How do you say it?

I am often the bearer of bad news. I don’t think I’ve ever been formally taught how to deliver bad news, but I’ve developed a style over the years, and I’m pretty good at it.

I work with medical residents every day in their outpatient clinics. Most of them have never had to deliver bad news. Some people are natural communicators, and some aren’t. Often, one of my residents just “gets it”—they have a great deal of empathy, can “read” the patient from moment to moment, and without any help from me, they can successfully give the news.

What does it mean to give bad news “successfully”?

In medicine, it means giving complex information in a short period of time, with proper emotional content, and in such a way that the patient takes it seriously, but doesn’t become so frightened that they forget the entire discussion. Once the word “cancer” comes out, little after that is retained. Over and over, I hear people say, “what was that thing you said I have?”

There is no substitute for young doctors giving bad news to their own patients, but it’s good to model behaviors and to pass along tips.

For example, if I have to tell someone they have HIV, I usually make sure to shake their hand, put a hand on their shoulder, sit near them, and keep my arms uncrossed. These signals set the tone for how they will view their illness. If you, as a doctor, seem physically distant, the patient will sense that, and may end up feeling stigmatized, isolated, and more afraid. Also, they may disappear out of fear, delaying further treatment.

Giving bad news has to be a flexible skill. All patients are different, and need to hear news differently. For example, I had a patient with a breast lump. She is a bright and straight-forward person, so I asked her, “Do you prefer a good surgeon who is warm and fuzzy and will hold your hand, or who will just get the job done?” She chose the latter.

I can only hope that my skills keep improving and that my residents keep learning. Unfortunately, there will always be people to give the news to.

Never say “hopeless”

I can’t tell you the number of people who complain to me about having their hope taken away. Exactly what this means, though, isn’t always clear.

Sometimes an oncologist will tell them (so they say) that they have a month to live. Sometimes their cardiologist tells them (so they say) not to travel to their grandson’s Bar Mitzvah. Sometimes the spine surgeon tells them their back will always hurt, no matter what. So they say.

Patients tell me a lot of things. I’m not always sure what other doctors really told them, but what is important is what the patient heard. The oncologist might have said “incurable” but followed it up by “but treatable for years.” I suspect after hearing “incurable”, not much else gets in.

One thing I’ve finally learned after a number of years is that patients actually listen, even if you don’t think they do. What they hear is a different story. Depending on their mood and circumstance, they may hang on single phrases, subtle inflection, the way your eyes dart.

To be an effective physician, you must also be an actor of sorts; not in the sense of pretense, but in the way you pay attention to everything your words and body do, and how your audience reacts.

I had a patient a few years back, a very pleasant older woman, who came to me with difficulty in swallowing. There can be a number of different reasons for this. A radiographic study, however, showed a lesion in her esophagus that was almost certainly cancer. Normally, I won’t speak on the phone to people about such things, but she and I had decided for various reasons that this would be the best way to communicate. I told her about the results:
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Do I have clients or patients?

One of my duties involves teaching nurse practitioner students. Nursing is quite different from medicine, and many of the linguistic markers of nursing differ significantly from medicine. As more physicians’ assistants and nurse practitioners enter the primary care world there will be a bit of a culture clash. For instance, my NP students often refer to a physical exam as an “assessment”, a misnomer which I do not allow them to use with me. Assessments come after you have spoken to and examined a patient. Another difference is in the common use of “client” in referring to patients. This debate seems to have originated in the late 80s or early 90s, and perhaps in psychiatry, but it spread rapidly. Its growth also coincided with the growth of HMOs and other managed care.

Language means something beyond the words themselves, and what we call the people we care for matters.

A patient is literally a “sufferer”, whereas a client is more literally a “customer” (although its roots in Latin refer to a much more specific relationship).

There are some pretty serious implications to calling a patient a “client”. A patient is someone who is suffering, and to whom we have an obligation to help. We are expected to put their needs above our own as much as is possible.

A client is a customer. We provide a service, they pay a fee.

As paternalism receded in favor of autonomy as a medico-ethical value, many felt that “client” somehow empowered a patient—as they were paying for a service they were on more equal footing with the doctor. As a patient, a doctor is “acting” upon them, rather than partnering with them.

What a load of bullshit.

The first day of my pathology class, Dr. Alexander Templeton looked at us and asked, “Why does a patient come to see you? Come on, don’t be shy. Tell us. Why do they come to see you?” After a few answers taking jabs at common illnesses, he shouted, “No, no, no! They hurt and they want you to make them feel better!”

