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Shapiro, Johanna PhD

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Dr. Shapiro is professor, Department of Family Medicine, and director, Program in Medical Humanities and Arts, University of California, Irvine, School of Medicine, Irvine, California.

Although bad news is often devastating for the patient to hear, it is also difficult for the physician to say. Doctors like to fix things. They like to fix broken bones, strep throats, malfunctioning hearts. They do not like things that cannot be fixed. That may be why in medical education we talk about “breaking” bad news because so much ends up broken for the patient, the patient’s family, and the physician.

The professional literature documents the negative effects of bad news poorly delivered,1 and many useful protocols exist detailing steps designed to ease the shock of hearing your life will never be the same again, or soon may simply not be.2 Yet we never hear accounts of how many problems patients have when good news is conveyed perfunctorily or uncaringly. That’s because, although hurtful, it doesn’t matter. Good news trumps bad delivery every time. Lamentably, although the edges can be softened, there is no way to trump bad news. Jerome Groopman, an oncologist and widely read author of medical philosophy and ethics, acknowledges that there is no foolproof technique for conducting this most exquisitely difficult of conversations.3

A small, haiku-like poem by cardiologist and acclaimed poet John Stone, “Talking to the Family,” conveys the fundamental helplessness of breaking bad news. Narrated from the point of view of the physician, the poem recounts in devastatingly simple images an account of a physician preparing to meet with a family. Although little specific information is offered, it seems that into this family a baby has been born, and the baby’s mother has either died or experienced a terrible medical outcome. The physician anticipates his conversation with the woman’s husband and sister.

The images of the poem are unremittingly cold, sterile, and white, which relate to the hospital where this dismal interaction is about to occur. The sister is wearing white high heels and a flimsy, thin dress in the middle of winter (perhaps she has flown in from a warmer climate or has hurriedly thrown on inappropriate clothes). Regardless, her clothing suggests flightiness, frivolity, naïve romanticism—all pointing to severe limitations as a substitute mother. The husband, holding the baby, is described as “milkless,” a term that in this context communicates similar inadequacy and helplessness.

It is not only the family that seems insufficient. Another image of whiteness is the physician’s white coat, a perennial symbol of authority and competence. Stone analogizes the coat as “like a parent,” evoking associations of strength, reliability, and wisdom. But there is also an awful irony in the analogy because, above all, parents are supposed to protect their children from harm and save them from tragedy. In this case, the doctor, no matter how attired, knows he will be unable to save his patient or protect the family. After breaking the news, the doctor peels off his coat, perhaps rejecting it in disgust. He returns home, to his own family, presumably as yet unbroken. What can he fix? The doctor chooses to replace a light bulb.

Reading this poem, we are immersed in awful ripples of loss and death. We sense the physician’s fundamental helplessness, and the family’s as well. The very starkness of the poem suggests the limitations of language in the face of overwhelming suffering and grief. Stone writes only, “I will tell them.” It is a bleak, uncompromising view of the impossibility of delivering bad news well.

Perhaps what this poem is really about is imperfect human beings making imperfect, but critical, human connections in the face of an unbearable circumstance. The slightly silly, inappropriately dressed sister and the helpless husband nevertheless are standing together, holding the baby. Despite our doubt and disbelief, we see the beginnings of a newly constituted family, not the family anyone wants, but the family that is left and must go forward. And amazingly enough, the physician, awkward and tongue-tied as he is, is also there. We readily absorb his reluctance to talk to the family. In fact, he’d rather be almost anywhere else, but he knows that his duty to his patient extends even beyond her death. He thinks about the family, knowing that like him, they will try to put things back together, only to realize they will always remain to some degree shattered. He imagines their suffering in an authentic act of empathy.

This poem is not an algorithm, nor a multistep protocol for breaking bad news. It does not reassure that planning, preparation, and procedure will transform bad news into something controllable and manageable, or tame the unruly chaos of anguish and death. It acknowledges how perpetually unready we are—patients, family members, and physicians alike—to face the abyss of mortality. It reminds us that we all want to fix things, put them back together, and that, in the face of the unthinkable, the “cut ends of [our] nerves will curl.” We all have the impulse, like this physician–narrator, to go back to our own homes, our own sanctuaries, and fix something, make something right. But this poem also says that somehow physicians can find the courage to speak the unspeakable, and somehow, those who are left behind can go on. Therein lies hope for all of us.

Johanna Shapiro, PhD

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References

1 Schofield PE, Butow PN, Thompson JF, Tattersall MHN, Beeney LJ, Dunn SM. Psychological responses of patients receiving a diagnosis of cancer. Ann Oncol. 2003;14:48–56.

2 Education for Physicians on End-of-Life Care (EPEC). Trainer’s Guide Module 2: Communicating Bad News. American Medical Association, 1999:1–16.

3 Groopman J. Dying words. The New Yorker. 2002 October 28, pp. 62–70.

© 2005 Association of American Medical Colleges

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