For 25 years, I have taught medical students how to give bad news.  Step one; be prepared.  Step two; find a safe, personal, quiet environment.  Step three, and this is most important; before you speak, ask.  What do the patient and family understand? Fail to follow this vital rule and reap the whirlwind.   So, therefore, you might ask, if I have such wisdom and experience in this critical area of communication, how did I screw up so badly?

It seemed simple.  I was making hospital rounds, seeing my own patients and covering for my partners.  My sign-out instructions said the husband of a patient who had been in the hospital for two weeks, wished to be called with the results of his wife’s biopsy.  Clear enough.  Therefore, when I saw the report, I picked up the phone.

Unfortunately, before I could consider my action further, he answered.  It would have saved a lot of angst, had he been in the shower.  Instead, after briefly introducing myself, I simply said, without a pause, without further reflection, “I am sorry, the news is not good. The biopsy came back and it shows lung cancer which has spread to the liver.”

Now, of course, I expected him to be upset. It was terrible news.  What I did not plan for, nor expect, was that he would become completely hysterical, loosing the ability to speak in a rational manner, sobbing, screaming and eventually slamming down the phone.

I was shocked.  What had I done wrong?  Why was he unhinged?  Perplexed, I took a deep breath and started to do my job the proper way.

I carefully reviewed the chart and spoke to the patient’s nurse. I learned that while the disease was advanced, the biopsy was in fact the first time that the cancer diagnosis had been proven.  In other words, for the husband my call was the first and final confirmation of his worst fears.

The second thing I learned, to my astonishment, was that while the patient had been in the hospital for a long time, no one had actually told the patient or the husband that she probably had cancer or that if she did it would likely be fatal. Rather the admission had focused on pneumonia and they believed the biopsy was to investigate a “small spot” in the liver.

Thus, I had violated all of my rules.  I was not fully prepared.  I had told awful life changing news over the phone.  Moreover, I did not start with the simple question, “what have they told you?”  I really screwed up and made a very hard moment much harder.

Now, I can argue, that after all those days in the hospital, all those treatments, preparing for and performing a biopsy, and finally waiting for the result, that the husband and patient should have been better prepared by the medical staff.  Alternatively, I can justify my stupidity by noting I was just following sign-out instructions.  Nevertheless, it is my responsibility, therefore my error.

I met with the husband, and then the two of them, later in the day.  We started from the beginning. I explained, piece by piece, everything that was happening. This time we sat quietly together in her room and I first listened to their understanding of what was happening.  Step-by-step with time for thought, tears and silence.

Of course, I apologized.  It helped, some, but I feel guilty and sad I put him through such a horrid and unprepared shock.  Not fair.  Not compassionate.

I will start again.  I will have similar conversations. I will teach students and add this story to my list of important experiences.  Just maybe, I will get the practice of medicine closer to right.


