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Bad news bearers: Scope@10,000

Radiologist Ali Tahvildari grapples with how to deliver an uncertain diagnosis. When does causing worry conflict with a doctor's pledge to "do no harm?"

The details of this case have been changed to protect patient privacy.

A 65-year-old woman, Ms. A, comes in with left lower abdominal pain. She has come to our office for a pelvic ultrasound to rule out ovarian cancer. The ovaries are normal, but there's a grapefruit sized mass.

The margins are obscured and I can't be sure what it is, but a mass this size makes me concerned about cancer. Maybe from the colon? But it's still possible it could be benign. I want her to get a CT scan while she's here so we can figure this out. 

Here's the part that every doctor dreads: delivering bad news. 

It's particularly challenging as a radiologist, since we typically don't have an established doctor-patient relationship. It's not easy telling someone they have cancer, especially the first time you meet them. And sometimes, there's a paradoxical guilt that comes with it -- as if you feel responsible for the cancer, even though you're just a witness, a messenger.

What compounds the difficulty here is that I don't know if it's cancer or not. The best I can offer Ms. A is a big fat question mark. And unfortunately, between her schedule and insurance preauthorization, the soonest she can get the scan is in five days. 

She'll have to spend the next five days worrying. If I were forced to bet, I'd say it was cancer (although maybe we're primed to consider the worst-case scenario), but I wouldn't dare tell her that so early in the work-up. It would only worsen her anxiety.

That thing we call "bedside manner" is perhaps knowing when to offer hope. On the other hand, one must be straightforward, otherwise your patient may fear you're hiding the truth.

All this makes me wonder: When does causing worry conflict with the ethical commitment to Do No Harm?

Diagnostic medicine is never perfect, and radiology has its share of false positives and mimics. Close to 10% of "positive" mammograms turn out to be noncancerous. I've seen a case where a doctor said a liver mass was a "textbook case" of a certain type of aggressive cancer, but it turned out to be benign. A friend was once diagnosed with a lethal brain tumor on MRI, but after a biopsy, it was found to be multiple sclerosis. 

Unfortunately, worry is unavoidable, and more, its effect varies from person to person. Some people want to know every little detail and some cherish blissful ignorance. In some cultures, it is considered an undue burden to inform an elderly patient of a cancer diagnosis. In this way, every bad news conversation must be customized.

I've asked friends in other medical specialties, from primary care to oncology, how they handle delivering bad news. Invariably, you must be honest with what you do and don't know in the moment. You can refer them to a specialist who can answer the questions you can't.

Ms. A is waiting for me. What's the best word to use? Lesion? Sounds too clinical. Tumor? Well, I'm not sure it is a tumor yet. Plus, it sounds intimidating. Spot? Too vague. Mass? Seems the most neutral.

"I see a mass in your abdomen. I can't be sure what it is on ultrasound, so I'd like to do a CT scan."

Ms. A keeps a brave face, but asks, "Is it ovarian cancer?"

"I can tell you for sure your ovaries are normal. This mass is separate."

She breathes a sigh of relief. "What do you think it is? Will I need surgery?"

I must answer honestly. "I don't know yet. We'll get a lot more information from the CT scan. We should make sure it's not cancer. I think it's too early to know about surgery right now."

"That's okay. I'll come back Thursday. I'm hopeful that it's not cancer." She doesn't project the same level of worry that I feel inside. Maybe the fact that we've ruled out ovarian cancer provides a big enough relief to buoy her over the next few days.

Fortunately for Ms. A, it wasn't cancer. Rather, it was a ball of inflammation around a retained surgical sponge from an operation she'd had years ago at a different hospital, a rare condition easily treatable with surgery. If only every story ended with such good news.

Ali Tahvildari, MD, is an adjunct clinical assistant professor of radiology at Stanford. He currently lives and works in the Washington, D.C. metro area. He is a member of the Pegasus Physician Writers at Stanford and enjoys writing fiction and poetry.

This piece is part of Scope@10,000, a series of original narrative essays from writers, physicians and thinkers in honor of Stanford Medicine's Scope blog publishing 10,000 posts.

Photo by Shutterstock

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