Breaking Bad News in Veterinary Medicine
Giving bad news is a crucial part of what we do. It’s an art, and those who excel in it are born, not made. But any veterinarian can learn to do a better than average job of it with a little effort. Indeed, not to try is probably a kind of sin Dante reserved a cusp of hell for.
I got to thinking about this while researching pet health blogs for last week’s post on blogging in the veterinary profession. Along my meandering way, I came across a slew of great MD bloggers I couldn’t help but envy for their honesty, their brio, their eff-it-all flair. This blogger, in particular, unnerved me with his honest account of how to break bad news in a blog post titled, "Bad News."
Here’s an excerpt from the blog, Musings of a Distractible Mind (interestingly subtitled, "Thoughts of a moderately strange [yet not harmful] primary care physician"):
It’s that part of the job that I’ve never gotten used to. I hope I never do.
I saw a man recently with an unexpected finding on his exam — a "lesion" that should not have been there. I was seeing him for his diabetes and blood pressure, and was doing my "ritual" physical exam, when the "lesion" blared into my vision.
I got a sick feeling in my stomach when I saw it. I like to make people better, I like to make them happy; now I had to give some bad news.
When broadsided like this by an unexpected finding, it’s work to keep a calm composure. I was surprised and very worried, but I tried not to show it on my face. Why do I feel the need to keep calm? My visceral reaction would be to exclaim, "Oh, no! What is that??" but even a small amount of shock and surprise could have a negative impact. I suppose it’s because people need to face hard things with confidence, and my reaction will have a big influence on his own outlook and perhaps even the outcome of his disease. I am sending him off toward one of the hardest things in his life, and I want him to go with the best possible mindset.
We physicians are not made differently than other people; we don’t have a stronger emotional reserve or innate knowledge on how to handle difficult situations. I want people to like me. I want people around me to be happy. I don’t enjoy throwing emotional grenades into the lives of people I’ve cared for over many years. Yet this is part of what I must do, and in doing so I have learned a number of things.
Here’s where the distractibly-minded doc outlines his six-step method, paraphrased here for brevity’s sake:
1. Stay calm. (Don’t go freaking out like an intern who’s just seen a maggot in a wound for the first time.)
2. Stick to facts. (Why project your fears when you don’t yet fully know what the lesion is?)
3. Don’t cloud things. (Be straightforward. Use the words, "possible cancer" when you have to.)
4. Give a clear next step. (Indeed, give a ladder-full of them if you have to. People need to know there’s a plan.)
5. No delays. (Help make a scary situation better by helping the client/patient take the first step so fears don’t end up delaying urgent care. This doc calls the specialist immediately while the owner is in the exam room. I do the very same thing. Sometimes it conveys the urgency of the situation better than anything else you could say.)
6. Personal after professional. (Even though my human instinct is to convey bad news as gently as possible, I know I can’t. Facts, clarity, steps, direct assistance … they all come first. After that I can be soothing. Until I get my point across … it wouldn’t be fair.)
So when I told this week’s client that the lesions I’d found in her young dog’s X-rays looked more like lymphoma than anything else, I couldn’t help but remember this fantastic blog post. I actually went back to check that I had covered all its bases. Thankfully, I had. In my own way, of course. This bit that Dr. Strange and Distractible leaves us with is exactly how I always feel after breaking bad news successfully:
Yes, it’s "just my job," but at one moment I have the opportunity and responsibility to play a huge role in one of the most important moments of a person’s life. That is a great honor as well as a big responsibility that I accepted when I agreed to be their doctor. If I do my job right, they leave me with an understanding of the situation, with a clear plan of action, with knowledge that I know they are hurting, and most importantly, with hope.”
Dr. Patty Khuly