, "Did you tell the patient?" And I was like, "No, I did not tell the patient because I think that, one, I'm a medical student and I want to make sure I'm answering all the proper questions. Number two, I think it's important that we discuss it with the team before I say anything."

When we were in the group setting, my resident and the physician were like, "Okay, we know this news. It's going to be hard. The family is there. Let's complete rounding on everybody and we'll go back and have a conversation." And I really appreciated that because they took the time to know that this is hard news. And even though our schedule is jam packed, they took out some time to deliver this news.

There are some things that you can just go and say a plan really quickly, like, "We're doing this, this and this for you." But I think when it comes to news that is difficult, you need time, and you need to revisit it as well.

Margaux: I agree.

Leen: I think going into medicine, we always have that fear in the back of our mind saying, "You have to be strong enough to be able to deliver bad news." We try to block it out when we go into medicine. I know growing up when I kept saying, "I'm going to be a doctor," everyone in my family said, "Oh, you have to be strong because you're going to have to get bad news." And that was kind of one of my fears going into med school.

And so, when I got into the wards, I decided, you know, this is something I have to get comfortable with unfortunately. And so I would take any opportunity . . . this sounds kind of weird, but I would take any opportunity that came to deliver difficult news, and I would take that opportunity to go and actually talk to the patient about it.

Harjit: It's actually such a good skill, because you knew you wanted to work on that, and then you went after it.

Leen: Yeah. And I feel like we're now at a point where, you know, being med students, we have the leeway for trial and error. But when we're an attending, when we're resident, and we're actually in charge of the care, we don't have that leeway. And so I feel like this is a good time to kind of be able to practice, gain the skills, see the skills, and then practice those skills on delivering difficult news to patients.

And I think the most difficult one I had was when I was on the pulmonology service and we had a patient with metastatic cancer. I remember my resident saying, you know . . . it was my patient, and the results came back and my resident was like, "We'll talk together with the patient. But if you want to go pre-round on the patient and talk to him, and then we can go back." And I said, "Okay, what about the news? Is it okay if I talk about it with the patient?" And he says, "Whatever you're comfortable with. If you're not comfortable, don't do it." And I said, "Well, I need to get comfortable."

So I remember in pre-rounding, I walk in and their family, maybe there were like 15 people there.

Harjit: Wow.

Leen: Yeah. I was talking to the patient and one family member would ask, "Well, what about the results?" Another family member would be like, "We know it's cancer." And I was like, "Oh, they kind of have a feeling." They kind of had an idea. Like, "The results came back. The imaging showed something here in the brain. What does that mean?"

And so I ended up opening the chart, and I would show them the images with permission from the patient, of course, and I said, "Is it okay if I talk about this with you with everybody here?" And, you know, they said, "Yes." And so I opened up the imaging. And again, I don't have all the answers, but I can point out on a CT or MRI and be like, "Yeah, look, see this lesion right here? That's unusual," or, "Here's your lung, and this is unusual. And so this is kind of what we're suspecting."

And so we kind of had a conversation. I thought this was very difficult, especially because you have the patient . . . at this point, the patient was shocked, but at the same time, they're ready for the next steps. The family was still in shock. And they were kind of asking me more of the emotional questions rather than the logical answers we can give them.

In general, I don't have the answers to help your emotions, right? But I can give you the evidence. I can give you the numbers. I can give you things like that. I can give you our plans and, in terms of evidence-based medicine, what's next. And that didn't seem to satisfy them very well. I think that's the very difficult part. You want to help the emotion, but you know at the same time that's also not something you can do.

Harjit: I think that's very insightful. Because one thing that I have learned as well is when you are delivering difficult news, you have to be honest and truthful and say what you do know, because just the clarity really helps people even though in the moment it might not. But in the long term, that's what we can do as future physicians.

Leen: Exactly. And I think the presentation of the knowledge you do have is also very important. You can't just walk in there and say, "Yeah, you have cancer. Bye." In this field, you have to take into account everything that revolves around this patient, and that includes the environment and their emotions and family emotions. You have to go in there as professional and as sympathetic as you can at the same time, but you also have to show that you're a leader and you're ready to take action for your patient if needed.

