It’s the right call for some
I had the sense to pull my car over to the side of the road when I heard the surgeon’s voice on my cellphone. It was a stunningly beautiful September morning, and I tried to keep anxiety over the biopsy at bay. His initial words, “We have an unpleasant surprise,” brought an abrupt end to such efforts. It was there, in my car, on the side of the road, that I became a cancer patient.
“You learned you had breast cancer in a phone call?” This is the reaction I get from well-meaning friends, ready to pounce on an example of uncaring doctors and the sorry state of 21st century medicine. I believe these friends are wrong. It has been more than four years since I received that phone call from a very caring physician, and I can recall every word and each gasp, every stretch of struggling silence. That was the moment I crossed the sharp divide from “before” to “after.” And the phone call -- followed that afternoon by an office visit -- was the correct and compassionate way in which to launch me on that strange crossing.
I have learned since then that the best way to inform a patient of test results, especially results that indicate bad news, is a subject of debate among doctors. This is especially true outside the hospital setting. Many doctors have specific policies about never giving results over the phone; others are more flexible and approach each case individually.
Most patients don’t give thought ahead of time to how they would like to receive the news. Generally, they aren’t asked. And once they receive the results -- good or bad -- they focus on the message itself. But the manner in which patients learn they have a progressive or potentially fatal disease will influence how they approach their illness and how they think about their health. This is the launch and, if it goes badly, the patient’s journey may be askew as well. That is why most doctors care about getting the conversation right, even as they disagree over the best way to do so.
I ended the phone call by asking the surgeon, “What happens next?” He asked me to come into the office that afternoon. During those few hours, I was able -- with my husband -- to work through the initial wave of shock and fear. We went out for lunch, and I slowly twirled my soup in my spoon, unable to eat. He assured me that we would get through this together. By the time we arrived in the doctor’s office that afternoon, I could listen, take notes and ask questions, even chuckle gratefully over a small joke.
Had I received the news that I had cancer in a prearranged appointment, sitting in the doctor’s office, the words “you have cancer” would have been the last thing I heard. The doctor would have talked, but the audio would have been missing. Whatever information was conveyed, whatever recommendations were made, would have been wasted. The only thing on the agenda would have been me, reacting.
Reacting to a cancer diagnosis isn’t pretty. There is a certain amount of dignity that comes with receiving the blunt edge of a cancer diagnosis in private. The patient can curse, wail, curl up in the fetal position and then pull herself together -- and call in supports such as husband or friends -- to go and learn more. I have heard of doctors who call -- or, more often, have a nurse call -- and say only, “We need you to come in and discuss your test results.”
This is the worst of both worlds: At that point the patient knows the jig is up. It’s all over but the actual wailing. Imagine the sense of dread as you sit in the waiting room, knowing that you are about to receive bad news. Compare that with the image of sitting in the waiting room after you have already received the bad news and you know you are about to get information that might help you get your mind around it all. There is something more dignified about the latter scenario, about not being put through the motions of a predetermined dance.
Beyond privacy, the phone call brings speed. There is no way of understanding the receipt of such tough news without understanding the particular torture involved in waiting for medical test results. Time slows down and becomes caustic. The mind fixates on floating scenarios unmoored to actual facts, intruding constantly into weak attempts at daily living.
If I am going through that slow drip of waiting, I want to end my torment as soon as possible. I want to know my test results when my doctor knows. If I have to wait a day, two days, five hours more, for that scheduled appointment -- and I know that my doctor knows the test results for that day, two days or five hours -- I will feel that something has been taken from me. It’s my body, my health and my future and I’ve been deprived of the relief of concrete information. There have been a few small studies examining how patients feel about the way they were told of their cancer diagnosis. Not surprisingly, these studies have found most patients prefer the face-to-face doctor’s appointment to the telephone. But none of these studies have examined patients who were told in a telephone call followed soon after by an office visit. A telephone call -- by itself -- leaves the patient hanging, with neither enough information nor enough support to fully understand and accept the news. The phone call is the quick and respectful detour sign, then the office visit lays down the asphalt for the new road ahead.
Not everyone will feel the way I do about receiving a difficult diagnosis over the phone. Some will want to be in the doctor’s office. The compassionate thing for a doctor to do, if it is possible, is to ask in the semi-objective light of the moment when the test is ordered: How would you like to receive the results?
A conversation about a conversation, isn’t that a bit much? Not if medical care is more than performing procedures and ordering tests. As long as there are doctors and patients, the space between them -- and the conversations that fill that space -- are elements of good medical care.