Breaking Bad News

[Portier]

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I had an experience last month on my Pediatrics Rotation that I would like to share, and solicit comments about.

There was a 6 month old caucasian boy with cephalomegaly. He did not have hyrocephalus, or any degenerative neurologic signs. His mother, however, was worried. Other parents and people on the street would stop her and make, "Wow your kid has a big head comments," which only worsened the situation.

She had been sent to Children's Hospital in New Orleans, and the neurosurgeon she consulted with was very dismissive. After waiting to see the female physician for three hours the Dr finally arrived only to lay her hands on the child's skull and say, "He's fine. I see this all the time."

The mother protested, so the Dr got a head X-ray. There was no abnormality noted.

Still determined to get a solid answer, the mother brought the child back to the general pediatrician. The pediatrician ordered a head CT. The CT showed agenesis of the corpus callosum, and frontal and temporal lobe atrophy.

This, still, in the abscense of neurological deficits.

So, we were in this room, with two very worried looking parents to give the bad news to them. When we started trying to explain the findings, we ran into one question over and over: "Will he be ok? Will he develop fine?"

I got involved in explaining the anatomical varriances, and possible outcomes (from what I'd read it was a spectrum of possible outcomes from normal to AFU). The father who was of hispanic heritage, about six feet plus, very brawny, with slight hypertelorism, and cephalomegaly himself was very worried, and kept askine me what was going to happen.

I felt incompetent and impotent when I couldn't tell him. I couldn't even maintain eye contact with this extremely worried parent. I later felt guilt not so much about the prognosis (we didn't cause it), but in my inability to maintain a upturned face while breaking the news.

I feel I should have been able to keep eye contact, say I was sorry and there's nothing else to do, and talk about the referral we were doing to a pediatric neurologist.

What do you think?

 

[(nicedream)]

I had an experience last month on my Pediatrics Rotation that I would like to share, and solicit comments about.

There was a 6 month old caucasian boy with cephalomegaly. He did not have hyrocephalus, or any degenerative neurologic signs. His mother, however, was worried. Other parents and people on the street would stop her and make, "Wow your kid has a big head comments," which only worsened the situation.

She had been sent to Children's Hospital in New Orleans, and the neurosurgeon she consulted with was very dismissive. After waiting to see the female physician for three hours the Dr finally arrived only to lay her hands on the child's skull and say, "He's fine. I see this all the time."

The mother protested, so the Dr got a head X-ray. There was no abnormality noted.

Still determined to get a solid answer, the mother brought the child back to the general pediatrician. The pediatrician ordered a head CT. The CT showed agenesis of the corpus callosum, and frontal and temporal lobe atrophy.

This, still, in the abscense of neurological deficits.

So, we were in this room, with two very worried looking parents to give the bad news to them. When we started trying to explain the findings, we ran into one question over and over: "Will he be ok? Will he develop fine?"

I got involved in explaining the anatomical varriances, and possible outcomes (from what I'd read it was a spectrum of possible outcomes from normal to AFU). The father who was of hispanic heritage, about six feet plus, very brawny, with slight hypertelorism, and cephalomegaly himself was very worried, and kept askine me what was going to happen.

I felt incompetent and impotent when I couldn't tell him. I couldn't even maintain eye contact with this extremely worried parent. I later felt guilt not so much about the prognosis (we didn't cause it), but in my inability to maintain a upturned face while breaking the news.

I feel I should have been able to keep eye contact, say I was sorry and there's nothing else to do, and talk about the referral we were doing to a pediatric neurologist.

What do you think?

You are beyond me in your training and I don't have any experience in breaking bad news, but I will say that you don't have anything to worry about. I'm sure skill at dealing with this issue is something that comes with experience. If you feel you should have kept eye contact, then next time just make an effort to do that. It's certainly understandable that you reacted the way you did. Also feel good that you explained things to the parents and helped them understand their child's condition a bit.

 

[cremaster2007]

You know that there are plenty of doctors who are uncomfortable with that and they have been doing it a lot longer than us. Its one of those things though, some people are good at it, some aren't. It comes with experience, but you should blame yourself for anything like that. Sometimes you just have to look people in the eye and say "I don't know"............

 

[1viking]

Why are you breaking bad news and not the attending? Seems like the attending should be doing this.

 

[Portier]

Private practice clinic.....me and the 1 doc on deck.

 

[Ice-1]

Why are you breaking bad news and not the attending? Seems like the attending should be doing this.

Word truth! When I was a 3rd year my attending made me go in and tell a patient that he had terminal metastatic cancer. The DX had been confirmed, but that kind of bad news should have been given by the attending and not by a medical student. I did it because I was required to do it. At least I held the patient's hand and spent about 30 minutes with him. But I did feel really dirty for a couple of days. You aren't going to like this experience one bit.

 

[1viking]

I think it is stupid that an attending won't break the news. I think the student should stand by the attending, but let the attending talk. Would you like to hear from a STUDENT that you have small cell carcinoma? Stupid docs.

 

[Portier]

I think it is stupid that an attending won't break the news. I think the student should stand by the attending, but let the attending talk. Would you like to hear from a STUDENT that you have small cell carcinoma? Stupid docs.

With respect to your comments (they are salient).....

