Yesterday was one of those bad days at work. With my resident, I had seen a patient in consultation a week ago, a very nice man with an evil cancer—metastatic malignant melanoma—who had been referred for post-operative radiation therapy. We were waiting for another test to be done which would help us with our radiation treatment planning. Unfortunately the test showed us that the cancer had already recurred, two months after his surgery, when he had barely healed. This meant that we needed to take a different approach with the patient than we had originally discussed, and we needed to tell both the patient and the referring MD. Since my resident had seen the patient last week, he offered to go and speak to the patient while I called the patient’s medical oncologist. By the time I came into the exam room, the mood was somber and the wife was fighting back tears. By habit, I asked the patient how he was feeling. His reply was, “I feel like having a bourbon.” In a moment of unguarded truthfulness, I blurted out “So do I!”.
This is the third time in three weeks that this has happened in my practice, where the disease turned out to be more advanced or extensive than was originally suspected. But if I think back through the years, there have been countless times when I have been required to give patients bad news. In medical school, you are taught to do physical exams, and make assessments and plans. But as yet there is no strong evidence that a medical student can be taught to deliver bad news to patients in a good way. The University of Oregon Health Sciences published a study in 1999 comparing the performances of students who had received some training in this area to those who had not. Although there was a trend in favor of those who had received formal instruction, the difference in performance was not significant. When the American Society of Clinical Oncologists surveyed its members on this issue, the majority listed “how to be honest with the patient yet not destroy hope” as the biggest concern. Educators have since been working hard to come up with guidelines on how to be the bearer of bad tidings—one that I found on line comes in the form of an acronym called SPIKES, which stands for (S) Setting up the interview (P) assessing the patient’s Perception (I) obtaining the patient’s Invitation (K) giving the patient Knowledge and information (E) addressing the patient’s Emotions with Empathic responses (S) Strategizing and Summarizing the information for the patients. Oh, surely I will remember all that when it comes time to give bad news again.
Call me a renegade, but I don’t think that empathy can be taught to a 20 something year old medical student. I think that it’s something that you’re either born with, or something that is learned very early in life. In the midst of assessing MCAT scores, grades, volunteer work, research and all of the other criteria that go into choosing who gets into medical school and who does not, somehow there MUST be a way to assess whether a prospective student can truly empathize with and care for another human being. The basic tools are a gift that the best doctors are born with. And then, if a student is very lucky, he or she will have a mentor at some point who shows compassion and grace when delivering devastating news to a patient, someone to emulate. I was lucky many times over in that regard and will be forever grateful.
Knowing my resident, I am sure that he did a good job delivering that bad news to our patient yesterday. But I still feel terrible about it, twenty four hours later.
I disagree. I think that empathic listening skills CAN be learned. Granted some people are by nature better at it. And some people will do poorly or will only learn by rote. But it can be learned with practice.
I went through an empathic listening training in 1979 and then went on to be part of a team that taught how to listen empathically. The experience of teaching the skills was, of course, when I REALLY learned how to do it.
And I remember two young men, pre-med students, who took our course so that they could be better doctors. I wish it could be taught in medical school, too, but it needs to be an interactive method with practice in active listening and I have a hard time imagining that in a medical curriculum.
I will say that my listening skills have been just about THE most important skill I have used in clinical practice over the years. I was damn lucky I had the opportunity to do that before going to vet school.
I couldn’t agree more that empathy is something you’re either born with or something learned early in life, if not it might be acquired with vast and willful training. Your writing, merely your willingness to write your experiences down demonstrates the incredible capacity to empathize you have shown for the many years I have known you. I look forward to reading all your posts!