I was standing at a counter on the medical ward, having my afternoon coffee, when one of the residents threw her hands up in the air.
“I hate my job,” she exclaimed.
She was reviewing an M.R.I. for her patient and the results had just come back. “Every time I talk to a patient, it seems like I am giving them more bad news – your cancer is back or your cancer has spread – it’s always something along those lines.”
A large part of what it means to be a physician is to be the harbinger of bad news. No wonder so many resources in medical school and residency training are devoted to teaching us how to break bad news to our patients and their loved ones.
What is almost universally ignored is that a large part of a physician’s job, and one of the primary reasons why many of us go down this road, is that we are also granted the opportunity to reveal positive news on a regular basis. Breaking good news, though, can sometimes be as challenging as breaking bad news.
“The most common good news I give is that a scan shows remission or treatment response,” said an oncologist colleague of mine. But while cancer remission is a classic example of “good news” in physicians’ minds, patients understand that it comes with an asterisk.
One study showed that about one in five patients whose cancer goes into remission still retain high levels of anxiety long after. Remission still means that patients have to continue getting scans and exams as doctors look for disease recurrence. Remission may also require additional chemotherapy to keep the disease at bay. So while the initial news of remission is often met with relief, many patients realize quickly that the good news comes with some grave caveats as they “wait for the axe to fall.”
Another common instance that physicians consider good news for patients is when we inform them that they are being discharged from the hospital. This usually means that a patient’s condition has improved and they are moving in the right direction.
Far from being overjoyed at the news, though, many patients become nervous and uncomfortable. Patients feel supported and protected in the controlled setting of the hospital, and leaving it can be disconcerting. Stress prior to discharge is especially high in older, weaker patients with poor support at home. Even new mothers often feel considerable anxiety before leaving the hospital.
In my clinic, I see patients with a variety of complaints – headaches, back pain, nausea. They are hoping that I will be able both to figure out what’s wrong with them and help treat it. When an X-ray doesn’t show pneumonia, or a brain scan fails to show hemorrhage, or an electrocardiogram doesn’t show a heart attack, patients face uncertainty about what might be ailing them, along with anxiety that their symptoms will continue unabated. A study that pooled the results of 14 clinical trials found that when diagnostic workups failed to find any abnormality, patients continued to feel anxious.
The truth is that what physicians like to think of as good news may not be shared by the patient. While a physician might think it is good news that the patient is ready to be discharged to a nursing home, the patient may have bad associations with nursing homes. Surviving a heart attack is obviously better than succumbing to one, but it leads to a lifetime of medications and lifestyle changes for the patient, who also now must live with the fear of lightning striking twice -– no ache or pain is ever going to be the same again. The patient realizes that even good news comes at a cost.
Teaching physicians how to break good news is as critical as teaching them how to deliver news that is not. One strategy I have found helpful is to emphasize the patient’s own role in overcoming adversity. For instance, instead of just informing patients that their disease is in remission, I congratulate them for all the effort they put into battling their disease and sticking with treatment. Or, when patients are being discharged from the hospital, instead of informing them on the day of discharge, I try to prepare them at least a day in advance so that they have time to process the change.
Of course, sometimes it can be difficult to embrace even the best of news. A close friend was worried sick after his mother was found to have a mass on one of her kidneys. The surgeon was so sure that it was cancer that he advised having the kidney removed even before getting a biopsy. Yet when they deferred and got a biopsy instead, the result showed that it was a benign lesion.
“Our family was stunned,” my friend told me. “We were prepared to find out that it was cancer. But when we found out it wasn’t, we just didn’t know how to feel.”
Haider Javed Warraich is a fellow in cardiovascular medicine at Duke University Medical Center.
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