I have a knack for tripping over the elephant in the room. But I ask you, how was I supposed to know that the attending got consent for an operation, performed it, and explained the procedure to the family afterwards – without ever stating outright that the patient had cancer? I don’t know, maybe he said it and the family were too upset to hear it. But I hate trying to backpedal when I say “cancer” casually as part of my explanation of the recovery period, and the family acts as though they were still hoping the object in question was benign, or perhaps a false alarm entirely. I’m getting good at a spiel for “I don’t explain this, I don’t have a lot of experience with this, I don’t want to misinform you, my attending will explain in due course,” along with my spiel for “swelling after surgery is normal” and “use the incentive spirometer or you’ll get a fever” and “please start walking now or you won’t be able to go home.”
Most of the attendings here have a policy that they won’t discuss pathology results until the patient leaves the hospital after surgery. I can see their point, after watching families and/or patients so devastated after learning the extent of the cancer that they have no will for recovery. But then the attending isn’t the one talking to the patients and families three times a day, and trying to sidestep the only question that people really care about – what did you find, how big was it, how bad is it, is further therapy needed . . . and of course, how much time do we have. People always think they want to know the worst of it right away, but perhaps it’s not best for them to know. I’m ok with saying that I’m not the attending, so what he chooses to tell the family isn’t my responsibility; but I wish he would give me the cue card for what he did say.
February 16, 2009 at 11:50 am
“People always think they want to know the worst of it right away, but perhaps it’s not best for them to know.” Alice, this sounds so very old fashioned and paternalistic. It seems to me that the decision ought to be made by the patient and doc before surgery on an individual basis. I live on the West Coast, and don’t see this attitude prevailing out this way. I’m wondering if you are in a very different part of the county, or even in the US.
February 18, 2009 at 8:49 pm
This post was meant to come across as me, having been educated in a system where “paternalism” is a bad word, trying to deal with my old-fashioned attendings’ method of handling bad news.
Things change in the hospital, though. I think for the first two days after surgery, people really are not thinking coherently, even when they’re on the regular floor, let alone in the ICU. I don’t know how much of how people thought they would handle things changes when they find themselves feeling horrible, in pain, high on drugs, and without their family there most of the time. . .
Not saying my attendings are right; their reticence makes my interactions with families a lot more complicated, because it’s contrary to my instincts. But with experience, I have more understanding for their decisions than I did as an intern.
March 13, 2009 at 5:14 pm
Wow, I find the attendings’ behaviour curious. In the ICU we are always very frank and open with the patients’ families, and this would seem to be at conflict with those surgeons’ approaches.
You mentioned that families or patients can be devastated when learning the extent of the disease. This may happen, but it still seems that a patient should be given the choice to decide how much he or she would like to know, rather than have that decision made for them.