Margaux: I agree with that, Leen. What really matters is taking time, even if you're busy, to sit down and talk and tell that patient in a very sympathetic way is very key to delivering bad news. And I wonder if, in this patient's case, they were an English speaker, if the resident would have done it differently, like actually pulled up a stool and sat face-to-face and delivered it a little bit better. But because it was an inconvenience of a different language or different culture, it was like, "Okay, I'm going to make this checkbox so I can move on and get to surgery."

And I think that's the pressure. Not just that resident, but the pressure of the system that they're working under is very quick. You have to be there super early just to round, and then you're in surgery all day and you're exhausted. So I think there are two parts there. I don't want to just blame that resident, but I also wonder and want to talk about the nuances of how we take care of patients.

I had another patient on the pulmonology service too, Leen, that was basically in the end stages of their life. And the doctor was trying to tell the family, who was also from a different country and spoke English very minimally, that their mother was dying. And the patient's daughter was like, "No, only God can tell us when."

I think you have to take into account cultural and religious aspects of death and dying, because sometimes you know that the patient is not going to live very long, but that's not what the family needs to hear. They maybe just need to hear that we're doing everything we can, and if God needs to take her, then we're here and ready for that too.

Leen: It's not a bad thing to say, "I don't know," as well. When we go into these conversations, we always think, "Oh my gosh, I'm not going to have every answer that they're going to ask." But there's something to be said about saying . . . when the patient asks you a question and we say, "We don't know that right now." When the patient said, "No, only God knows that," that's okay to also say, "We do not know the circumstances. But in terms of what we can do in medicine, this is as far as what we know."

Harjit: Leen, I think it's really cool that you brought up this point because I've been actually thinking about this a lot this week. I actually have a resident who I was having a conversation with, and a lot of the times when . . . this is relating, but it might seem off topic for a minute, so just follow with me.

My resident said something to me that was very powerful. Sometimes it's our ego that comes in to want to explain things. And if you just don't know the answers, just say it. And I think that was so profound.

And the reason why it relates to this topic is because the truth is we do not know, and those people that believe in God, we're not God, right? And so, in that sense, none of us can predict the future.

I think a lot of times we say, "We think it's this," just because it gives us satisfaction. And that's where we need to know that our patients are humans, and we should value their own feelings as their own. This is their news. It's not our news, right?

And so, Leen, I think it's really powerful that you said that, because I think you are so right. Sometimes we just need to give the facts, like, "This is what it is," in a compassionate way. I don't mean like, "Give facts x, y, z." What I mean is just give the facts and say, "You know, this is something that they have. It's something we can't fix. And so things will be difficult."

Margaux: I think that's very true. Just even acknowledging that delivering that bad news and that we don't know and we don't have the answers is difficult for the patient to hear, but also for us to deliver too, and just bringing that forward and making it known instead of just saying, "I don't know. We're working on it," and leaving. I think acknowledging our own humanism in this is a key point as well.

So, to change it to maybe a little bit brighter side, I did have an experience in clinic with a doctor who sees a lot of melanoma patients, and a patient presented with an aggressive form of melanoma that's almost always very quickly metastatic, especially by the time you catch it. And the way she sat down with the patient face to face and had a very compassionate and sympathetic conversation, it was a good example of how I could see and learn from an attending delivering bad news to the patient.

The patient cried. The attending did tear up a little bit too, which to me was like, "Okay, that's what I would do. That's what I want to do." That's very human to recognize, like we were just talking about, "Yeah, I don't know the answers, but I feel you and I feel that this is difficult for you to get this news."

Leen: And can I say there's one field in medicine that I did not know of going into medicine until I was on the wards, and that was palliative care. And palliative care is a specialized field in medicine where you focus on end-of-life goals and you focus on end-of-life medicine across the spectrum of ages.

I remember when we first had a patient that had really disheartening news in terms of what we can do medically for them. We said, "Let's consult palliative care." So these physicians come in and they started off the discussion saying, "Tell us about the patient." They didn't go straight to, "By the way, the patient is dying, so, you know." No, they stopped and they asked the family, "Tell us about this patient. Who was this patient to you? What do they love? Who are they as a person?"

And then they said, "Would this patient like to be the way they are now in the hospital, where they don't get that same freedom of being active and sporty and whoever they were or are?" They kind of helped the family come to terms with the news in a much more smoother and much more careful and very much sympathetic way. And it helps the family. It kind of clears their mind so that they can think more logically about the situation.

I very much respect this field now. I feel like from my background and my culture, this isn't really a field we have. This isn't a specialty in medicine.

