Letters to the Editor

Privately Breaking Bad News

to the editor: I salute the article “Breaking Bad News”¹ and the techniques described therein. I agree that the impact of bad news delivered to a patient can be softened by establishing a therapeutic relationship and communicating effectively and compassionately.

However, the ABCDE mnemonic (Advance preparation; Build a therapeutic environment/relationship; Communicate well; Deal with patient and family reactions; Encourage and validate emotions) described in the article does not address the protection of the patient's privacy. Every day, situations occur in which staff members other than the patient’s physician give the patient news of abnormal test results, sometimes over the phone, or in which technicians are unable to conceal their discoveries. These occurrences can leave patients feeling lost, bewildered, and with a sense of impending doom.

New regulations in the Health Insurance Portability and Accountability Act (HIPAA) specifically address the issue of patients’ consent regarding who has access to their medical records and how this information is disclosed. Noncompliance can result in civil and possible criminal penalties.^2,3

The concepts of "advance preparation" and "build(ing) a therapeutic environment/relationship" should include establishing patient consents before initiating diagnostic testing, treatment, and management, and should outline measures of protecting patients’ privacy. This topic is not only timely but should be a required course for physicians.

ARLENE A. LEWIS, M.D.
Park Central Family Practice
5014 Snapfinger Woods Dr.
Dacatur, GA 30035

REFERENCES

1. Vandekieft GK. Breaking bad news. Am Fam Physician 2001;64:1975-8.
2. Josefson D. US sets national standards for patient privacy. BMJ 2001;322:8.
3. Kibbe DC. What you need to know about HIPAA now. Fam Pract Manag 2001;8:43-7.

What Is the Clinical Validity of TSH Levels?

TO THE EDITOR: I enjoyed the excellent review, entitled "Treatment of Hypothyroidism."¹ However, the article does not address the issue of the clinical validity of thyrotropin-stimulating hormone (TSH) levels in patients recovering from major illness. It is known that TSH production is suppressed in severely ill patients and that there may be a temporary rebound to above-normal levels during convalescence. What does this say about the reliability of TSH results obtained shortly before or shortly after the patient is discharged from the hospital?

ROBERT D. GILLETTE, M.D.
32 Audubon Lane
Poland, OH 44514

REFERENCES

1.  Hueston WJ. Treatment of hypothyroidism. Am Fam Physician 2001;64:1717-24.

IN REPLY: As Dr. Gillette points out, the measurement of thyroid-stimulating hormone (TSH) during episodes of acute illness can be inaccurate in some patients. Investigators have found that acute illness blunts the primary response to TSH, which would account for low TSH values during times of physiologic stress,¹ producing falsely depressed TSH levels during illness. However, another group² found that TSH levels were elevated during acute illness. Finally, a third study³ found both falsely depressed (9 percent of cases) and falsely elevated (4 percent of cases) TSH levels in geriatric patients with acute illness. Any abnormality in TSH obtained during an acute illness should be interpreted cautiously, and the thyroid status of the patient should be reexamined after recovery.

WILLIAM J. HUESTON, M.D.
Medical University of South Carolina
Charleston, SC 29425

REFERENCES

1. Bratusch-Marrain P, Vierhapper H, Grubeck-Loebenstein B, Waldhausl W, Kleinberger G. Pituitary-thyroid dysfunction in severe non-thyroid disease: "low-T4 syndrome." Endorkrinologie 1982;80:207-12.
2. Wong ET, Bradley SG, Schultz AL. Elevations of thyroid-stimulating hormone during acute nontyhroidal illness. Arch Intern Med 1981;141:873-5.
3. Bhakri HL, Fisher R, Khadri A, MacMahon DG. Longitudinal study of thyroid function in acutely ill elderly patients using a sensitive TSH assay-defer testing until recovery. Gerontology 1990;36:140-4.