When something this emotional is going on, "I" feel prompted to help clarify details. In this case, there was Neuroanatomy involved....hard to learn....even harder to explain to the lay person.

Also, the physician was female. As wrong as it sounds, a lot of times regardless of your level of training your genitalia will be used to judge you. Some people only want to talk to a male physician.....and even if you are the trainee and she's the boss....it remains.

I tried to interject some clarifying point of Neuroanatomy after the physician started and got bogged down with the parents...and it got me stuck in the front...like when you're playing hearts.

 

[1viking]

I understand what you are saying and it makes sense. What an interesting world we live in.

 

[ambernikel]

Even though you didn't maintain eye contact it sounds as if you really tried your best to help explain their options. I'm not even in med school yet but during my internship at the NICU I sat in while the doc explained to a woman that her son had some brain degeneration and a genetic disorder. He had an anatomy chart of the brain and tried to explain how the missing connection between the two sides can result in multiple symptoms and can vary in severity from no visible signs to MR. This child also had Tet of Fallot and some other obvious genetic signs. I think I heard later that he had DiGeorge's. He was soon sent to a bigger children's hospital.

My point is that with these kind of things there isn't much you can say especially as a general pediatrician. All you can do is tell what you know and hand them tissues (this was my job) and be supportive. It really sounds as if you cared and that sincerity will shine through, eye contact or not. Especially since you spent time talking with them which they were obviously denied with the specialist. I can't speak yet as a doc but as a human who has been with people during tragedy I can say that support and empathy goes along way even if answers aren't available. I don't know that this ever gets any easier.

 

[RuralMedicine]

With respect to your comments (they are salient).....

When something this emotional is going on, "I" feel prompted to help clarify details. In this case, there was Neuroanatomy involved....hard to learn....even harder to explain to the lay person.

Also, the physician was female. As wrong as it sounds, a lot of times regardless of your level of training your genitalia will be used to judge you. Some people only want to talk to a male physician.....and even if you are the trainee and she's the boss....it remains.

I tried to interject some clarifying point of Neuroanatomy after the physician started and got bogged down with the parents...and it got me stuck in the front...like when you're playing hearts.

So your attending brought you along to discuss this with the parents I'm guessing from reading between the lines in your anecdote? I don't think that is inappropriate if some briefing and perhaps guidelines for their role are communicated to the student beforehand. I do think that we learn the "style aspects" of medicine from our observation of our mentors. I think in this scenario I might have asked that you remain silent as it sounds like this was an outpatient experience where you had met the parents at perhaps that visit and hopefully the pediatrician had established some relationship and trust with the family. (If this was a patient/ family that you had had continued exposure to and had previous relationship with as might occur in an inpatient experience or if you attended a school with a longitudinal clinic and had the opportunity to follow patients over several months and this was your patient then I might have discussed with you the points I felt we needed to convey and allowed you to rehearse your points and then allow you to be the primary communicator while being present to answer questions you could not or help you out if things were not going well) Whether or not your interjection to clarify was appropriate or not I wouldn't know without observing the full interaction.

As far as your original question I think that with pediatrics especially, pathology and prognosis do not always have complete correlation. Additionally I think we are often fooled with younger infants that seem to be "keeping up" developmentally because the developmental milestones are less separating at 6 months than say 18 months. I have frequently told parents that it is impossible to predict with certainty the future for any child but that in my experience I expect that their child will......(insert explanation here). I think it is very helpful to focus on functional and day to day stuff. Parents want to know will my child be able to walk? will they talk? will they be able to live independently ever? I also have found it helpful to remind parents that this is the same child (use the child's name) it was before we had this diagnosis and they will love that child just like they did before and we now have information that will help us be better able to do everything we can to help their child achieve their maximum potential. It won't sink in all at once, its often helpful to come back later in the day or schedule them to return later in the week and continue the discussion after they have processed some of the what you have told them.

 

[RuralMedicine]

My point is that with these kind of things there isn't much you can say especially as a general pediatrician. All you can do is tell what you know and hand them tissues (this was my job) and be supportive. It really sounds as if you cared and that sincerity will shine through, eye contact or not. Especially since you spent time talking with them which they were obviously denied with the specialist. I can't speak yet as a doc but as a human who has been with people during tragedy I can say that support and empathy goes along way even if answers aren't available. I don't know that this ever gets any easier.

Actually as a general pediatrician I think you play a huge role. Being a primary care provider at its best means being the one person responsible for coordinating and advocating for your patient. Sure you need back up and appropriate referrals to subspecialists are sometimes critical but it all comes back to you to be able to answer the questions the parents were embarrassed to ask the subspecialist (or did ask and were not answered because he "still had 20 patients to see before lunch), to realize that if you blindly follow the recommendations of both the pulmonologist and the nephrologist you may kill the child, etc. Medical home is the buzzword of 2005 I'm sure and I admit that when I first heard the term a few years ago as a resident who was supposed to create medical homes in my continuity clinic I shuddered too. But as I got over my distaste for the lingo I realized that it basically represented utopia in primary care. Does it happen for all my patients? No I'm sure it doesn't but I'm still young and idealistic enough to strive for it.

I've also found most subspecialists to be very helpful if I can ask specific questions of them with my referrals and if I maintain open communication as we attempt to "share" the patient.