I see my parents with the bad news they got about their parents. To this day, it still affects them. My mom will always talk about her mom, and it kind of hurts me to hear her say this. And I just wish if palliative care was there, and they could have walked her through this, "Your mom is coming at the end of life. Who was she as a person? What would she want at this point for you? What would she want for herself?" and kind of bring together the situation . . . It's almost like a therapy, but at the same time, it helps them think logically about the situation. I truly believe it helps comfort the family later on as well.

Harjit: I think it's so important that you brought this up because, in general, death in our society, I might have different opinions, but it's a place of fear for a lot of people. And I think because of that, we get a lot of raw emotions. And it's really important that we deconstruct those emotions because, yes, they can leave a lasting impact on us. I am so excited that there also is a field like this in medicine, which I will tell you I didn't know about either, Leen. I'm really appreciative that it exists.

Margaux: Now the question I think a lot of our viewers have, and for us moving forward into fourth-year and as physicians after that, is how do you acquire and then use these skills? Like you, Leen, were saying, third-year is the time to practice and fail without having much consequence. But at the same time, if you go and, say, deliver bad news poorly, I think that's going to sit with you. So how do you guys think or how have you been taking these skills and acquiring them, and how do you think you'll practice them moving forward?

Leen: So there's not really one way to teach empathy and sympathy, but I think there's something to be said that when you walk into that room, it's okay to feel terrified about giving that news. After all, we are humans as well, and it just brings you closer to understand what this patient is also fearing as well. It's not the same, but can you imagine yourself receiving the same news?

You can't really teach it, but it's almost like being in a place that's really gut wrenching when you're receiving bad news, just knowing that feeling and now realizing your patients are going to feel this and probably worse, kind of can bring you a little bit to say, "How am I going to approach this so that we can be in a good place all together as a healthcare team, incorporating into this patient's holistic care?"

Harjit: Man, you're just giving so many points for me to talk about and think about, which I love.

So I saw that empathetic means you've been in the same situation as another person so you can relate to them. And sympathetic means you've never been in the same situation as them, but you're going to try to come to a place where you understand their feelings. And I think that really stuck with me.

So like you said, Leen, we will never know. We will never know, unless we've been in that exact same situation, how another person feels. And I think just being aware of that fact is really, really important for us. And I think it's one thing that a lot of people don't think about. I think it's one thing that really comforts others too, if you let them know, "Yes, I do not understand where you're coming from, but these are the things that I'm good at and this is how I can help you. This is the thing the oncologist is good at, so this is how they'll help you. This is the thing the social worker is good at, so this is how they can help you."

I think that's kind of what I want to take forward with me is that I cannot maybe be empathetic in every situation, but I should be sympathetic. And how you learn to do that is you experience and listen to people's stories. I think that's where we can be most powerful. We should know that we are learning every day from every single patient, and these experiences will add up to make us better physicians.

Margaux: I think that's very true, Harjit. Understanding the difference between empathy and sympathy is key. And like you said, Leen, there aren't really things that you can teach. But what I would recommend building on both of you for starting third-year or whenever you do your clinical rotations is to volunteer to take on the difficult patients, to make sure you can be in the room while the attending is delivering bad news as much as possible, and then observe what's going on. Feel what feels okay, what feels really bad.

And just acknowledge that it's going to feel awkward and it's going to feel sad, and you're naturally going to want to move away from that and not want to be in any situation. But the more you can give yourself the opportunity as a student to be in those situations and watch and learn, the more stories you will have heard and the more experience you can have to build off of to develop this empathy.

So I think it comes down to just opening yourself and your heart and letting yourself be vulnerable with the patient that you're delivering bad news to.

Harjit: I love that.

Margaux: Thanks. So, with that, we're going to wrap up, but I hope that all of you can move forward and through your clinical rotations and careers as medical students and physicians, pushing into the uncomfortable situations and learning from them, and knowing that we're all at one point going to have them.

Harjit: We are the Bundle of Hers.

Leen: Speaking of wrapping up.

Harjit: Do your wrap-up spiel.

Margaux: So, on that note, if you have a story or any input on how to share and deliver bad news, what was good, what was bad, please share with us @bundleofhers on Instagram or Facebook. And until next time, bye-bye.

Harjit: Oh, that was really good.

Margaux: I know. I'm a good imitator.

Harjit: Do it again.

Margaux: No, that was a one-time thing.