  • Linda
    Most importantly you learned. What a shame this happened. You are a kind and compassionate doctor. You are human. Forgive yourself and know you are a wonderful doctor.
  • Liz
    You are not the only one who has done this… I reacted a bit differently than your patient when my doctor started with (over the phone after a biopsy) what the treatment was going to be. I said, "we are going to start this conversation all over again. First you are going to tell me what you found then you are going to tell me what that means. Then you will tell me what the treatment choices are". We had a much better conversation after that. Finding out you have cancer is a horrid, terrible shock no matter HOW you find out. No matter how compassionate the person telling you is. Begin compassionate, kind, etc. DOES NOT soften the blow or change that one iota. No one can change that and nothing you do can change that. Being compassionate in how someone is told does make you feel like someone cares that this horrid, terrible thing has happened to YOU. Tell your students this too - it is telling people this awful news in a way that makes them feel like you aren't just another cancer they have to deal with, rather that you are a person WITH cancer; that they care about the person side of you; that you are worth their time and energy to tell you gently, even if they can't change the cancer news.
  • I'm not sure about conveying the information over the phone- especially such dreaded news. Like Lisa said, you can't change the cancer news but delivery of such in the most delicate way possible could be key. You are such a good person, Doctor, and it's always wonderful to hear your thoughts. Keep on keepin' on.
    • Jetgirl
      Phone works for me - as soon as you know I'd like to know and if it can't be done in person that is ok.
  • Kathryn Zusmanis
    I was told I had cancer over the phone by the radiologist. She called me at 5 PM while I was at work. I wasn't able to speak, ask questions or much else. I closed up my office and cried the entire hour long commute home. I'm not sure this news can be given without tears and fears surfacing immediately, but every doctor I saw during the next steps, also called me at 5 PM while I was trying to catch a bus home from work. I was seen by "top notch", busy doctors. Calling patients at the end of the day, regardless of patient's schedules, seemed to be their preferred method. This way they don't interrupt their work schedule and avoid patient questions, and melt downs. Thank you for understanding this isn't the best practice. If you have influence over the medical community, please teach and preach your mistake was a human oversight, and should not be the standard of care for serious illness.
  • Dg
    Forgive yourself for the error but honor yourself for the time and understanding you gave back to them by meeting with them and creating a bond of trust by your honesty and humility. From personal experience it is better to deal with the truth as hard as it can be then to wander thru a maze of "what if's" with no known goals in mind . Thank you Dr. Salwitz for your compassion and honesty. You're truly blessed as a physician.
  • D Someya Reed
    Equally, or even more so, to blame are those who told the couple nothing at all. Granted, over the phone is not the best way to break such news but had you asked your "What have they told you" question, the couple would have known it was bad. If you'd said, why don't you come in and we'll discuss it in my office they would've equally known it was bad. There really is no good way to have this conversation. If you think that yours was a mistake, what would you call ours (and in person, no less)? The doctor walked into the room...no Hello...no How are you? He merely said without even a moment's hesitation (or a moment's examination), "You have ovarian cancer. You're going to die. I'm going to step out in the hall for 5 minutes to let you discuss whether or not you want to pursue treatment." Then he walked out. He said this with all the "warmth" of the Marquis de Sade or Vlad the Impaler. It is forever burned in my brain. Word for word. After surgery, it also turned out that he was totally wrong. She didn't have ovarian cancer but endometriosis with an unusually high over-expression of ascites fluid. Never saw or heard from that doctor again. You can certainly take comfort in knowing that you are not "that kind" of doctor. And if any of your students show the same "level of compassion" that we were subjected to (even in jest) then, in my opinion, they should NEVER be allowed to graduate. Period.
  • I want to comment. I want to compare this to when I received my own cancer diagnosis from a brusque, busy doctor who also had the secretary standing in the room with me waiting to be yelled for an error. But I don't know how to make the comparison. I do want to
  • Kathryn Zusmanis
    Physician "heal" thyself! A robotic, computerized, print out would have equally sufficed.
  • Remember the Phrase " never assume anything" . It will make an ass out of you and Me. I was taught that on my first day of Nursing Scool and I can't tell you how many times that saying changed the outcome or treatment for a patient. Now being a Stage 4 Melanoma patient I cringe at some of the things I did or said. I considered myself a very caring empathetic nurse and loved nothing better than taking care of patients but could I have done better? Absolutely! Also never assume a health care professional knows everything about their health situations. I woke up after a VATS lung surgery with a chest tube. Everybody assumes I would have known. I had no clue and thought something had gone wrong during the surgery. Dr S love your posts. It gives us an insight into what Oncologists go through. You are doing a great job!
  • Rich Green e
    I was told I had cancer over the phone while I was in the hospital after a TURP. The doctor had arranged for a nurse to be in the room while I was told. He chose to tell me over the phone because I was complaining because I couldn't go home; he wanted me to stay in the hospital for additional tests so he had to tell me something. I was actually relieved by hearing it because I had suspected something was wrong because I hadn't been released. The full impact hit me later but after I spoke with the doctor in person the next day. I was referred to a cancer hospital here in town for further care because the urologist felt I'd get more advanced treatment than he could offer. A month after diagnosis, I had a major heart attack. I think the heart attack is what led to further communication problems. The doctors were recommending prostatectomy/cystectomy. My heart was not strong enough for the surgery so cardiac rehab took precedence over the surgery. Meanwhile I was on hormone therapy to try and shrink the mass. Fast forward six months--the cardiologist had approved me for surgery and I met with several doctors to discuss treatment. The surgeon I had met with before had moved to another hospital and I had a new one. He started out with "usually with Stage IV prostate cancer like yours"... I never heard the rest. None of the five doctors I had seen told me I had Stage IV cancer and the diagnosis had been made six months earlier! The meeting with the surgeon went downhill as he discussed the diagnosis and the proposed treatment that would also include some work on a kidney because of the problems it would likely cause down the road. (No one had told me about that too.) I was devastated, especially after I had recovered so well from the heart attack. I cried every day for three months and my family often cried with me. On the other hand, what he told me explained why I had large blood clots in my urine and occasional blockages that required trips to the ER, six trips in 4 months. The pain and consternation could have been avoided had the surgeon asked me what I had already been told. Of course, he had every valid reason to assume I'd been told the extent of what was going on. He was probably as shocked as I was by how our meeting was going. He had the look of a deer in headlights. Fortunately, I forced myself to see him again because I had learned he was the best around for what I needed. We have a much better relationship now and I actually enjoy our appointments.
  • […] just a minute to read this offering. In it, Dr. Salwitz describes a clinical encounter in which he breaks every one of his three rules […]

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