Groundhog Day and Allergies – misadventures in bad news delivery.

Treating patients with cancer is not a funny business, but sometimes funny (odd) things happen.  Early on in my career I had a patient I was about to see with a very curable cancer.  I was suffering from seasonal allergies at the time, and entered the room with my eyes watering, blowing my nose, and looking like sh@t.  The patient also had her eyes watering, was blowing her nose, and looked like she was having a hard time.  In my self-absorbedness I asked her “Oh, do you have allergies too?”.  She looked at me like I was from Mars and said “No, Cancer”.  There was an awkward pause as I apologized, and then we both had a good laugh at my faux pas.  Not the icebreaker I generally use, but it did ease the tension and relaxed everybody…

One of my other memorable patients had a very bad cancer – pancreatic cancer, which he was going to die from at some point.  He was simple – picture Forrest Gump simple – and tolerated chemotherapy really well which held his disease at bay for several months with good quality of life.  However, everytime I saw him, we’d have the same conversation.  “Doc, I’m doing well, but be honest, pancreatic cancer isn’t good is it?  I’m probably going to die from this?”.  For the first few times, I answered him honestly – “I’m sorry, but yes this cancer will get worse at some point and you are very likely to die from this”.  He would then break down and cry unconsolably for the next five to ten minutes, and then suddenly stop, feel better, and be chipper and positive once again.  The amazing thing was that every four weeks when I saw him it was the same – it felt like Groundhog Day.

After the first several times, when I realized that this wasn’t a matter of repeating things so that he would eventually come to terms with it, I stopped answering him directly – in general I’m a doctor who when asked a direct question will give a direct answer.  However, with him, I didn’t think I was offering any therapeutic benefit by answering his question, and instead would redirect and give a political answer..  It probably didn’t affect him one way or another, but it saved me from the devastating feeling you get as a physician when your patient is devastated with bad news.

The point of this – rather extreme example – is that there is a widespread belief that oncologists don’t discuss prognosis with their patients, or that patients are somehow misinformed.  If this patient would have went to see another doctor – like an emergency room physician, there is no question that they would have said “No, I have no idea what’s going to happen”, and the ER doc would say “Damn oncologists, they never talk to their patients about prognosis”.

Breaking Bad. News.

I recently listened to a podcast on ‘Breaking Bad’, where it was considered one of the best shows of the 21st century.  I have never watched an episode – mainly because I don’t like a show that reminds me of work.

No, I don’t deal/make crystal meth (the drugs I deal with are much more dangerous if you don’t use them right).  I do however deal with patients with lung cancer.  The main character in ‘Breaking Bad’ had incurable lung cancer, diagnosed in season 1, episode 1.  This was enough for me not to watch.  Breaking Bad lasted for 5 seasons.  The odds of a TV show making it 5 seasons is about 10%.

When I’m dealing with lung cancer patients, the vast majority are in Walter White’s situation – advanced and incurable.  With lung cancer, approximately 10% of patients are alive at 5 years.   With advanced and incurable, that number drops to about 5%.

At least several times per week, I meet with new patients who have lung cancer that has spread.

I approach each patient I see with similar questions – “What have you been told, and what information do you want to know?”.  The majority of patients say they want to know ‘it all’, others say “I don’t want to know any bad news, I just want to fight”.  When patients say “I want to know everything”, they are usually asking what the timelines are, and what’s going to happen (am I going to suffer?).

People ask me “Don’t you find oncology depressing, how do you handle it?” – to which I reply – gee, when I chose a career in oncology, I thought we cured everybody with lung cancer, way to ‘bait and switch’ me Mr. Career Path”…

Of course the news I give is depressing, and of course it’s emotional giving that type of news, but that’s the topic for another post.

If you want to know though, here is how that conversation often goes:

Patient:  “Yes doctor, I want to know timelines”.

Me:  “Ok, why do you want to know?  What will you do differently?”

Patient:”Well, I guess I want to know for my family, so I can make arrangements.  What’s going to happen to me?”

Me: “Ok.  Well, as Dan Quayle/Yogi Berra said “it’s difficult to make predictions – especially about the future”, so I don’t know exactly what is going to happen to you.  I can tell you a worst case scenario, a best case scenario, and a ‘most likely scenario’.  I can tell you if I had 100 identical people to you in a room, how long it would be before half of those people died, how long it would be expected before 10 of those people died, and how long it would be before 90 people had died.  What I can’t tell you is whether you are in the 10 who die early, the 50 who die by 8 months, or if you are around in the room after all others have left.  Plan your stuff, get your affairs in order (paperwork, relationships, letters etc.) in case things happen quickly, but hope for the best.”


Of course (and as expected), the conversation often goes this way, but I think sometimes patients just hear blah, blah, blah 8 months, blah blah blah and tune out.  I don’t take this as an offense – I think it’s common for people in doctors offices to only remember one or two things when they are given bad news.

Breaking bad.  I would have expected it to have lasted less than a year, but there it was, still pumping out quality in year 5.  (so I’m told, as I mentioned I never saw it…)