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Thoughts on Journeys Through

Difficult Diagnoses:

I particularly enjoyed this session of the student conference, not just because of its relevance for

our medical careers, but because it discussed a particularly critical time in patient care; a time

where our action have such an enormous and lasting effect on the patient.

The term used in the plenary was a difficult diagnosis. However, it is clear to me that my

colleagues in the medical profession dont always understand who exactly the diagnosis is difficult

for. The diagnosis is not simply difficult because it is difficult for the medical practitioner to deliver

the news effectively and sensitively. It is not even difficult because of the emotional impact on the

medical professional. It might seem incredibly obvious, but I really believe it is important to

remember that a difficult diagnosis is named as such because it represents enormous difficulty

for the patient. Note: not for the doctor, difficult for the patient. For the patient, a difficult diagnosisis the moment their life changes completely. Some may argue that a difficult diagnosis is difficult

because of the stresses placed on both the patient and the doctor, but in my opinion, this trivialises

the impact of the diagnosis upon the patient by equating it to the short-term discomfort of the

doctor imparting unwelcome newsas if they were in any way comparable in magnitude.

Bearing all that in mind, I suppose it is no great surprise that I particularly welcomed Professor

Trumbles 3rdtool from his communication toolbox: its not about you.But so many unhelpful

practices of doctors conveying bad news come back to this exact point.

Some doctors may avoid seeing a patient, prolonging the time until they must be faced and thediagnosis must be given. But its not about you; its not about how difficult it might be to tell

someone something they dread to hear, its still your duty to do it. The anxious anticipation of a

diagnosis can be a worse feeling for the patient than coming to terms with the diagnosis itself. Very

rarely would a patient be completely oblivious to their condition, and the diagnosis comes

completely out of the blue. Even without knowing exactly what is wrong, most patients will

understand that something is wrong, and many will probably begin to fear that the most morbid

possibility is the most likely explanation. By waiting to address a patients concerns,you

unnecessarily prolong the patients fear of what they do not yet know, and could even be

unintentionally prolonging the patients belief that they are about to receive an even worse

diagnosis than the one you are avoiding giving to them.

Some people say delivering bad news or a difficult diagnosis, in principle, is simple; a common-

sense subject. Treat others as you would want to be treated yourself. But to abide by this ethos is

to ignore the inherent diversity of humanity. Would you treat every single patient as if it were you

standing in their shoes? In other words, would you treat every individual patient in exactly the same

way? Or, pushing the concept further, would you treat every patient as if they were a doctor, just

like you?

One of the most common complaints about doctors, in my experience, is their perceived lack of

effective communication. Two of the most common reasons for this are: 1) A complicated topic or

diagnosis was not thoroughly explained, and 2) the complicated topic or diagnosis was explained

in language that the patient did not understand.

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Mr. Boris Struk, who also presented at this plenary, was told that his son had Duchenne Muscular

Dystrophya term he had never heard of, and certainly did not understand. If Boris was a doctor,

he would have immediately understood what Duchenne Muscular Dystrophy (DMD) meant, and

the catastrophic repercussions it would have for his son and his family. But instead, Boris was

confused and misinformed. Perhaps he had been treated in the manner which the specialising

doctor would have treated himself just the bare factsbut that was nowhere near an acceptable

level of communication to Boris, a concerned father completely lacking medical experience.

Treating others the way you would treat yourself flies completely in the face of patient-centred

care, a concept which were all encouraged to strive for and achieve. Boris did not benefit from the

sparse explanation his doctor gave him for his sons condition, but neither would he have

benefitted from an in-depth analysis of the pathophysiology of DMD and the latest researched

treatments for it.

Your patient is not the same person as you; they are going to expect and ask for more information

about certain aspects, and shy away from others. And there is only one way to really know what

the patient needs from you; you need to be listening with both ears and eyes wide open. Thisplenary helped me to revisit the importance of being receptive in the doctor-patient communication

exchange.

Truly listening to a patient requires multiple faculties. The content of what the patient says is not

the only important thing to listen to and absorb. The manner in which they communicate to us, their

body language, their actions and reactions; all of this must be considered when tailoring the nature

of the support given by the doctor to the patient. Are they crying? Perhaps they need a hand to

hold on to, or a tissue, or maybe neither of those things, and just need to be given a moment to

cry. It all depends on the person, the patient, and what they will respond best to. Dont think for a

moment that I am under any illusion that each patient is a specific formula, and that there is aperfect breaking bad news consultation. It is an overwhelming task to respond as empathically as

possible to a person at one of the most vulnerable times of their life, especially when you become

so aware of how important what you say and do is toward influencing how the patient will feel

about their illness and about their life as a whole.

I am a firm believer that in that particular moment, you are not a doctor, and they are not a patient.

That might sound strange, but Ive stated that sentence deliberately in that fashion because I

believe that when delivering bad news there should be as little imbalance of power in the doctor-

patient relationship as possible. Without advocating a complete lack of professionalism, I think it is

important in that moment to transcend our role as medical professionals, and become a human

being.

Delivering a difficult diagnosis to a patient is difficult for the doctor because there are so many

things youd like to get right. Im not going to pretend it isnt difficult, because I dont think it could

ever become easy, even with the greatest amount of experience. Like I said earlier, it simply

doesnt rate when compare with the difficulty faced by the patient, which is notably more long-term.

It is difficult because it is a consultation that is impossible to perfect; we are all human and we all

make mistakes sometimes, even if we dont like to admit it.

But that is exactly the conclusion I arrived at. We are all human. Despite how tricky delivering bad

news can be to get right as a doctor, we can all be human in that moment by recognising the

humanity of the moment, and the frailty of the person who has just received dramatically life-

changing news. It is a perfectly natural process that requires us to accept that we are not in control,

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we do not have the answers or the magic empathetic formula, and that listening and being

receptive to person in front of youthe human, the person, the patientcan be done right by

simply trying. It wont ever be perfected, but trying ensures that as much as possible, empathic

patient-centred practice remains the aim of one of the most challenging types of consultation.

As we saw and heard from Ms. Sue Blandford and Mr. Boris Struk, it is something, good or bad,

that the patient will carry with them for a long time. This I feel cements the importance of reflectingupon the subject of empathically delivering a difficult diagnosis. And I hope, by reflecting on the

matter, that I will more able to do better when I am fully qualified and the time comes.