Wednesday, July 15, 2009

Somewhere in England on St Swithin's Day

'Tis my birthday today and what better way to celebrate than to get up extraordinarily early and go and take part in an exam for medical students?

Yes, I know, a few people said that. "You're doing WHAT on your birthday?"

My part of the exam was testing the students on their ability to break bad news. So I was playing a patient who had to be told that I had a very serious illness.

It's a strange thing, breaking bad news. Students who aren't naturally good at doing it with sensitivity can be taught techniques of how to do it, some of which are:

find out what the patient knows already

fire a "warning shot" such as "I'm afraid that I have some bad news to tell you" so the patient can prepare

tell the news clearly - - none of that beating about the bush with "it might be something nasty" that doctors tend to do because they don't want to actually say the name of the illness

don't give false hope - none of that "I'm sure you'll be fine" when actually, you're sure they won't

check the patient's understanding

offer a further opportunity to ask questions when the news has sunk in

That kind of thing. Of course, there are some students, and indeed some doctors, who do it instinctively and what's more have such a great "bedside manner" that they can make the patient feel cared for even whilst they are telling the most frightening of diagnoses.

The trouble is, the weaker ones often know the "rules" - - but because they lack sensitivity, or maturity, or experience, or all three, they just don't know how to apply them.

Suppose the exam "station" was about a patient with a possible brain tumour (it wasn't - I am protecting the guilty).

Out of the many students I saw today, a few were brilliant, so much so that I wanted to fling my arms around their necks and cry "Will you be my doctor when you qualify?" (No, I didn't).

Many were - - well, okay - - - - if I'd been that patient I would have known what the diagnosis was, but they missed out crucial bits - - so they never found out, for example, about my tricky family circumstances, because they never asked.

And just a few - - well - - they did things that made me want to hide under the table.

They had to read the results of the patient's tests, put them into accessible English, and tell the patient that I had a brain tumour.

There was one who just read the results out to me.

"Tell me if there's anything you don't understand - - it says here that you have a Z10 squibulous gonzanoma - - I'm not sure what that means actually - - mind you, I know it's very bad indeed"

There was one who bounced into the room and said,

"Hello, Mrs Boggins, welcome to the fast-track brain tumour clinic!"

It took quite a lot of me going "What - - you mean I've got - - a brain tumour?" for her to realise the gaffe she'd made.

And then there was American Cowgirl.

"Well, howdy ma'am, how ya doin'?" - - - To be fair, she did improve greatly after this somewhat shaky start - - and she was actually American - - and I did find myself looking for the Stetson and the boots.

Many of them have taken the "don't give false hope" so much to heart that they did exactly the opposite.

"So, Mrs Boggins, do you understand what I've said? That it's a BRAIN TUMOUR? Do you know how very serious this is? And that we can't cure it? Do you want to know how long you've got to live?"

The best ones do this very tricky and complicated task so naturally that they appear to just be having a chat.

The worst ones show that, even if you give someone a set of careful instructions to follow, it can still go horribly wrong.

Some are apparently effortlessly good at it. Some can, with a bit of help, move from adequate to good, or from good to brilliant.

And one or two in every year group - - well, you think - - why on earth did you want to go into medicine when you appear to have all the sensitivity of a slab of concrete?

Anyway, after a very long morning being given this grim diagnosis, I came home and worked in the office for a while.

And then, in the evening, we went out for a lovely meal, with great food and great company. It's been a strange birthday, perhaps, and, d'you know what, all interesting, all rewarding, all enjoyable.


Blogger Silverback said...

Glad I was part of it......cracking meal and company.

As for these trainee doctors, it's all a bit depressing in many ways and reminds me of how I was 'told' I'd had a heart attack. Sad to hear things haven't changed much.

11:51 pm  
Blogger Daphne said...

I'm glad you were part of it too, of course, Silverback!
I think the average standard of doctors' communication skills has improved a lot in recent years - - it's just that there are still a few REALLY duff ones, such as the ones, sadly, that you encountered.

12:09 am  
Blogger Malc said...

