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 diagnosis is 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 news as 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 3rd tool 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 the diagnosis 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 commonsense 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.

Mr. Boris Struk, who also presented at this plenary, was told that his son had Duchenne Muscular Dystrophy a 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 facts but 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 f or 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. This plenary 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 a perfect 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 doctorpatient 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 lifechanging news. It is a perfectly natural process that requires us to accept that we are not in control,

we do not have the answers or the magic empathetic formula, and that listening and being receptive to person in front of you the human, the person, the patient can 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 reflecting upon 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.