By Anthony L. Back, MD
University of Washington, Fred Hutchinson Cancer Research Center
John was waiting in the exam room for me. I was standing outside the door, not wanting to go inside. Two years ago his colon cancer was resected; one year ago his adjuvant chemo was completed. John had changed his diet, started hiking every weekend, and cut out a lot of beer. He lost 40 pounds and looked like a new person. At his last visit I remembered saying, “You are doing such a terrific job!” He beamed, full of pride and hope. Today, however, my pre-visit review had not been so terrific: his CT showed two new centimeter-sized pulmonary nodules.
Oh, ugh, I thought. I’m going to ruin his day.
As a fellow, I remember watching a mentor handle a similar kind of challenge with aplomb. “New lesions,” he said, “let’s see what the surgeon says.” And before I knew it, he was out of the room. Over time, I absorbed the strategy: tell the bad news as quickly as possible, focus on the next step, and avoid getting bogged down. That mentor is gone, but his lessons, I’ve found, live on in the hidden curriculum.
Just last month, a fellow demonstrated the same strategy to me. “Let’s check this with a PET scan,” she told a middle-aged woman with carcinomatosis, starting to enter the order electronically.
“Could I add something?” I interjected. “Would it be helpful to talk about what this means?” The patient looked at me and burst into tears; it turned out she knew all too well, after getting her CT report prior to our visit and looking up the unfamiliar words on the internet.
After the visit, the fellow was apologetic. “I didn’t think that would happen,” she said. And I realized that while I had prepared myself, I hadn’t prepared her. She didn’t know what I knew.
This fellow had seen the lecture about giving bad news, and she had even asked our patient early in the visit if she was ready to discuss the news. But when it came to saying the words, “Your cancer is back and it’s now incurable,” something happened that she didn’t anticipate. Her emotional intelligence made her understand, sitting in that moment with her patient, what this news really meant. And she couldn’t process that and talk to her patient simultaneously. That’s what she didn’t know.
With everything we talk about in oncology, there is a rational side and an emotional side. The rational side gets a lot more air time, for good reasons (we need evidence) and bad ones (if it’s not rational, we don’t know how to teach it). The emotional side, however, commands its own kind of respect. What I’ve learned in dealing with the emotional side is that my own emotions carry their own wisdom. The wisdom of my emotions is usually inconvenient, but trying to ignore it is bad for me and worse for my patients.
Just as I’m about to turn the door handle to John’s room, I get one of those inconvenient messages. “Don’t rush in,” it says. But I’m late, and he’s worried, and I should get this over with, I think. Isn’t that rational? “Don’t rush, just breathe,” it says. And I remember: my upset feeling has its own trajectory, and if I begin talking to John before I’ve gotten a handle on it, I’ll say something stupid. Something that will set us both back, like “don’t worry”—something that I know to be untrue, and that signals to him that I’m not someone with whom he can share his worries.
A wise thing I’ve learned for these situations is from a study of married couples. Instead of wondering why you’re not perfect and impermeable, imagine that a friend who cares about you can see everything that has happened. What would the friend say about this situation, and what advice would they give you? It turns out this friend never says rush in and blurt it out. The friend says you’ve done your best, and it’s not going the way you hoped.
That’s right, I say to my imaginary friend, this sucks. It really sucks. Reality looms darkly—how will I talk my way out of that? Hmm… But paradoxically, saying that to myself gives me a little mental space. Ok, I’ll just start from square one, I think. What choice do I have? I’ll see what John can take in today. Then I realize: what John has been showing me, all this time, is that he’s got some inner resources. He’s risen to one challenge. Maybe he could rise to another.
That shift in my own voice, from I’m going to ruin his day to maybe he could rise to another challenge, puts me in a different stance towards my job communicating the news, and towards John as a person—it opens me to more of him, and new kinds of discussions about how he might find a way to live with metastatic cancer. How I work with the emotional side of oncology, I’ve found, has a huge effect on how I see my work, how I’m able to be of service to patients and their families, and what I end up talking about. There are ways we can teach and support each other in this capacity, and for us to take care of our patients as the complex and amazing people they are, we will need to learn this together.