I find being a physician a great privilege. As a physician, I strive daily to help patients, either directly while they are under my care, or in the future by studying, teaching medical students and residents, or doing research. My profession challenges me intellectually, and often rewards me on a personal level. Most times when I enter a room and meet a patient for the first time, he/she looks at me kindly, with trust, and assumes that I care. Patients like their physicians.

While our jobs are usually challenging, yet pleasing, sometimes we must deliver bad news. I would like to present a couple of patient scenarios for your consideration, then refer you to a well written article about bad news.

Once, in the 1990s, I got a call from the pathology lab. The pathologist called and said she wanted to discuss a laboratory result on one of my patients. The patient was newly HIV positive. The problem was I did not recognize the patient's name. So I called my secretary and asked if the patient was scheduled to see me. In fact he was scheduled the next week as a new patient. So I asked who referred him, and found out that a general surgeon had made the referral. "Call the surgeon," I thought. Our discussion revealed that this 29 year old man had come to him for evaluation of posterior cervical adenopathy. The surgeon biopsied the nodes with the pathology suggesting AIDS. He sent off an HIV test and referred the patient.

I thought about the situation, and decided that I could probably do a better job breaking the bad news to the patient than could the surgeon (knowing his style, and the circumstances of the referral). I remember telling the patient the diagnosis, and having a productive long discussion with him that day. He did well during the 2 years that I followed him, eventually referring him to an HIV specialty clinic.

Recently, a 61 year old man was referred to our inpatient service to 'confirm his non-Hodgkin's lymphoma'. The patient had become sick a couple months previously. After a month of routine outpatient antibiotics and symptomatic treatments, a chest X-ray showed bilateral hilar adenopathy. A CT of the chest and abdomen showed many nodes and splenomegaly. The patient had a hemolytic anemia and thrombocytopenia. We had pulmonary and oncology consults, both of who suspected lymphoma, both of whom wanted a definitive diagnosis.

At the other hospital, he had had a peripheral node biopsy which showed reactive lymph tissue. A bone marrow biopsy was 'abnormal, but non-specific'. The referring physician had told the patient and his wife that he had lymphoma, and that she was referring him to us to confirm the diagnosis.

We sat down with the patient and his wife to understand their comprehension, their fears and try to understand their interactive style. As the data mounted, it became more likely that the patient did no have a lymphoma. Several days into the hospitalization, we sat down (I as the attending did most of the talking, but the resident, interns and students were present in the room) to discuss what we knew and what we did not know. Our previous discussion had made it clear that the wife especially was not ready for uncertain news. She did not want to know that he probably had lymphoma; she wanted a more certain diagnosis. The bad news (on incomplete data) had shocked the patient, his wife, and the children.

Our evaluation proceed slowly. After peripheral biopsies, another bone marrow biopsy, a mediastinoscopy with biopsies, a bronchoscopy with biopsies and many serologies we determined that in fact he did not have lymphoma. We believe that he has a rheumatologic diagnosis (in fact the precise diagnosis remains a bit uncertain). He has responded beautifully to oral prednisone. We did not discuss his presumed diagnosis until we had successfully eliminated lymphoma from our differential diagnosis.

What principles do I derive from these two patients? First, breaking bad news is a primary responsibility of generalist physicians (whether family physician, pediatrician, internist or hospitalists). We probably have more opportunities, and therefore we must learn how to help patients work through these difficult situations. Second, we should not break bad news until we are certain of the bad news. My patient with the hilar adenopathy is not unique. A colleague had a similar patient with a large lung mass and brain mass recently, which turned out to be an infection despite everyone thinking cancer. Prior to shepherding the patient through an emotional rollercoaster, we must have as much certainty as one can get in medicine.

I always have to emotionally prepare for these conversations. I usually decompress by discussing the conversation with the housestaff and students. This decompression helps and supports my feelings, and hopefully provides some role modeling for their future encounters.

Browsing the web today, I found this article - Breaking Bad News. I highly recommend reading this nicely written exposition on the skills of breaking bad news. I plan to hand the article out to my housestaff and students, and then discuss the details. Hopefully, by focusing on this issue, we can improve, to the benefit of our patients and their families.