During a medical school interview, particularly in a multiple-mini-interview (MMI) format, you might be asked how you would go about breaking bad news to a patient. While this task might seem unfair to ask of a candidate medical student, it is no less daunting for me – now a second-year student, and in fact, for practicing physicians.
This week, NPR reported about the challenges doctors encounter when discussing a cancer prognosis with a patient. Many, though not all, patients will want to know how long they have to live when faced with the often terminal cancer diagnosis. “How long do I have?”
Being able to answer this question gets to the very essence of the role of a doctor. As a scientist, a physician might tell her patient the median survival time, using data from the medical literature. Knowing that he is a critical source of comfort and support, the doctor might instead err on the side of optimism when discussing prognosis with his patient. There are problems with both of these approaches for patients, doctors, and their relationship.
Last year, my friend C was diagnosed with lung cancer. After discussing the prognosis with his oncologist, C was obsessed with “two months.” Whether the doctor told him that the median survival for his late-stage disease was “two months,” worst-case scenario was a “couple months,” or flat out said, “You have two months to live,” I will never know. What I do know is that, from that encounter forward, C was convinced that he had a definite expiration date, and no amount of explaining would allow him to let go of this idea that in T-minus two months he would be dead.
In fact, C lived about seven months, before finally succumbing to his disease at home last January. I was left with the uncomfortable notion that somewhere along the way communication between doctor and patient had failed my friend.
Though we all live with the uncertainty about when we are going to die, most of us feel like death is rather far off, and that we have some degree of control over our fate. By eating right, exercising, and getting enough sleep we can keep our bodies going like well-oiled machines. When, however, the body begins to malfunction on its own without external insult, we lose our sense control and are suddenly operating with an even greater deal of uncertainty. It unmasks the possibility that more might go wrong. It is no wonder then that cancer patients want to know when things will start to go wrong and how long they have left to live. More pragmatically, faced with a limited amount of time, patients must figure out what decisions they have to make and which of their goals they will be able to accomplish.
The problem with generating an estimate for a patient is that it rather artificially imposes certainty on an inherently uncertain and unstable process. Even after being told that “median” survival time means that half of people with the same cancer will live a shorter period and half a longer period, patients like my friend tend to understand the number as absolute, according to psychiatrist Tomer Levin, who works with cancer patients at Memorial Sloan Kettering Cancer Center in New York. Therefore, doctors – with the good intent to inform patients that there is a range – are interpreted as giving a sentence.
Perhaps this is why most physicians (63%, according to a study published in the British Medical Journal) overestimate survival of terminally ill cancer patients. Knowing that patients will cling to any specter of certainty, doctors overshoot. In some cases perhaps it seems most humane to offer patients and their families hope. Among many physicians and non-physicians it is agreed that people with something to live for live longer: married men, for example, live longer than the unmarried, and “natural cause” deaths spike on Christmas, December 26, and New Years Day as if people were holding out to make it through the holidays. Perhaps physicians believe that high expectations can be self-fulfilling, and offering hope might actually extend life. However, by being overly optimistic you risk setting patients up for disappointment or the feeling of being cheated when they start to decline “early.”
Dr. Levin suggests giving patients the worst-case scenario, the best-case scenario, and the most likely scenario. This approach allows patients to hope for the best case, plan for the worst, and accept the uncertainty that they will likely fall somewhere in the middle.
I like this suggestion, and hope very much to employ it as I go forward in my career, however I know that my own first inclination is towards optimism. When confronted with the task of telling a standardized patient, (an actor posing in a hospital bed), with inoperable pancreatic cancer her prognosis in our Doctoring class, I was reluctant to use numbers at all, euphemistically telling her that she likely had “on the order of months” to live. I was quick to add that we did not know how long it would be, and it was possible that she might surprise us and live a lot longer. Though it was easier to plan for end-of-life “palliative” care after acknowledging the terminal prognosis, I was overcome with emotion realizing that she was the same age as my mother, (a reaction termed countertransference in psychiatry). This is to say that the duty of discussing prognosis is further complicated by the physician’s own emotional experience.
To make a gross generalization, doctors thrive on knowledge. Operating under uncertainty and admitting that there is a limit to your knowledge is uncomfortable. Additionally, most of us chose the profession to help people – we like being in a position of providing strength and comfort to patients and their families at vulnerable moments. Just as we must be aware that we are providing important information and hope to patients when we discuss prognoses, we must also be aware that quoting numbers from medical literature helps us feel like we can impose order in the face of uncertainty and being overly optimistic helps us cope with our own vulnerability to losing a patient. Our compassion is not reserved entirely for our patients, but is also operating in the interest of self-preservation.
There may not be a right way to break bad news, but rather it is a balancing act of tailoring science and compassion to the individuals on either end of the conversation. Therefore, when in medical school interviews and your future career you are confronted with breaking bad news, know that it is an art as emblematic of your role as a physician as providing life-saving treatment, and a skill upon which all physicians must strive to improve.