It was a particularly harrowing morning, and I was already running 40 minutes behind after my first couple of patients. My nurse practitioner was out, so I had added a number of her routine follow-up visits to my normal schedule, and I was having trouble keeping up.

When I entered Mr. Anderson’s* room, I’m sure I was letting some of my mood show. But I had known this patient for years, and we had developed an excellent rapport, so I felt sure he would cut me some slack if some of my frustration spilled out. He was there for a routine chemotherapy visit, had few side effects up to this point, and his recent scans were stable so there was no real expectation on my part that anything would be wrong. In truth, I was hoping this would be a quick visit that would allow me to catch up a bit.

From the moment I shook his hand, something seemed off about his manner. He looked at me nervously, pale and ill at ease, and he didn’t make the usual small talk as I called up his labs. They were normal, as were his vital signs and weight. “So, how are you feeling?” I asked.

“Ooo-kaay, I guess?” he answered, dragging the word out and looking at me uncertainly. That snapped me out of my funk, and I immediately shifted into interrogation mode. In the past, his lung cancer had stayed stable for up to a year at a time on various therapies, but when it progressed, it was often very quick. His back pain would flare up, he would blame it on wrestling with his kids, and we would both laugh nervously and wait a bit until the pain either went away or did not improve, and then imaging would show progression.

“Is your back feeling worse?” I asked, probably too sharply. “No, not really, feels about the same.” How about breathing? Coughing? Hemoptysis? Appetite? Headaches? Anything out of the ordinary?

If he was nervous at the beginning, Mr. Anderson was sweating now. But, no, his ROS was completely negative. His labs were fine. His exam was normal. So I told him everything seemed to be fine, and he could head down to get chemotherapy.

He looked at me with confusion and even suspicion. “Is that all?” he asked. “My cancer isn’t worse? When I saw that I was seeing you today and not Amanda I was sure something was wrong.”

And then all the pieces clicked into place. He had been told that morning that his visit had been switched from my NP to me, which in the past had always heralded the delivery of bad news. When I came in 40 minutes late, he was convinced I was conferring with other experts over terrible, horrible, no-good, very bad scans. And my face when I entered the room, followed by a spate of questions about his symptoms, had confirmed his fears. When I told him what had happened and apologized for the confusion, his whole manner changed and we were friends again.

Of course, I am aware of how my demeanor may get interpreted by my patients; it is a burden all oncologists must bear. We have an unfair advantage, scans and lab work to tell us what is going on with the patient, while the patient must rely on us to tell them if things are going well or not. I have learned on “scan days” to keep my face and manner carefully neutral so as not tip off the news, good or bad. My patients tell me after the fact that they can tell anyway, although I think they’re making that up with the benefit of hindsight.

Recently, I called a patient back to return a message and when I identified myself, she said, “Uh oh. You never call me with good news.” My only news was that I was the only one left to return her call before the weekend, but I got her point. Like the Banshee of Irish folklore who only cries out when someone is about to die, I do usually only see patients or return calls when something significant has happened. It is one of the tradeoffs one makes in an academic career that doesn’t allow me as much clinical time as I’d like.

However, encounters like the one above remind me that we have to always be cognizant of what we say and how we act around patients, because you can bet they are examining us with discerning eyes, searching for clues, trying to tease out if they are still well or if the moment they dread most has come round at last.

*Name changed to protect anonymity.