There is no formula for telling a patient that he or she has
cancer. The diagnosis is still perceived, for the most part, as a
death sentence, and a patients reaction is usually a
combination of fear, despair, and anger. How a physician delivers the
news about the diagnosis, however, and his or her empathy for the
patients situation have a profound effect on the patients
emotional well-being. This commentary, adapted from an article that
appeared in InTouch (June/July 1999), describes the anguish
surrounding both the bearer and receiver of bad news.
One March morning in 1994, Linda Rhodes sat in
her fifth-floor office in Houston, Texas. She was catching up on some
paperwork when the telephone rang. It was her doctor, whom she had
been trying to reach for days to get the results of a bone scan taken
a week earlier.
Linda, the physician said, it looks like the cancer
is in your spine, referring to the spread of breast cancer
Rhodes thought she had beaten 2 years earlier. She was devastated.
The cancer had returned, this time to her bones, and she knew the
prognosis was poor. Her first thought was that she would die fairly
soon. Theres nothing more we can do for you at this
hospital, the doctor said abruptly, and the conversation ended.
Rhodes, an optometrist with a busy private practice, instructed her
secretary to cancel all her appointments for the next 2 weeks. Too
distraught to drive home, she called her 19-year-old son for a ride.
As a 45-year-old single mother, her mind raced with questions: Who
will take care of her children? What will happen to her house? What
will she do with her practice? What next?
Two weeks later, Rhodes went to see another doctor, who informed her
that her medical tests had been misinterpreted. The area diagnosed as
a tumor was actually a herniated disc and slightly fractured
vertebrae caused by a jet ski accident several months earlier. The
fracture never bothered her and required no treatment. When I
got the news, I felt like somebody waved a magic wand over me,
she said. Still, all those moments [when she received the bad
news] are frozen in my memory, she added.
A Study in Contrasts
Studies show that the way a doctor delivers bad news stamps an
indelible mark on the patient-doctor relationship, in some cases even
prompting lawsuits. Like a hit-and-run driver, Dr. Rhodess
physician knocked her flat with bad news, didnt stop to see how
she took it, and fled the scene. That memory lingers in sharp
contrast to the first time a doctor told her she had breast cancer, 2
I went in for a breast biopsy, and I was in the recovery
room, she recalls. Her doctor sat down on her bed, looked her
in the eyes, and told her that her biopsy indicated breast cancer.
He touched my shoulder and let me cry for a while before he
started outlining a treatment plan for me, she said. By
the time I left half an hour later, I had a plan that gave me hope
that something could be done.
In her later experience, Rhodes learned first-hand that when a doctor
delivers bad news over the phone and doesnt allow time for a
person to react, or neglects to say what will happen next, the news
can be devastating.
However, most medical schools dont offer students any formal
instruction in breaking bad news, and physicians often have to devise
their own method.
Surveys have shown that doctors rank discussing a recurrence of
cancer with patients as one of the most difficult tasks they perform.
Telling a patient that he or she has cancer for the first time is
easier for most doctors because they can usually offer hope in the
form of treatment options.
Oncologists, some of whom have to break bad news as often as 20 times
a month, often feel unprepared to deal with the emotional demands of
such sessions. A patient may break down in tears or turn hostile.
Without training or guidance from a peer, even the most empathetic
doctor will find this tough to handle. So they often adopt an air of
aloofness, and that hampers good communication, said Walter Baile,
MD, chief of psychiatry at The University of Texas M. D. Anderson
Cancer Center in Houston.
Doctors are taught that in order to apply their technical
expertise, they have to be detached emotionally, but patients may
experience this aloofness as insensitivity, he said.
Dr. Baile and his colleague Robert Buckman, MD, an oncologist at the
University of Toronto, have developed a program doctors can follow
when breaking bad news.
Effective Listening: An Oft-Overlooked Technique
Some of the techniques that Drs. Baile and Buckman outline are common
sense: talking face-to-face in a private room rather than over the
telephone, discussing treatment options in language that a layperson
can understand, and answering all the patients questions.
