Night shift is like a nonstop final exam. Remember how waiting for the test score was sometimes harder than studying for the test? Nights is a series of problem-solving exercises, where you have to come up with your best explanation and plan, then leave the building. You come back twelve hours later, and like it or not, the answer is up in public view. The rest of the residents and attendings on that service have had all day to think about it, and the official position is out: you got it right, or you missed this or that diagnosis or test or medication, and everyone knows.
I need a handbook, something like “Medical Spanish for Dummies,” maybe “How to Break Bad News in Three Easy Steps.” Last night was the worst test ever: a CT scan so bad I had to look at it three times before I completely realized how bad it was (and then radiology was overwhelmed, and perhaps felt I’d used up my quota of over-the-phone consults, and couldn’t read it for me till two hours after I needed it). After a few bad experiences early in the year, there’s a couple of conversations I try to avoid having with patients: being the first one to tell them they have cancer, especially as a consultant; giving bad news in the middle of the night; giving bad news without a family member available for support. So I looked at the CT another three times, to see if I could get out of it, and I couldn’t. How do you tell someone, You’re going to die within the next few days; I could try to stop it, but you really don’t want me to. And then, in the textbook scenarios, the patient is supposed to have something to say to that: questions, denial, grief – something. When they don’t say anything except, OK – you can’t even really try to comfort them, because there’s nothing left to say.
As if that wasn’t bad enough, then I felt obliged to call their family and explain the momentous decision we’d made. No one answered the phone, so I thought I had escaped at least that difficult conversation. Then, ten minutes before the end of my shift, the family got my message and called back; so I did have to tell them. I could have deferred it to the primary service (we were just consultants), or to the daylight team that I had already signed out to, but although I try not to be the one giving bad news (I think I’m still too junior to be the one making life and death pronouncements), I despise doctors who dodge their responsibility, and let days go by without telling patients and families the bad news that the medical team already knows. I was the one who’d read the scan, talked to the primary service and my attending, and had the discussion with the patient. So I talked to the family, on the phone (even worse than in person; another rule from medical school – don’t give bad news over the phone), stammering and repeating myself and hiding in a forest of medical details. They understood me, though; the only question was, how long do we have?
(And how do you answer that question, anyway? I’m in the business of trying to keep people alive. I’m not really familiar with how things go when we decide to give up. All I could do was make a guess, and warn them that I could be off by several days in either direction.)
So then I had to go home, and try to sleep, and wait to come back in the evening and find out –if the radiology attending agreed with our preliminary reading of the scan (what if I had made all these dramatic statements, and been wrong on the diagnosis?); if the surgery attending agreed with my assessment of how bad the prognosis was; if discussion with the family in the light of day changed the decision about whether to intervene or not. I couldn’t decide whether to wish that I had been flamingly, humiliatingly incorrect on all points, and the patient would do better than I thought, or that I was correct, with all that implied for patient.
I was right.
I don’t feel any better.