They don’t tell you how to give bad news in medical school

By Arne Vainio, M.D.
News From Indian Country
 
Wanda was my last patient on a Thursday afternoon toward the end of my residency in Seattle and I hadn’t seen her in a really long time. I first started seeing her when her husband was dying from liver failure due to alcoholism. She came in to see me often at first and she waited a long time to start the antidepressant medicine I eventually put her on. When she finally did start taking it she did very well and didn’t need to see me as often.
 
She fell and broke her hip the year after that and I saw her a few times while she was recuperating from her surgery. She never asked for much and was able to go back to her own home and again I didn’t see her for a while.  Now she was back in because she was short of breath and tired all the time. She was gaunt and thin and pale and I could tell this had been going on for a long time.
 
Her blood pressure was low and she had lost over 25 pounds since her last visit. On her exam I wasn’t hearing breath sounds on the right side of her chest. A lab test showed her white blood cell count was up only a little bit. White blood cells fight infection and the count goes high when they are needed. I already suspected this was cancer. I sent her for a chest x-ray and the film came back showing a mass that filled most of her right chest and the area around her heart. I knew this was a death sentence for her.
 
She was going to need some additional workup and we were going into the long Easter weekend. I knew nothing would be done over the holiday and I was able to get her set up for a CT scan early the next week so we could decide what to do next.
 
“What is it, Dr. Vainio?” She had seen other doctors in the time I knew her and even though I was relatively new, I knew she trusted me and would never do anything without talking to me first. Her question had a pleading quality to it and I could tell she was extremely anxious. I showed her the x-ray and it was clear there was something there, even for someone who’s never seen an x-ray.
 
“There’s something right here, Wanda and it looks like it’s been there for awhile.”
 
“It could be pneumonia, right, Dr. Vainio?”
 
“It’s possible, Wanda, but it looks more like a mass.”
 
“But it could be a pneumonia, right?” She seemed like she was desperately asking for this to be something else and I didn’t want her worrying over the long weekend if there was nothing else to do. I didn’t want her calling the doctor on call as he wouldn’t know anything different and would have nothing new to offer her and would likely make her even more anxious.
 
I started her on an antibiotic and her sense of relief was obvious and she was openly grateful. I never used the word cancer because I didn’t want her dwelling on it over the weekend and I did not have cancer as a certain diagnosis yet. The word mass was somewhat vague and that was intentional on my part.
 
She got worse over the weekend and her nephew brought her in to the Emergency Room. She had labs drawn and a chest x-ray was done and she was admitted for shortness of breath and a new diagnosis of lung cancer. On Monday I got the report from the admitting doctor in the hospital, a hospital where I did not practice. The history and physical document stated that Dr. Vainio at the Indian Clinic diagnosed her with “pneumonia” and treated her with an antibiotic.
 
The word pneumonia was in quotes and the doctor who dictated the note would have had to tell the transcriptionist to put that word in quotes specifically. Inside those quotation marks was buried much more than just the word pneumonia. Inside those quotes it was saying family practice doctors are incapable of reading a chest x-ray. Inside those quotes it was saying all those things I fought against as an Ojibwe medical student and even as a college student before that. It implied I was allowed to become a doctor to fill some sort of quota and that my training was inadequate. It was saying the “Indian Clinic” was providing substandard care for its patients. Inside those quotes it was saying I missed an obvious lung cancer and treated her inappropriately.
 
She was seen by a Pulmonologist (lung specialist) and an Oncologist (cancer specialist) while she was in the hospital and her follow up visits were with them. I wanted a chance to explain myself, but I never saw her again. I wanted to let her know I didn’t miss that lung cancer on her chest x-ray. I wanted her to know I was trying to spare her a weekend of torment waiting for the next week to finally come by.
 
I wanted to tell her I was sorry.
 
Subsequent notes from the specialists revealed her cancer was in both lungs and was inoperable. She was only able to tolerate a short course of chemotherapy and it made her so sick she begged them to let her stop taking it. She was given radiation treatments, but her cancer was so aggressive it spread to her brain in just a few short months. She was admitted to hospice and she died at home with her family around her.
 
I never met any of them, and no one ever came to talk to me. I didn’t feel right going to her funeral and didn’t think that was the place to try to explain myself. I don’t know that it would have mattered to them or if they would have even believed me. I didn’t want to reopen any of their wounds.
 
All of this came from me not being brutally open with her right from the start. If I had told her she had lung cancer on that Thursday, the diagnosis of “pneumonia” never would have been in quotes. She would have continued to see me as part of her medical team. My education and my abilities never would have come into question. But she would have gone into her Easter weekend with a death sentence hanging over her head and nowhere to turn for answers. She didn’t have many days left, and those few days with her family were important. Knowing her diagnosis two days earlier did not change her outcome.
 
I can’t blame my education or my medical school for this. I don’t know that any of us are ever truly ready to give someone really bad news, and it never gets any easier. I still struggle with this, and I don’t know that I would do this any differently right now under those same circumstances.
 
In many ways I’m still a medical student. I learn from my patients every single day. I want this to be a conversation, and I’m listening. My email is listed below and there is a comment section at the end of the online version of this article.
 
What should I have done differently?
 
Arne Vainio, M.D. is an enrolled member of the Mille Lacs Band of Ojibwe and is a family practice physician on the Fond du Lac reservation in Cloquet, Minnesota. He can be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it..  
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