I am a semester 5 medical student preparing for my final exam before I end my first phase of medical school. It is late and I am preparing to go to bed.
Suddenly, my phone rang. It’s dad.
Dad. He rarely calls, he is always very busy. Why…
‘Hey, dad. What’s up?’
‘Honey… it’s your mom.’ He paused. Is he sobbing? I am not sure.
‘She was complaining of chest pain a few hours ago and I brought her to the ED. They did all they can…’
‘Dad…what’re you talking about? Where’s mom?’
‘She’s gone, honey. She’s at a better place now…’
‘Wha… No… No no…’
Slowly the sad background music went off.
Source: pantip.com
The above is neither an excerpt from the famous crime TV series ‘Breaking Bad’ nor something that happened to me. So no, this article is not about ‘Breaking Bad’ or my past.
On a fine Tuesday morning, Dr. S made us sit in her lecture and dimmed the lights. She turned on really sad background music and sister K (one of the nurses working in our Clinical Skills Unit) took us on a journey we never expected. She told us to imagine ourselves being the medical student in the story she will be telling. And the above is the story.
I guess I really put myself into the story and imagined my own father calling me and telling me that. Then I stopped. No. That is not me and it cannot happen to me. Or at least that’s what I wanted to believe.
But who am I kidding? It happens and can happen to anyone.
The lecture was about one of the hardest thing a doctor will have to do again and again throughout their entire career.
Breaking bad news.
Honestly, I never really thought of death, you know, as part of my future job. It is always me imagining myself saving lives (whenever Allah wills) and family members in their happy tears, thanking me. I know some doctors would jump at this simplistic idea of the profession. Well, I think it is okay since I am still in the very early segment of this career but that session we had, really made me think about death more and deeper than I have ever had before.
We were taught about the SPIKES Protocol (2), which was developed by Dr. Buckman and Dr. Baile sometime in the late 90s to help physicians break bad news to their cancer patients. It emphasizes on the environment in which you are going to break the news, understanding the patient and what they want to know at that particular moment, dealing with emotions and finally your plans for the patient. But who are we kidding; doctors do not always get the luxury of having a secluded place to talk to patients, do they? Sometimes, it has to be at the ward itself. And every bad news will always be as difficult to every patient. So will it ever be easy for us?
Imagine a person coming in with a disease, see people get their hopes high for recovery and suddenly you get to be the one telling, there is nothing you can do anymore? Can you imagine how suffocating that can be?
A young lady, married for a year or so, came in with lower back pain and dyspareunia, which is pain during sexual intercourse, and after a lot of hospital visits and tests, a full body scan was done and bam! The diagnosis was breast cancer. How do you tell her that? She is young, just got married and is trying to have a baby! Will you be able to remember your SPIKES then?
There you are, suffocating again.
I know that life is not a fairy tale and not all stories have happy endings. I also understand that there should be some distance between us and our patients so as to maintain the professional patient-doctor relationship, but how do you not connect to their sufferings? How do you ignore the fact that this person, probably of the same age as you, is about to go through some really tough times from now on? Do we just shut our feelings and numb our hearts?
There is something called “isolation of affect” which can be seen, usually, in medical students and doctors. It is an inhibitory ego defense mechanism characterized by a separation of feelings from ideas and events (1). We separate ourselves from the patients and whatever that happens to them. We treat them and we put our all and everything into it. But when we cannot do anything anymore, we tell them just that and we find another patient to save. Yes, of course in some cases, we try our best to help lessen their pain through palliative care because there is just so much we can do. So I ask, is this wrong? Is this mechanism a screwed up one? Because it definitely sounds like it can make things easier.
After working for years, probably even when you saved a life, you might just be too tired to feel anything as they thank you. Soon, happy news or otherwise – it is just another case.
But that is definitely not how I imagine myself to be as a doctor. I want to care for my patients like family and get broken every time I have to experience and relay the bad news. I want to cry for them and at the same time, offer comfort for them. I want to be with them, for them. I truly appreciate interaction with patients. I guess it is one of the main reasons why I think Medicine is for me.
I am scared that as I go along this road, I forget that one important reason and start working for different reasons. When I turn into something like that, I guess I will be able to say that breaking bad news is easy. Ask me now, I will tell you that I do not want it to be easy – ever. Because when it is difficult, I will know that deep down there I am still sensitive to others’ suffering and can still get hurt in hurtful situations. I do not want to be numb to these things but at the same time, I am not sure if I can handle it. And that is exactly what I am scared about.
I guess, I will only figure this out once I become a doctor myself. Till then, I will just have to pray for what is best for me.
“There’re two kinds of doctors; there’s the kind that get rid of their feelings and the kind that hold on to them. If you’re gonna hold on to your feelings, you’re gonna get ‘sick’ every once in a while – it’s part of it.”
–John Carter (Doctor, ER series)
Aziza Aini is a medical student in International Medical University. Know more about the Young Columnists Program under The Team tab.
References:
- Todd A. Swanson M.D. PhD, Sandra I. Kim MD PhD, Nadeem N. Hussain . Underground Clinical Vignettes Step 1: Behavioral Science (Underground Clinical Vignettes Series), 5th ed. : Lippincott Williams & Wilkins; 2007
- Walter F. Bailea, Robert Buckmanb, Renato Lenzia, Gary Globera, Estela A. Bealea and Andrzej P. Kudelkab. SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. http://theoncologist.alphamedpress.org/content/5/4/302.full (accessed 13 April 2014).
Good writing here Aziza!
You have a good lecturer and nursing sister to guide you through this topic, much better than my med school days.
Somehow only few times out of many that I have to encounter this situation at my setting. Some folk sometimes just smile when I tell them they have cancer, cause they are not aware what cancer is. Glad I read this for the few that need it. Thanks 🙂
Thank you Dr Ahmad! 😛 I’ve never done it myself (expected, since I’m still studying) but never observed other doctors doing it either. Am still wondering if I’m ready!
Very interesting article on breaking bad news. Certainly never easy to do so and even the most experienced clinician will shrink from doing so. As an FY2 I have worked in palliative care and breaking bad news was relatively common. Being a doctor is not only curing, healing and saving lives, but also to provide comfort. Its part of life that some patients will be diagnosed with an incurable disease. Certainly we can’t reverse it, but we can provide comfort and care to ease the pain/anxiety/breathlessness. Important to always involve the family when doing so.
Thank you!