As medicine deals with illness, and illness is unwelcome and unpleasant, all doctors have had the experience of telling someone something that they don’t want to hear. This encounter has been extensively analysed and a suggested format for how to do it (and how not to do it) is now taught in most British medical schools, usually under the heading of Breaking Bad News.
Breaking bad news comes with a set of rules which seem, at first glance, like the codification of common sense. You should find somewhere quiet and, ideally, private; give a colleague your bleep; turn off your phone. You should try to discover how much the person you’re talking to knows already, to avoid giving a biopsy result to someone who doesn’t actually realise they’ve had a biopsy. After this, you’re meant to fire a warning shot – “I’m afraid I have bad news” – allow a pause for the implication to sink in, then give the facts (having first established if your patient wants to be told everything or, if not, how much of everything they wish to hear).
You should avoid: delivering a mass of information to a listener who is too upset to take anything in; using vague, misleading or medical language; offering misplaced reassurance. In role-plays at medical school this was easy, bordering on trite, as your interviewee was another medical student mute with embarrassment and boredom. In reality, it is fraught.
For one thing, this sort of common sense is often ignored in practice. Bad news is still delivered on hospital wards – often in the corridor, because it’s the quietest place. The temptation to avoid bad words can be overwhelming: there is a “shadow”, a “patch”, a “funny spot” on a scan. The relatives keep referring to the “growth”, so you say “growth”; a warm feeling develops between you, no one says cancer. At the other extreme, the too-thorough application of checklists can lend a horrible glibness to the situation: bad newsiness. The undertow of insincerity is not cancelled by overuse of the so-called “oncologist’s head-tilt” (the posture thought to signal maximum empathy), or by excessive patting or petting.
The playwright Simon Gray came to recognise such touches when he met different doctors on his way to a diagnosis of lung cancer, as described in his last book, Coda. “They’ve concentrated themselves into a single figure, young-to-middle-aged male, spruce, in a neat suit, greeting me with gloomy courtesy, and at some point in the conversation making brief but significant physical contact – a squeeze on the shoulder, a touch on my wrist … a kind of mimed proclamation of my death sentence.”
The British ideal does also depend on the idea that there is some universally shared notion of badness. Not every culture views every death as a disaster. This can come over hurtfully when that is the last thing intended. When an elderly man on our ward died of pneumonia, the family gathered sadly at the bedside. My colleague, a Nigerian doctor of 20 years’ experience, was bemused. The family, he explained, ought to be celebrating: the patient had lived to the incredible age of 94. This was not bad news. Dr O had a carefree frankness in imparting information to patients that had so far stymied two attempts to enter GP training. Despite his ability to diagnose most illnesses from the sounds he could hear through the cubicle curtain, he was just too cheerful about death for GP recruitment.
Sophie Harrison is a hospital doctor in South Yorkshire