Medical Student Perspectives: Revealing Unfortunate News
It was my first rotation of third year, and I had never been more excited. I was fresh out of the gate, as they would say, ready for anything. I was thrilled to finally use all the information I had been learning for the past two years. I couldn't wait to see the patients, and I was enjoying every minute of it. Every day I was learning something new which was heightening my experience.
Early one morning a woman in her late sixties came to the office for her usual annual exam. I grabbed her chart and called her to come back. I introduced myself and proceeded to take a thorough history. In the review of systems it was discovered that the patient noticed a sore on her right nipple that had not gone away. She had tried over-the-counter fungal ointment but the sore persisted. I took note and proceeded through the rest of the interview. After presenting the patient to my attending, we felt that it was important to examine the lesion on her breast. After a thorough bilateral breast exam my heart dropped to my stomach. During the exam we had palpated some axillary nodes on the affected side of the lesion. From what little experience I had I knew that was concerning. As my attending explained our plan to the patient I couldn't help but think about what I had discovered. I tried to remain expressionless but internally my medical student mind was racing. I kept thinking to myself that I was glad that I took a thorough history. What if I had missed this? I got it together and focused on watching my attending handle the situation perfectly. Our patient was informed of the possible causes of this presentation and was reassured that we would do all the necessary tests to come to the right diagnosis.
A week went by and I was doing my normal tasks as a medical student when my attending called me to his office. I sat down and he said, "Norm, we got the results of our patient's biopsy." He handed me the pathology report, and I immediately recognized the patient's name. I scrolled through the rest of paper, and as I read my heart sank to my stomach once again. At the bottom of the page it stated, "final diagnosis: invasive breast carcinoma."
As quickly as I had read the report my attending said, "Our patient is coming in today and I would like you to discuss the results with her." He paused and went on to say, "This encounter is vital for you as a student to experience. You will learn more today than you probably will this entire rotation." I could not believe what I had just heard. A feeling of inadequacy fell over me. I asked myself how I would be able to do it. I asked the attending if he really felt I was the right person, and he replied with a confident, "yes." He went on to coach me on how to approach this delicate subject. We discussed how to properly deliver news of this magnitude. Before leaving his office, he once more reassured me that I could handle the situation.
When the time came to call the patient back in, my attending was right by my side. When we entered the room, I could tell that the patient was worried. My attending broke the ice, and we exchanged greetings. I continued by saying, "As you know we are here to discuss the results of the testing you just had done." I paused, and she quickly replied with, "I have cancer don't I?" A whirlwind of anticipation filled within me. What do I say now? I went right to the point, responding with, "The results came back positive for breast cancer. Today we would like to discuss with you what we are dealing with and our options for treatment." As the patient processed the news her eyes started tearing up. She was now visibly distraught. I gave her a tissue and reached out to hold her hand. I told her, "We will fight this disease together." With my attending standing near me and filling in the gaps as they lay we discussed with her our detailed plan of action. We answered her questions and informed her of other options that would help during her treatment, such as support groups. As she left the interview room, she expressed her gratitude. I escorted her to the lobby. On the way she said to me, "I know that wasn't easy but I just wanted to thank you for everything." I thanked her for her bravery and said good-bye.
On my way home that afternoon I found myself reflecting on my encounter with this patient. I thought about what my attending had told me earlier in the day. This experience was essential for me. I faced my anxiety of delivering bad news and I was able to curb the emotions that came along with it. As human beings we naturally want to sympathize with someone who is saddened. What I learned from this encounter was that my patient was actually looking for someone who was not as scared as she was. I believe that this is probably true for most patients who are receiving news like this. They look to us for courage. Walking with them through uncertain doors and standing next to them when the future is uncertain gives them the courage to press on. This experience helped me grow, and is one that I will never forget. I encourage each of you to take on the challenge of breaking bad news when a supervised opportunity arises. Although the conversation will be a difficult one, you may surprise yourself by finding your courage just in time to share it with the person who needs it most.
Norman L. Beatty