Why Delivering Bad News Can Be A Good Deed
Thursday, June 2, 2011 at 9:13AM 
2nd Year Residency, 6 Month Rotation On The Long Term In-Patient Service For People With Psychotic Disorders
“No, he’ll never work as a doctor again,” the attending answered my question about the patient’s prognosis. It was morning rounds with her, fellow residents and ward staff.
“You’ll have to tell him. And his wife too.” My heart sank. My stomach ooked. My mouth dried.
Married, with two children, Dr. K had suffered his first psychotic break shortly after finishing his internal medicine residency. Multiple hospitalizations followed. Multiple medications failed. He had been on this teaching ward for three years now. With no improvement.
What could be worse than permanently losing your mind (for no apparent reason) in young adulthood, while your body chugs along as usual?
He was frankly psychotic in the schizophrenic manner: withdrawn, internally preoccupied with the voices in his head, and delusional. His delusion was sad: he was on the unit working as a physician.
His wife couldn’t understand what was happening, and couldn’t accept it. Every time she came in, several times weekly, she asked the same questions. What was taking so long getting him better? Couldn’t I give him a new medicine? When would he return to work? Befuddlement, exasperation, and shame infused all her interactions with him.
I assumed both would take the news badly, which was enough to make me dread delivering it.
But being psychotic made Dr. K unpredictable. How would he react when the irresistible force of his delusion met the immovable object of reality? Real fear salted my usual aversion to conflict.
I knew somebody had to give Dr. K the bad news, but why, oh why, couldn’t it have been the resident before me? Or the one coming after?
“OK,” I said stoically. “Do you have any recommendations for softening the blow?”
“Just tell him. Calmly and matter-of-factly.” My stomach got even ookier.
“What about his wife?”
“Same.” My mouth got even drier. Maybe I’d tell them tomorrow, or next week. The attending looked me in the eye: “Report in tomorrow how it went.” Great.
Later that day, with a muscular staff guy on tap outside the dingy interview room….
I boldly opened with, “So…, uh... Dr. K…, how are you today?”
No reaction. He sat hunched across from me on a hard-plastic chair, a mouse of a man, head angled down, gaze turned in.
The voices in his head were obviously louder than mine. I turned up the volume: “Dr. K!” He startled.
He hardly spoke, and then only in a whisper. He had to be coaxed into session, to meals, to shower, to take medicine. He sat there mute, a deer caught in the headlights. I empathized with his wife’s exasperation.
It was always like this, being with him. Ten minutes was an endless desert, and just as parching. I had to get this over with.
“Dr. K., how do you feel about returning to work?” His gaze hovered over my right shoulder. The silence lengthened uncomfortably.
“Dr. K, how would you feel about NOT returning to work?” His eyes tracked vaguely.
“You’ve been here for over three years now. You probably won’t be going back to work.” Aaargh!— I had hedged!
I had to undo that. I couldn’t leave him with false hope, for two reasons. I would have to go through this again. I would be embarrassed at rounds tomorrow.
His head bent down on his neck, like a heavy flower. His lips moved silently, talking to the voices in his head. Did they have an opinion about whether he should work or not?
I bit the bullet. “Dr. K, you’ll never work as a doctor again.” I tensed—What would he do?
He seemed to return from a far distance. His eyes settled on the area around my chin. “No?” he whispered.
“No. I’m sorry.”
“OK.” He shifted forward in the chair. “Can I go?” He stood up slowly and shuffled toward the door.
That was it?! I studied him closely.
Was that slight curve to his lips a smile? Was it possible he was relieved? He quietly opened the door and left the room.
I assumed the truth would come as a body blow. But that presumed he wanted to work. Felt capable of working. Maybe he didn’t. Maybe he knew he couldn’t. Maybe I had just let him off the hook. Maybe I had just delivered good news, not bad.
I flashed on my internship in internal medicine. Feeling always as if I were just one judgment call away from disaster. Pleasure has been defined as cessation of pain. The relief when I finished was orgasmic. Maybe Dr. K felt something like that now.
The door opened. The aide stuck his head in, “Everything OK?” I nodded, smiling.
I took a deep, luxurious breath, as if a heavy weight had just rolled off my chest. The world felt much, much roomier. My job was to be open minded, not presumptuous.
My operating assumption about how Dr. K would react had been limited by my personal experience. Which didn’t include being psychotic. Or being married to someone psychotic.
I saw that his wife, after the initial upset, would be relieved too. After years of waiting for him to recover, she could give up hope, and move on to build a new life for herself and her children.
That’s why hope was in Pandora’s box of the world’s evils. It traps you in time like an insect in amber.
That attending did me a great favor. I learned a valuable lesson early in my career: While it’s always uncomfortable to deliver news that banishes hope, doing so frees people to move forward.
They may not like it, but you can’t do anything about that. It’s patronizing and disrespectful to withhold information people need to make informed choices because it might upset them (or you).
That puts being the agent of someone’s upset in perspective. It helps me cope with the anxiety that being straight with patients always stirs up.
It is natural to get upset when given bad news. It’s to be expected. It’s the first part of a process that needs to play out.
That’s useful to know and to accept. It empowers you say and do the right thing. With anybody, be it a patient, a child, a spouse, a friend, a coworker, or an employee.
And it’s a comfort, in a dark, grown up sort of way.
PHOTO CREDIT: Michael Tischendorf
Reader Comments (6)
What a thoughtful and thought-provoking post. I especially like the last line -- "It's a comfort in a dark, grown up sort of way." Well done.
Delivering bad news well is not one of my major skills. Your method works at least as well as anything else, and hedging is bad bad bad! It took me repeated painful episodes to learn.
But I definitely want a sign like that!
Perhaps if we had a resident occasionally offer us "bad" news, more of us might find what we would rather be doing. Wonderfully written, properly tense and satisfying. Love these back stories.
Daniela, I love love love this post! I always find something helpful on your blog and this is no exception. I struggle with a capital S on delivering bad news. This has helped change my perspective!
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