Teaching and Learning Moments
Bad news: Any information that adversely and seriously affects an individual’s view of his or her future.
I teach physician assistant students the art of the medical interview. I had just finished teaching a lesson called “Delivering Bad News.” I walked the students through cases. I told them how it is our privilege to deliver bad news and that how we do this can shape a patient’s experience with life-changing information. I explained that one of the challenges of primary care is that we often deal with uncertainty, yet we are there for the patient as the answers emerge. The most important thing that I teach the students is to be human. To see the person sitting in front of you. To be kind.
My last patient that day was new to me. She was 47 years old and had had a cough and chest tightness for over a week that just wouldn’t go away. She wasn’t sick, but she knew something was wrong. She was a survivor of early adulthood non-Hodgkin lymphoma and was 30 years out from her treatment, including chest radiation. Although she was calm and her exam was reassuring, she felt like she couldn’t take a deep breath. She was alone at her visit; she hadn’t told her wife yet that she was coming in, that she was worried. We both agreed that if she hadn’t previously had cancer, we would have watched and waited, but an X-ray was warranted in her case.
The films weren’t good. Bilateral hilar lymph node enlargement. Patchy perihilar opacities. Could it be fibrotic changes? Scarring? I called the radiologist, and he asked when she had been diagnosed with lung cancer. “Apparently today,” I mumbled.
Walking back into the exam room, I forgot about the medical interviewing class that I had taught so many times. I sat next to my patient, and we looked at her X-ray together. She was at one time shocked but not surprised. She was sad and had questions that I didn’t know how to answer. I knew that she needed a CT and labs, that I couldn’t confirm anything that day, that she was sick. Again. We discussed telling her wife. Her kids. We discussed next steps and trying to stay present. I gave her my phone number. Said I would call tomorrow. She said she felt okay to go home.
That evening, I got into my car and cried. I cried for her and her family. For the unfairness of disease and the fact that treatment for one cancer can cause another. And because it’s human nature, I cried for myself. Six years out from my own cancer diagnosis, I remembered the surgeon who gave me her home number. When I was being stoic about lymph node involvement and positive margins, she gave me permission to grieve. Five years out from my last treatment, I had hoped that sometime in the future I could stop worrying about the headache that lasts a little too long or the cough that doesn’t make sense. That sometime in the future you get to rest and not look for recurrence or new disease. I cried because I know that’s not true. I can’t think about it every day or I wouldn’t be able to work, to move forward, to be a spouse, to look at my daughter. But I feel it when I don’t use the words cancer free or remission to talk about my health. That knowledge is always there.
When I could breathe again, I drove home. I went back to teach the following week. I told my students to be human. To see the person sitting in front of you. To be kind.