TW:  anything related to bad news, trauma, grief

My beloved car failed the NCT this week.  Not just failed, but spectacularly slapped with a Major – Dangerous sticker on the windscreen.  The kind where they threaten you with 5 penalty points and to call the Gardaí if you even try to drive it home.

What happened? the car was in perfect order and only recently serviced – with the idea that there would be no small thing caught in the NCT that would mean re-testing.  While the old girl is getting on in years, she’s seen me through years of nights on-call, adopting a dog, adding 2 kids, and a pandemic with never even a hiccup.

It was bad news :   sudden, unexpected and out of the blue bad news.  My husband and I started to grieve for my little car. The report made no sense to us, but seemed serious.  “Ah, it was 10 years.”    With little hope, my husband took the car to the local mechanics.  Who had a better look and said that 1) it was more minor than the report found 2) 100% fixable 3) much, much cheaper than our fears.  

How to make sense of this?  Maybe NCT mechanic just was having a bad day.  I’ll be getting my car back next week, but as I look forward to a week of public transport I am thinking about Bad News.

The worst part of being a doctor is not getting bad news – it is giving bad news. Sometimes, the most difficult bad news to give is not expected test results, but that out-of-the-blue abnormal result from something routine.  The result that means there is something that is definitely, seriously wrong and more tests are needed to get more information and make a treatment plan.  And twice recently,  I had these discussions.

It is far worse to falsely reassure.  The horror moment was in my first year of training: The consultant was aware of what the patient’s biopsy results.  But on rounds that morning, when the patient directly asked for results, the consultant didn’t answer any of her direct questions because he didn’t want to give the bad news himself – and started to walk away.  She became distressed:  “But am I okay?!”  The consultant choked a bit and said awkwardly:  “For now.” (this was 17 years ago and I have never forgotten witnessing that moment).

So, I had to give bad and unexpected news twice within 24 hours last month.  Both patients were in with what should have been something routine but quickly ended up as something much more serious.  I didn’t have a final diagnosis and treatment plan for these patients.  Which happens.  There is always a first step on these journeys.  To the best of my ability, I’m always open and honest with patients about:

• what we know and what we don’t know

• what the next steps will be

• what options, in any, there are at this point.

• What decision there are to be made, if any, at this point

Most patients, understandably, still find it over-whelming.

Fear of the unknown is the worst fear.

Here is the advice I give my own patients if I am there at the start of their journeys.  Other doctors may do it differently — or even far better –but here is the advice I hope my patients find helpful:

1. When you leave this room, you are going to realise you have so many more questions. Many of these questions don’t have answers right now, but they are all really important questions.  Start a list, write them down when you think of them, and bring it along with you to your next appointments.  As we have answers, we will do our best to start answering them.

2. When you get home, do you have a strong preference about a choice going forward? Write down preferences and concerns, and bring it in.  It’s perfectly valid to ask about options for where you attend treatment.  Sometimes, certain options aren’t possible but no harm having the discussion early if you have strong preferences or concerns.

3. I strongly advise against a Dr. Google consult or crowd-source: “what do you think it could be?” from social media.  If your doctor can’t give you a firm diagnosis or treatment plan on the day due to outstanding investigations or expert specialty opinion, Dr. Google definitely can’t either.  One patient’s journey is not another patient’s journey, so avoid a situation where you end up getting bombarded with helpful stories that start with “[I/mother/cousin’s friend] had symptoms just like that and test results at first showed [x], and it ended up being [insert horrifying diagnosis here] and then [insert awful experience here.]   While support from patient groups can be fantastic, these stories may not be helpful to your mental health at a time of uncertainty.

4. Pick one family member (or close friend) to be your support. Bring them with you to appointments as a second set of ears or even to help take notes and ask questions. Ideally, designate them to be your next-of-kin going forward on your journey.  We will get to know them and you along the journey.

5. You can ask your doctor to write down information for you: What do we know now?  What step is next?  Anything that I should or shouldn’t do now?

6. Remind me/your other doctors before you leave an appointment if you need something short-term. For example, if the reason you are there is something like pain, it’s easy to forget that in the moment of getting test results.  And your doctor is equally emotionally distracted sometimes (we shouldn’t be, but trust me, it does happen).  It’s okay to ask us to re-focus on the immediate problem if we forget: “Okay, we know it is likely something serious causing my pain and you are concerned. I need more tests, but what can we do now about this severe pain while I’m waiting for my urgent scan next week?”

7. Remember your medical information is private. If you need time off work or school for extra medical appointments, you have no obligation to tell anyone the specifics if you don’t want to talk about it.  If you are pressured, you have the option of politely thanking the person for their well-intentioned concern but saying that it is a private matter – or more firmly reminding them that you have a right to privacy.  I have a practice of always only writing a vague “illness” or “injury” as reason for attendance on the medical appointment certs that school or work sees.