Tuesday, January 15, 2008

Metastatic Prostate Cancer

This one is heavy.
"You and I talked yesterday about the blood prostate test that came back with a very high value. That combined with your low blood counts is why we did the bone scan this morning. It looks like some prostate cancer has spread to your pelvis and tailbone."
It's taken a while for me to work this first experience delivering a cancer diagnosis into a cogent journal entry. When it comes to this blog, I have the most success transcribing ideas and feelings immediately. This one required more drafts; a whole folder of entries spanning several days sits tucked away on my hard drive. What I keep coming back to is that through my entire experience with this patient, I never felt uneasy.

Sitting on his bed, without my white coat, without my clipboard, and without a rehearsed statement, I was simply present with him. I still can't find the words to describe my feelings in that moment. Why can I not pin down my emotions? Was it confidence about a puzzle solved? Relief that the patient was finally given an answer? Surprise at how much the patient already knew (even without symptoms or knowledge of lab results)? Was I feeling an adrenaline rush due to an awareness that I was participating in an important point in this man's life?

In the end, the question I need guidance about is: Is it wrong to be comfortable delivering bad news?

This patient gave me permission to write about these experiences but asked me not to use his name.


Drugmonkey said...

A doctor who finds that s/he is skilled at the "bedside manner" tasks should take just as much pride as does the surgeon.

gay CME guy said...

First, excellent post!

From the perspective of a patient who has received more than his share of unwanted, less than good medical diagnosises, no, it's not wrong for you as the physician to feel comfortable in giving me/the patient bad news. Your comfort (I hesitate to use the word "ease") in telling me what I'd rather not be hearing, while maybe not making it better, makes in "less sucky".
I've been told in a very clinical, albeit professional manner, "There's nothing more I can do for you." from a specialist. And, I've been told, "these are not the results we'd hoped for, but don't give up. I'm going to be with you all the way until we figure this out.", from my PCP. (Same diagnosis) He then put his hand on my shoulder, and gave me a comforting hug. Granted, this is not SOP for physicians. I had his pager number, with permission to call it if I needed to. I did so, only once. When he told me that he was moving out of state, I cried. While I may be a gay man, I'm not a wuss. It's been six years, and I'm now finally starting to get close to that same comfort level with his replacement.
When you have to deliver that news, the one thing for sure that we know as patients, is that our lives have just changed drastically as a result of this news. And we're scared as hell.
The best thing you can do for your patients is to allow them to see and know that you are human. This may sound trite, but I can't stress how important it is to the patient.
In your own words, "...Sitting on his bed, without my white coat, without my clipboard, and without a rehearsed statement, I was simply present with him." You will probably never fully realize just how much that simple act meant to your patient. Trust me, it was huge.