Dec 7, 2009

The Bad News Room

A reader asks:

On rare occasions, a doctor won't say anything while I'm on the tissue-covered table and silently escorts me to a small room with ugly upholstered furniture for a conversation. I think the idea is that this is a more "comforting" environment, but to me, it's just another strange medical space. Perhaps you could explain how your compatriots decide where to speak to patients?
Yes, some doctors have this weird idea that bad news is only tolerable when given in a sitting room with upholstered chairs and fake plants.

The trouble, of course, is that patients suspect this and therefore getting moved to the little room with comfy chairs significantly worsens your already nerve-racking visit. You know the bad news is coming, so the comfy room feels like a cell where you await your sentence.

As I've mentioned before, giving bad news is always a rough part of this job. We want to be as gentle as possible, but I think the little room is more for our comfort than yours.

Doctor D believes the most important thing about news is to give it straightforwardly and in a private place. Last thing your doc needs to do is to give it in crowded ER when your neighbor is listening on the other side of the curtain. Of course, the small, busy ER where Doctor D works has lots of curtains and no cute little room. D has even been known to take people in the medicine closet for a talk when it's the only safe place to protect their privacy.

But when privacy isn't a concern, the last thing I want to do is move you somewhere where you know you are waiting for bad news. I'll tell you straight up what I'm thinking. Doctor D believes people care more about hearing news directly, honestly, and kindly than they do about the location where they are told. I have used offices or these little sitting rooms in the past, but only because the patient wanted me to tell a lot of family members that wouldn't fit anywhere else.

I start directly and tell you straight up wherever we are. I know their will be lots of further discussion and questions. I'm always glad to finish the conversation wherever you would prefer to talk.
What do you think? Would you be upset by being told in an exam room sitting on that tissue-covered table? Would you prefer to be moved to the room with the comfy chairs? Let Doctor D know if he should change his strategy!


Doctor D said...

I should also add:

I try not to tell anybody bad news when they are naked or wearing one of those flimsy gowns. It just feels so vulnerable for the patients when they aren't dressed. When I can I let them put their clothes back on before giving difficult news.

Helen said...

You sound like a very sensitive and empathetic doctor.

I was told I needed my defibrillator while I was lying on a table in the electrophysiology lab, catheters still stuck in my femoral artery, naked and hooked up to all sorts of things, and still shaking off the effects of adenosine. It's not the sort of "bad news" you're talking about, but I would have appreciated it if I'd been on a more equal footing with my doc and able to carry on a proper conversation.

The things you mention - that the patient is clothed and not feeling physically vulnerable - are more important than the location of the discussion.

Anonymous said...

It seems to me that privacy and dignity are the most important part of any discussion with a doctor, regardless of whether it's good or bad news. Personally, I don't care where the discussion takes place as long as its honest, straightforward, clear and kind. When I was a child, the doctor would have my mother bring me to his office after the exam was over and I was dressed, and he'd go over his diagnosis and instructions for my care with my mother while I picked a small toy out of a jar he kept there for his younger patients. It was a comforting routine, and I've missed that as an adult.

WordDoc said...

I always have patients get dressed before we talk, whether the news is good, bad, or even no news at all. All my exam rooms have antiques and my favorite art work so they are not too clinical nor too cute.

Here's my dilemma though, I get bad news back by report, say a mammo, biopsy, or lab test. If I have my office call the patient to make an appt, they know it's bad news, why else would I call them in? So I often opt to tell them on the phone. I know that's ghastly impersonal, but I figure they'd rather know ASAP then agonize for the day or two until their appt. I always give them my home phone then so they can think it over, digest it, discuss with family and friends, and then call me back, or I offer them an appt the next day to go over the news again with a designated listener in tow. What do you all think of phoned bad news?

Doctor D said...

Yeah Helen, I hate those discussions when my patient is naked and hooked to everything. Sometimes it can't be avoided though. Which is hard on patient and doctor. Unfortunately, a lot of us doctors get used to talking to folks in this condition and forget how weird it feels for the patient.

WordDoc you are awesome! Sounds like you are working to create that dignity in your practice that Wren mentioned.

When I worked at Crayzee Clinic I spent a weekend and cleaned all the dingy exam rooms and hung bright art posters on the wall. I also set up my office as a comfortable space where patients and their could always sit with me. I didn't move from exam room to office to make anybody nervous, but for every new patient visit, yearly physical, or well-child check we started in my office. I wanted everyone to feel like they were being welcomed into my space and that they could feel comfortable with me.

After doing all that one of the workers at Crayzee Clinic said, "Why waste all your time decorating? This is a poor people's clinic not some fancy specialist office!" I should have known right then I wasn't going to work out at Crayzee Clinic. I wanted to run a community clinic like a welcoming home and they wanted to run it like the DMV.

tracy said...

Word Doc i think phoned bad news or any news is just fine. As you mentioned, it is far better than the waiting, which, as the song says, " the hardest part." i also love that you give the patient your phone number and a chance for an appointment very soon. You sound like an excellent and very compassionate physicaian.

Ask An MD You, too, are a blessing. Thank you for a dear heart and a wonderful blog!

Anonymous said...

WordDoc, I'd much rather hear bad news over the phone than have to wait for it for several days, worrying. I'm not sure there's an optimal situation for receiving bad news, but it sounds like you've done the best you can to make your patients feel cared about -- and that counts for more than you know. You and Dr. D seem like very good, compassionate physicians. Thanks.

Anonymous said...

I don't mind bad news by phone, so long as it is my actual doctor giving me the news him/herself. I don't want the designated nurse calling me. I adore my own doc exactly because he calls me with any news, good or bad, himself. If I want to talk further, I can make an appointment, but at least I'm not left to wonder.

Bendy_Clutz said...

My mom often talks about her old OBGYN that after every exam, would have her get dressed and then meet in his office (it was a clinic of a big HMO) to go over the visit, results and just to touch base. For her, it made all the difference in the world (she ended up with a lot of problems over hte years till they finally took everything out in her mid-30's)

I personally don't mind talking in the exam room but my last 2 doc's had me sit in a chair fully clothed to talk, which I did appreciate and liked.

dixiemomx2 said...

My problem orthopaedic in nature. I have PVNS (pigmented villonodular synovitis) in my ankle, so the most naked I get is taking my sock off and exposing my bare foot. When I visited my ankle surgeon to go over my most recent MRI results, I could tell he hated to inform me it had returned. He was being so nice that I didn't have the heart to tell him I already knew. Before he ever entered the exam room, I overheard him tell his assistant to get my Ortho Oncologist on the phone. I knew he wouldn't be calling him prior to talking to me if it was good news.

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