I was lying on a trolley in Wolverhampton's New Cross Hospital when the doctor marched up to me with the test results and announced: "You have heart attack," and stomped off down the corridor.

I hadn't "have heart attack" as it happened, so he was crap in two ways.

12:26 am  
Blogger Daphne said...

Malc - - as with Silverback, why can't some doctors realise that the news that you've had a heart attack is really quite important, and hence care should be taken over its delivery?
I love your phrase "crap in two ways" and will be relating it, and your story (anonymously of course) to help to train future generations of student doctors!

12:30 am  
Blogger Debby said...

Happy St. Swithin's day!

Not exactly how I'd like to spend my birthday....but glad it's not terminal!

2:39 am  
Anonymous Anonymous said...

Hopefully the students with the "sensitivity of a slab of concrete" (lovely phrase, and a perfect descritpion of some doctors I've worked with!)will go into research. Sadly I fear this will probably not happen because they usually think that they are truly wonderful at patient communication. The people left picking up the pieces are mostly nurses. Can you tell I'm a nurse?
Great post & many happy returns of the day

8:13 am  
Blogger Jennyta said...

Many happy (belated) returns, Daphne. I wonder if age has a part to play sometimes. Medical students are young, often patients suffering terminal conditions are a lot older and often young, healthy people regard much older people as 'having had their innings' - old age for them is far away in the distance so it can be difficult to empathise. (They don't realise that inside we are still 20!)

9:36 am  
Blogger Daphne said...

Debby - - thank you. In America do you have "St Swithin's Day, if thou shalt rain, for forty days it shall remain?" - - Yes, it rained.
Christine thank you. - I work with nurses too and, although there ARE nurses with poor communication skills, they are far fewer in my experience. A doctor once told me he'd been told by a senior doctor "And if the patient cries, you go and fetch a nurse". Perhaps nurses are, on average, - and I stress it's on average because I've met some brilliant student doctors - better communicators because no nurse ever went into it for the money and the status.

9:44 am  
Blogger Daphne said...

Jenny - yes, there's some truth in that, I'm sure. And, of course, we make allowances for nerves too - - but then a brilliantly caring one comes along and I think - - sod it! They should ALL be like that!

9:46 am  
Blogger rhymeswithplague said...

I do solemnly swear or affirm that I had not read this post when I created my post yesterday afternoon for publication today (July 16th). You have only my word for it, but my word is good.

As for your learning that you had a [faux] brain tumor on St. Swithin's Day, I can only say, "Into each life some rain must fall."


2:03 pm  
Blogger rhymeswithplague said...

And by the by, I'm married to a nurse.

2:04 pm  
Anonymous ruth said...

Having recently had a lot of real life experience of doctors breaking bad news (most of them good, some of them dubious), I am so glad you are involved in testing (and training) student doctors.

Just as some student doctors may not be naturally good at doing something but can be taught the techniques, many roleplayers are not naturally good at what they do but I suspect they never achieve the level of professionalism and intuition you have.

PS many happy returns for yesterday

5:58 pm  
Anonymous gingerfield said...

whatever happened to 'how long have I got doc?' 'well Mr Smith, put it this way: don't buy any long playing records'

8:26 pm  
Blogger Yorkshire Pudding said...

Belated Happy Birthday Greetings Daphne! What could be better on your birthday than being told in different ways that you have a brain tumour! The best way to cope with such news is obviously to have a "cracking meal" with other Leodians (Is that how you spell it?). Do you use knives and forks up there yet?

9:45 pm  
Blogger Daphne said...

RWP - nobody ever notices St Swithin's day so I'm glad you did.
Ruth - thank you.
Gingerfield - - ahhh the old ones are the best!
YP - thank you for the birthday greetings! Knives and forks are for soft Southerners who've never tasted proper fish and chips. I think the word you were seeking is Leodensian but nobody uses it - what are you lot in the Deep South of Sheffield called, besides "envious?"

11:01 pm  
Anonymous Milo said...

Happy (belated) birthday!

Those doctors sound very hit and miss. Like you say, some are great and you'd love to have them as your GP - others sound awful!

11:35 am  

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