Letters to the Editor
To the Editor:
The teaching clinic setting provides a valuable opportunity for students to develop their history taking, physical exam, presentation, and assessment formulation skills, but the primary goal of such clinics must ultimately be to provide patient care. As I describe below, a recent experience I had as a student in a teaching clinic illustrates that the benefit to the student in performing a basic postoperative checkup is outweighed by the increased anxiety and prolongation of the patient’s suffering. Students can still benefit from joining the senior in the examination room to learn more about both the diagnosis and disclosure of bad news, but when avoidable, as in this instance, the student should not be the first person in the patient’s room.
I stood in the room of a patient who eagerly awaited the pathology results from a massive surgery a week prior. Attempting to avoid the patient’s true chief complaint, I awkwardly asked my standard questions: Are you in pain? Are you using the bathroom normally? “Is it cancer?” she asked, as if completely unfazed by the three hours she waited to be seen at this busy clinic that treats patients with poor access to care. All I could reply was, “The resident will come into the room in a few minutes to discuss the findings with you.” Let down, she nodded and told me she understood. Even as I attempted to comfort my patient, I knew it would take quite some time before a resident would be able to see her in this busy teaching clinic. An hour after I had left the room, the resident walked into the room, introduced himself to the patient, and told her that the pathology demonstrated a widely disseminated Stage IV cancer. This is no way to deliver bad news.
During my time as a student, this practice has been commonplace. Yet, this most recent episode irked me more than ever, perhaps because of the prognosis or the patient’s kind personality, which had made her a favorite of all the students who worked with her. While the consensus may be that students are to defer disclosure of diagnoses to a more senior member of the team,1 situations such as these can and should be avoided or minimized. If students are never to disclose a patient’s diagnosis in the teaching clinic setting, they should not be the first to see the patient when the patient’s desire to know of a diagnosis is ultimately the chief complaint.
Kyle T. Amber
Fourth-year medical student, University of Miami
Miller School of Medicine, Miami, Florida;