Today for the first time I told a patient that he had cancer.
I’m angry with myself, because I didn’t do it the way that I had always planned to. I didn’t ask what they’d been expecting, or break it gently, or hold his hand or his wife’s. I went in to talk about how he’d need to be admitted to the hospital, and how we’d be consulting these different groups. His wife said, “So then you think there’s something wrong?” And only then did I remember that they didn’t know.
After all, it was obvious to me from the moment they walked in. Two sentences of history from the man, and I knew it had to be cancer. The physical exam completely confirmed it; the signs were all there, glaringly obvious. To my mind, I ordered the CT simply as a formality, a box to check off before I could call an admitting physician and say definitively that the patient had cancer. There was really nothing else it could be. They’d been sent in urgently from their family doctor’s office; of course he knew what it was too, and he just wanted us to run the CT scan and admit the guy for a workup before starting chemo. Somehow I thought the family doctor would have given some clue, that between his deep concern and the unmistakable symptoms, the man would have had some idea of what was coming.
But no. “Do you think there’s something wrong?” Yes, I’m sorry, it’s bad news, but you seem to have a mass. It’s most likely cancer. I’m sorry. “What about a blood vessel bleeding? Maybe it’s just inflammation?” No, honestly, I know we only have a basic CT right now, but there’s nothing else it can be. With the story you’re telling me, and what we saw on the pictures, it really is cancer. I can’t say what kind, we’ll need more tests, but it is cancer. [I called the radiologist, but I didn’t need to; even an intern can recognize that shape.] “How about if we go home, and come back tomorrow?” (They’re in denial now, and I can’t blame them; they’re hoping it might go away overnight; perhaps at a different hospital the tests will come out differently.) No, I’m sorry, your symptoms are moving quickly enough that we’re not comfortable sending you home. You need to be in the hospital for observation while we do more tests. [It might not be safe for you to be at home.]
And the whole time, I was itching to get out of the room, not even really going slow enough, or being sympathetic enough (how can you be sympathetic enough when you give someone a death sentence?), because I wanted to get back to the phone to get started on the long slow process of tracking down their family doctor (why do you send someone who obviously has cancer to the ER to get admitted for a workup without telling anyone – hospitalist, oncologist, ER attending – that you’re sending them?) and pinning down a hospital team to admit him. In the end it would make that particular night a little easier for him if I could get him a bed before midnight – but it would also get me out of the ER a little closer to the end of my shift, rather than three hours later (as it happened).
I was so concentrated on the mechanical business of arranging the admission that I even followed the textbook (give them a minute to think about it, to let things sink in, then ask if they have questions), answered the questions, behaved as empathetically as possible, and was out of the room, before I realized what I’d done: I diagnosed someone with cancer, and told him about it. His life changed forever in five minutes, and I wasn’t even paying attention. I’m a paper-pushing machine, not really a doctor; this isn’t right. I hate the cancer for existing, and myself for doing this wrong. (And underneath, I’m happy that I got the diagnosis right.)
Cut On The Dotted Line 
December 19, 2007 at 2:06 am
a learning experience. you’ll do better next time. meanwhile, don’t beat yourself up about it.
there is another side to this. often doctors make a diagnosis but don’t tell the patient because it is too difficult. then they refer to surgeons to supposedly confirm the diagnosis. but they actually want us to break the news. don’t assume a patient knows he has cancer because his doctor knows. the referral might just be so he doesn’t need to tell him. welcome to the wonderful world of surgery.
but if you get good at breaking this type of news, it will be better for the patient to end up with you rather than hear it from his spineless doctor.
January 3, 2008 at 12:45 am
Alice,
Unless the man went to his doc for an annual physical, he knew something was wrong. Maybe the wife didn’t, but the man did. He gave you the information you needed to make the diagnosis — very concisely. He knew. He probably even guessed it was cancer, but couldn’t bring himself to tell his wife.
Shame on his personal physician for not discussing this with him. My husband’s mother was diagnosed with lung cancer on the basis of physical exam (not even chest xray – it was that advanced). The physician told her before he sent her for studies and chemo.
January 8, 2008 at 1:08 pm
I know the feeling – the man’s that is. I was admitted to the ER for severe pain and vomiting. CT scan revealed a 13cm abdominal mass, which the ER doc assumed was breast cancer mets, as I had been treated just the year before. He told me I had a 13cm solid mass that was not a cyst. I asked if it was a tumor. He said he didn’t know what else it could be. Then he left and didn’t come back. I was left alone to contemplate my death for hours. I tried to get the nurse to talk to me, but as soon as I told her the doctor’s assessment she fled. It was one of the loneliest nights of my life. I just kept chanting to myself that they were wrong. They were wrong. And guess what: they were.