It is “The Talk”. It is the difficult act of telling someone that they or a family member is catastrophically ill or dying. It is always hard on the patient or family member. What is not so well known, however, is the fact that it is just as hard for many doctors untrained to handle the scenario or its unpredictable results.
The movies have more than a few of those heavy scenes when the doctor gives the ultimate bad news — you are dying, the loved one is dying, there is no hope. Television soap operas brought these scenes to the summit of melodrama. Very slowly the medical profession is beginning to address the training of physicians to better do the difficult job of explaining illness, pain or death.
Woody Allen made it a joke. His characters imagine the scene in their hypochondria or tell stories about “the talk” or an imagined discussion of mortality. The heavy talks are not comedy but some sense of humor or, at least, sense of the others’ feelings would be helpful.
There were the scenes after my heart attack twelve years ago. The first was the day after the heart attack. I soon learned that the cardiologist (who had saved my life) was totally without a bedside manner. He visited my hospital bed where I — still in a state of disbelief and denial — was saying “You can’t mean I had a heart attack!”
“Absolutely,” he said. “But don’t worry. If all else fails you are a great candidate for a transplant.”
“A” in cardiology, “F” in sensitivity.
Five years ago, when the bypassed arteries totally closed again and I was in great pain, sucking on an oxygen tank, my cardiologist (in Mexico) told me it was time to go back to the US. He hugged me and said that he “hoped to see me again”. More sensitive; more frightening.
There were the early days after the heart attack when I would go to the doctor for regular EKGs and blood tests and ask if the EKG showed improvement. They would look uncomfortable and explain they never showed improvement. Their discomfort was discomforting.
Just recently the Philadelphia Inquirer reported in“Bad News” that medical schools are now, finally, addressing the issue of how physicians learn “how to handle the ‘talk.’” Only a decade ago the schools gave no training in the kind of situation that should be discussed and taught since it is one “repeated thousands of times a day at bedsides, across desktops and over the phone, turning lives upside down.” Now a majority of the medical schools at least address the issue, says a spokeswoman from the Association of American Medical Schools.
A 2005 study of third-year medical students showed that in a majority of cases where their patients died during their internal medicine rotation, the medical team never brought up death. When they did it was treated only in terms of medical technicalities. The attending physicians only mentioned emotional issues in six of 27 cases.
One physician thinking and writing on the subject created the seminal book, How To Break Bad News: A Guide For Health Care Professionals. In it, Robert Buckman, a Toronto oncologist, outlines six steps in giving out bad news. He starts with setting the scene in a quiet place. Seems pretty obvious to me, but physicians are so focused away from emotions and feelings that the whole thing was ignored until recently. “Hey, pal. You’re dying,” might have been acceptable for specialists before doctors were expected to be sensitive. Only those Norman Rockwell doctors with the neat, black leather bags, Drs. Welby and Kildare, could do it better.
Dennis Novak, Dean at the Drexel (Philadelphia) School of Medicine related how he had taught himself the practice of giving bad news. “There was one patient who asked me, ‘Am I dying?,’ and I just said, ‘Yes.’ I would never say that now.” Novak and colleagues at Drexel recently received $200,000 to create “Doc.com”, which is making 40 videos that can be downloaded and used at medical schools where scenarios are made using experts and actors posing as patients to start discussions relating to patients and families during these crisis.
But doctors say that no matter how seasoned, some reactions can’t be anticipated. “My colleague told a family that their mother was very sick, and the son had a heart attack in her office,” says David Muller, dean of Mount Sinai Medical School in New York.
Like many areas where sensitivity is needed in the medical profession, it’s about time for a start.