However, one of the most important techniqueseffective
listeningis often overlooked.
Studies have shown that in an average office visit, patients talk a
mere 18 seconds before their physician interrupts them. Less than a
quarter of patients even get to finish their opening statements.
Part of the problem is that listening takes timea precious
commodity for most doctors. But given that listening plays a critical
role in helping a patient digest bad news, failure to do so can
derail even the most well-meaning attempts to relay bad news gently.
Tips From a Physician Cancer Survivor
Jane Poulson, md, a practicing internist at the Toronto/Princess
Margaret Hospital, also teaches communication skills to medical
students at the University of Toronto. Her own diagnosis of breast
cancer in 1996 and the emotional roller coaster ride that followed
came as a rude awakening. I realized the number of bitter pills
I had unwittingly delivered to patients during my 15 years of
practice, she recalled. Dr. Poulson wrote about her experience
in the Journal of the American Medical Association (338:1844-1846,
Whenever Dr. Poulson had to break bad news to patients, she tried to
buoy them with reports of how much less mutilating breast surgery had
become, or how some new technology had made for better colostomies.
Few patients seemed encouraged by this kind of information, but it
made Dr. Poulson feel better to tell them some good things
about the procedures.
However, her own experience as a patient taught her that if I
were to do it again, I wouldnt rush in with the good
news. When people suffer the initial shock of a cancer
diagnosis, they need to vent their fears or anger, Dr.
Poulson observed, and a doctor should resist the temptation to
staunch the flow of their feelings. Its hard to knock
someone down and resuscitate them in the same sentence, she said.
A better strategy is for the doctor to say something like This
must be difficult for you, thus opening the door for a patient
to express his or her feelings. Drs. Baile and Buckman advise
physicians to first ask a patient what he or she knows about the
situation; then deliver the news in small chunks and simple language;
and then acknowledge the strong emotions that follow. They caution
doctors not to interrupt, rather they should make eye contact, and
repeat key points.
Dont Worry and Other Platitudes
Dr. Poulson acknowledged that before she began losing her own hair
during chemotherapy treatments, she had no idea how awful it felt.
She used to reassure her patients that their hair would grow back,
but she didnt realize that hair loss is symbolic of all
that happens to your body when you have cancer. Telling a person,
dont worry, your hair will grow back, doesnt
really address the problem of the despair theyre feeling about
what is happening.
Sometimes, an off-hand comment early on makes breaking bad news later
more difficult. When Christine Perry, a newsletter editor in Boston,
was told that she needed a biopsy on a small growth on her lip, she
asked her doctor if the growth might be cancerous. Youre
30 years old, dont worry about it, her doctor responded
while moving toward the door. If its cancerous, youd
have surgery, but just dont worry about it.
Ms. Perry wanted to probe more, but felt like I was taking up
too much of her time by asking questions.
Several days later, she found out that the growth was, in fact,
cancerous. Ms. Perrys doctor had an assistant telephone her at
work to break the bad news.
Hearing the news over the phone left Perry shaken and tearful from
fear and frustration.
I know that the doctor was probably just trying to make me feel
better before the biopsy, said Ms. Perry, but the doctors
failure to address her concerns before she received the bad news made
absorbing it later that much more difficult.
Phrases to Avoid
Another thing some doctors may unwittingly do when delivering bad
news is use phrases like theres nothing more we can do
for you. Even when theyve exhausted all treatment
options, doctors can still help patients die with comfort and
dignity, said Michael Levy, MD, head of the Supportive Oncology
Program at Fox Chase Cancer Center in Philadelphia. Dr. Levy
recommends that doctors explain that in some cases continuing
treatment does more harm than good, and that pain management and
other strategies can relieve a patients discomfort at the end
He also suggests that physicians should never say we got it
all after a course of treatment. This sort of pronouncement
implies that the patient has been cured of canceran
overstatement that can come back to haunt both the patient and doctor
if the disease recurs. A better phrase would be we got
everything we could see at this time, offers Dr. Levy.