Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, July 07, 2008

Giving Bad News Over the Phone

How do you avoid giving a patient bad news over the phone?

This is a trick question, because the real answer is, "You can't."

I know how they say you're supposed to do it: have the patient make an appointment and give her the news face to face.

Oh yeah? Let's see exactly how that works:

Patient: Do you have my results?

Receptionist: Let me check. (finds pathology results; notices that it says "highly suspicious* for carcinoma"; hems, haws) Let me check with the nurse. (finds RN; shows results; gets told to schedule patient for MD appointment right away.) Um, yes. The doctor would like to see you to go over them. Can you come in first thing tomorrow?

Cut me a break! How much more clearly can you say "BAD NEWS!" but in the worst possible way. Now she's left terrified -- still having to wait until tomorrow.

I know, I know. Schedule all patients for return visits after all tests; no exceptions. The only problem is that makes for piss-poor customer service the 95+% of the time the results are completely negative. I sometimes fudge that by having them make the appointment, then calling them with the normal result and canceling the return visit. Still, that does nothing for the inevitable quandry of having bad results in hand with the patient on the phone.

Those waiting for me to hand down some masterful stroke of saurian wisdom are out of luck. However you cut it, this situation completely sucks, especially when the call above was to the specialist's office and the next call was to me. The specialist's office then faxed me the path report with a note, "Patient unaware of results; has appointment tomorrow to discuss."

What was I going to say to her? There was no way I was going to make her feel better and the risk of making her feel worse was considerable. She was seeing the other doctor in the morning. I weighed the pros and cons and made a unique decision: I intentionally did not return the call. I don't know if this was the right thing or the wrong thing to do, but it's what I did; didn't do, that is.

BY THE WAY: This is NOT how I handle these things in my own practice. I *always* call patients back with *all* results (therefore when a patient calls to see if the results are in, my staff can always say, "No; you will get a call when they are.") When things are abnormal, I do come out and say so over the phone, giving enough information to assuage their fears until I can see them in the office and go over the everything in greater detail. But in this case, I was stuck.

Any ideas?

*In Pathology-speak, "highly suspicious for" = "is"


At Mon Jul 07, 07:21:00 PM, Blogger Unknown said...

You did the right thing in this case.
I like your idea about scheduling everyone for a return visit for lab results and then canceling the negative ones after a callback. Will have to pass that one on to Mrs. WhiteCoat.

At Mon Jul 07, 07:59:00 PM, Anonymous Anonymous said...

I like how you handled this one.

I work at an HIV/AIDS clinic, and on several occasions have had patients whose family physician called them and gave them their HIV diagnosis over the phone. All of these patients were extremely distressed by this. One attempted suicide the day after the call.

Major diagnoses should always be given in person.

At Mon Jul 07, 08:07:00 PM, Blogger rlbates said...

I think it did fine. Life does not always go as planned for them or us. We sometimes have to wing it and be as compassionate as we can in those tough moments.

At Mon Jul 07, 08:35:00 PM, Blogger Angry Professor said...

I wish to god my doctor was you. I am so sick of the interval of waiting for what I know is bad news. That said, I don't see how you could have done anything else without stepping on your colleague's toes.

Ask me about the three (3!) first-trimester ultrasounds where I heard the doctor say, "You must have your dates wrong," (after years of infertility and knowing exactly the date of each ovulation) and the subsequent two weeks of waiting for the second ultrasounds to confirm my retained abortions.

At Mon Jul 07, 10:13:00 PM, Anonymous Anonymous said...

I appreciate your predicament. The whole situation is highly suspicious for crappy.

At Tue Jul 08, 12:02:00 PM, Anonymous Anonymous said...

I think your response was acceptable; you spared her an evening of anxiety, and nothing you did changed the outcome in any way.

I suppose you could have come over to her house to discuss it with her in person in the short time before her appointment with the other doctor...but that seems like overkill.

Can you schedule a phone consult with her after the other appointment to see if she would like to talk anything over? Maybe that would make you feel like you had done ALL you could, since this post sounds like you have some regret.

At Wed Jul 09, 01:10:00 PM, Blogger Radioactive Tori said...

I found out I had cancer over the phone and am truly grateful that my doctor had enough respect to NOT make me wait to see him in person. He made sure to call me with enough time available for me to ask whatever I wanted, and then made me come in the next day to go over what we had talked about to make sure I understood and had no other questions. There is no good way to find out bad news, but this was the best possibly way I could imagine.

I did have a chest CT that was not good and my doctor (primary doctor, who I also love) did not call me back to talk about the results the day he said he would. I already had an appointment scheduled with a different doctor (for all the cancer stuff)the next day and I guess he figured by not calling me back, he wouldn't have to tell me the bad news since I was going the next day to someone else who would then give me the bad news in person.

I have to say that when he did not call me back, I KNEW something was not good. If you normally call back and skip it, it raises some red flags for me and while you might think the patient doesn't know, I did and I am sure there are others who figure it out too. Not saying it isn't ok to do that, just saying that you can never be positive that the patient isn't smart enough to figure out what is going on. I was and I was correct each time.

At Wed Jul 16, 08:18:00 PM, Blogger Tony said...

You handle it perfectly.

Two comments:

Normal paps and mammos get a mailed result and I tell them that they will get in two weeks (it usually only takes 7 days.) I call them with abnormals before two weeks so they are not waiting.

NEVER give bad news on Friday afternoon of day before a holiday. The patient will always fret over the weekend, call the on-call doc with questions he/she cannot answer, etc. Worse, you get the machine and pt sees the call-back number at 6pm Friday with no discussion over the weekend or holiday!!


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