“My rheumatologist was the one who told me I have cancer because for nine months we thought my back pain was due to a type of arthritis. He felt really bad about it and when he called me to tell me the diagnosis, he started crying on the phone.”
A student in my second-year medical school class says this when we are in the big lecture hall for a class presentation on how to give bad news. This lecture is supposed to prepare us for a standardized patient encounter where we practice this skill in person. I think all 200 of us already understood the importance and the challenge of giving bad news, but this hits closer to home. This was someone our age being diagnosed with cancer by an experienced doctor. I always thought you got better at this with time.
“During your last visit we discussed the stomach pain you have been having and I ran some tests to figure out what might be causing it. The results came back and unfortunately they indicate that you have pancreatic cancer.” I hear myself say these words to a young man sitting next to me in the doctor’s office. He is a standardized patient and I am playing doctor. No, he does not actually have cancer but I try to be empathetic, to not overwhelm him with information, and to act exactly as if this was a real patient encounter in clinic.
Except I have no idea what I am doing. I am at the end of my second year of medical school and the closest I get to human interaction is talking to my First Aid book. Surprisingly, it has not been the best conversationalist — although I have told it some wild stories about the Krebs cycle. I stumble through the information about a cancer with one of the highest mortality rates — the majority of patients do not survive for more than six months. I take pauses when I think it is appropriate to let the patient process what is happening. When he asks what his prognosis is, I skirt around the fact that he probably has a couple of months to live and I cover my tracks with statistics. I have no idea how to end the encounter and I accidently say “Have a nice day!” as I exit the room.
I feel mortified and yet extremely grateful for the experience. I now know what it feels like to tell someone they have cancer. I am clearly terrible at it, but I have taken the first step. And yet … what is the next step? You get better at this with time, with practice. After more reactions you learn how to walk the tightrope between concerned and attached, between thorough and overwhelming. You will gather feedback from attending physicians and sometimes the patients … right?
The idea behind this standardized patient exam is to give you a grade (out of 100 points) and some feedback for improvement. We do not get any feedback in person and we are not allowed to talk with the standardized patient after the clinical scenario is up. Considering I have a lot of questions on how to improve my performance, I eagerly await the several weeks until we receive written comments and our grade. When scores are in, I open up the packet and read the one comment my patient has provided:
“When you said that you understand how I’m upset, I felt angry because you have no idea how this feels. It made me feel more distant.”
Okay. I replay that five-second clip in my mind. Then I think about the other 14 minutes and 55 seconds. Yes, I agree that there are more tactful ways to show empathy while respecting the patient’s experience. I should have said that it is understandable for him to feel this way; that many people feel this way in such a situation … there is room to work on this. But what about the rest of the clinical encounter? What about the amount of details I provided or the pauses I took? Did that give him time to process what was happening or did he just feel more awkward? Did I make enough eye contact? What about my response when he asked if he did something to cause this? His past medical history said he was an alcoholic and I answered that sometimes numerous bouts of pancreatitis due to alcohol use can increase the risk for pancreatic cancer, but there is no way for us to know exactly what caused his. There is so, so much more that I want to know, and for once I can not find the answers in a textbook or even UpToDate.
Donald Rumsfeld once spoke of known unknowns versus unknown unknowns. According to him, not knowing what exactly you do not know is much more challenging and leaves you more vulnerable to surprise (or a political attack, if you think back to his context). There is almost something comforting in recognizing what you still do not know. Even though he was talking about foreign countries and defense of American soil, his words strongly resonate with how I feel about this experience. I am edified to realize how much I do not know about giving bad news (the known unknown), but I am incensed by the fact that this is still an unknown when I could have received clear and more thorough feedback from a five-minute live session with the standardized patient.
I do not know how many medical schools are having students practice giving bad news but I firmly believe that every school should and I don’t want to minimize the importance of even this limited experience. Medical education has changed tremendously over the last several decades and is only striving to emphasize the humanity of healing more and more. However, there is still a lot of room for improvement.
Every time an exam is aimed at communication skills and building rapport, school faculty should consider how to maximize student learning even at the expense of logistical ease and cost. This includes verbal feedback provided after standardized patient exams. Is it logistically easier and faster to not allow standardized patients to participate in a debriefing session? Yes. Will you have to pay them more if you tack on an extra five minutes to each encounter? Probably. Does this increased length mean you may not be able to test as many students per day? Possibly. Is all this worth it? Resoundingly yes. More students should stand up and provide detailed feedback on training experiences. Because this comes back to the patients and just like learning how to put in a central line or a Foley catheter, we need to know how to do this right.