If someone is a client, I have no obligation to make them feel better. If they come to me a gallbladder problem, my obligation is to order the correct tests, make the correct referrals, and collect my fee. If someone is my patient, I’m obliged to do all of that, plus try to make them feel better.

There have been a few small studies that polled patient to find their preference, but I don’t think this helps—it isn’t a matter of democracy, but humanity.

The authors of these studies listed some important disadvantages to “client”, some of which are:

• Denial that the person has an illness or that certain
treatments (e.g., drug therapy for schizophrenia) may
be important in helping a sick person.
• Denial of access to the sick role, from a failure to
recognize that society allows sick people or patients
certain rights to be cared for, and even denial of access
to these rights.
• Lack of protection (by the use of the term “client”
per se) against the power and dependency that can
exist in a doctor-patient relationship.
• Lack of recognition of the importance of the doctor-
patient relationship and its confidentiality.
• Lack of the special elements of care and compassion
implicit in the term “patient.”

In this tug between paternalism, autonomy, and language, it is important to remember one fact: a patient comes to you for help, and as a doctor or a nurse, you are obliged to help them. Sure, you can’t (and shouldn’t) work for free, but between “client” and not working for free, there is a lot of ground. The most generous spin I can put on this is that a patient is a special subset of client, but that doesn’t work for me. There just isn’t the same compassion in a doctor-client relationship as their is in a doctor-patient relationship.

I never see clients, only patients, and that’s the way I’m going to keep teaching it.

Peter C. Wing, MB, ChB. Patient or client? If in doubt, ask. Canadian Medical Association Journal. 1997;157:287-9.

Women physicians—a waste of a good education?

Think about your own experiences—you’re at a party or a restaurant, and someone you’re with says something obviously racist. You cringe, but given the setting, you can’t decide how to react; after a pause, you probably decide to say something. Now imagine you’re at meeting for work, and a senior partner says something racist. You want to say something, and you even know that under some circumstances there are laws behind you, but you don’t want to get branded a trouble maker and risk subtle (or not-so-subtle) discrimination.

Now imagine you are sitting in the doctors’ lounge, and a senior physician says that sending women to medical school is a bit of a waste. The people sitting around the table make decisions every day about who to accept and reject to medical schools and residency programs, who to hire, who to promote, but hey, it’s just a group of guys having a cup of coffee. How would you react?

In the early 1960’s, about 5% of medical American medical students were women. Now about half are. Women are first authors on more medical papers than ever, yet fill only about 11% of department chairs, and fill about 15% of full professorship positions.

What’s behind this?

There is literature studying the trends in academic and clinical medicine. I’ll point you to the reference below as a starting point, but I’d like to give you a front-line perspective.

Something I hear every week is that women are likely to take time off for kids, and to work part-time, and that this somehow renders them less valuable. I’m not sure how this reasoning works. After all, doctors treat people of all ages, genders, and ethnicities, and doctors of different backgrounds often have different experiences and skills to bring to the table.

But I can see how some of these ideas are perpetuated. Slots in medical schools, residencies, and fellowships are quite limited, and it costs much more to create a doctor than tuition could ever cover. Some take a false utilitarian view that because it costs so much to create a doctor, only those who can give back the most in time and money should be trained.

Residencies are limited in both the number of residents they can take, and in how many hours these residents can work. When one becomes pregnant, it can burden the entire program.

Well, this is the real world, and in the real world, half of us are women, and women are the ones who bear children. Also, the prime years for physician training are prime child-bearing years. Get used to it. If we think women have at least as much to offer as physicians as men, we better get used to the fact that they have “lady parts” and that this has real effects. Are we to limit the contributions women are allowed to make because a short period of their lives may or may not involve child-bearing?

In clinical medicine (as opposed to academic medicine), there seem to be many more opportunities to work part-time than in the past. The less you work, the less you get paid, but the pay is still pretty good. But academia is still about productivity, and gaps are not acceptable.

As a society and a profession, we have to decide to take the role of women seriously. If we demean women’s role in our profession, we may be more likely to demean our female patients and family members.

Things are getting better, but we still have a long way to go.


Reshma Jagsi, M.D., D.Phil., Elizabeth A. Guancial, M.D., Cynthia Cooper Worobey, M.D., Lori E. Henault, M.P.H., Yuchiao Chang, Ph.D., Rebecca Starr, M.B.A., M.S.W., Nancy J. Tarbell, M.D., and Elaine M. Hylek, M.D., M.P.H. The “Gender Gap” in Authorship of Academic Medical Literature — A 35-Year Perspective. NEJM 355(3); 281-287. July 20, 2006.