Letters to the Editor

'Bad News' May Predispose Patients' Attitudes

EDITOR'S NOTE: I am responding to the article, "Breaking Bad News,"¹ by Dr. Vandekieft. I appreciate the efforts of American Family Physician to improve the comfort level of family physicians when it comes to communicating difficult issues to their patients. However, I have long opposed using the term "bad news," even though it was used in the Educating Physicians on End-of-Life Care (EPEC) course I took when I became a trainer for EPEC.

Reporting to patients, "I have bad news" is a "set-up." It affects the patients' attitudes and feelings and is an immediate and premature negative imposition on their psyches. Physicians need to realize that the information we impart to patients has an individual effect on each person. By prefacing the information with phrases such as, "I have bad news," we are putting a bias of our own values on the information.

I recently told a woman, "I believe you have Alzheimer's disease." I paused, and she responded, "Well, at least I didn't get it sooner." Another patient's response to a diagnosis of cancer was, "I have a friend who had it, and he's cured." Saying "I have bad news" immediately decreases hope, and hope is a very powerful human emotion and force.

When we learn that our patient has a disease that could cause disability or death, we must carefully measure our words and consider elements of communication, such as our body posture, tone of voice, and the location we're in, when we share this information with the patient and family. We also need to have as much insight as possible about our own feelings. We should continue to improve our caring relational skills. It is not in the patients' or the physicians' best interest to label certain diagnoses as "bad news."

ROBERT W. MATTHIES, M.D.
Oaklawn Family Practice
1672 Oaklawn Dr.
Prescott, AZ 86305

REFERENCE

1. Vandekieft GK. Breaking bad news. Am Fam Physician 2001;64:1975-8.

Figure Is Inaccurate Depiction of Procedure

to the editor: In the article entitled, "Peritonsillar Abscess: Diagnosis and Treatment,"¹ the illustration of needle aspiration in Figure 3 is misleading. Figure 3 shows the needle penetrating the tissue of the palatine tonsil in an attempt to drain an abscess. For several reasons, this method is not recommended by otolaryngologists. First, tonsils tend to bleed significantly if traumatized. Second, the easiest place to aspirate an abscess is in the superior peritonsillar bulge that universally accompanies this entity. This bulge is not depicted in Figure 3. Based on Figure 3 alone, one might assume that there is no abscess but rather unilateral tonsillar hypertrophy. Third, the angle of the needle as depicted increases the risk of carotid artery injury. The appropriate aspiration occurs in the palatoglossal arch without aiming the needle laterally if it can be avoided.

RICHARD D. THRASHER, M.D.
Department of Otolaryngology
University of Colorado Health Sciences Center
4200 E. Ninth Ave.
Denver, Colorado 80262

REFERENCE

1. Steyer TE. Peritonsillar abscess: diagnosis and treatment. Am Fam Physician 2002;65:93-6.

EDITOR'S NOTE: Dr. Thrasher's comments are correct. The published figure does not accurately depict a peritonsillar abscess, nor does it show correct needle placement and angulation for safe drainage of an abscess. Figures 2 and 3 have been removed from the online version of the article.

Self-Referred Screening CT Scans in an Unselected Population

to the editor: A 58-year-old, healthy, asymptomatic woman came to our clinic for follow-up after a self-referred computed tomographic (CT) screening examination was abnormal. She came with a detailed report and photographic reproductions from the scan. The report stated that a 3.2-cm, right paratracheal mass was found, likely to be an enlarged thyroid lobe, and recommended further evaluation. The patient was very anxious and upset.

Physical examination revealed no apparent abnormalities; the thyroid gland was normal and the mass was not palpable. Thyroid function studies were all within normal range. An ultrasound of the thyroid revealed a heterogeneous mass in the right lobe, believed to represent goiter formation. Radionuclide scanning of the thyroid revealed moderately increased uptake on the right side. Needle core biopsies of the mass revealed variable-sized follicles and focal stromal fibrosis, consistent with a benign adenomatous nodule.

Regional or full body CT scanning has recently been promoted as a way to provide early diagnosis of cancer as well as cardiac and other diseases. A number of Web sites are devoted to promoting full-body scans. Many sites advertise and promote the procedure based on reports of questionable scientific validity. Proponents cite anecdotal evidence of cancer found at an early, curable stage, or early detection of coronary artery disease allowing for intervention before myocardial infarction.¹ Unfortunately, no studies exist to support the usefulness or cost effectiveness of CT screening on an unselected, asymptomatic population. The U.S. Food and Drug Administration and the American College of Radiology have both concluded that there is no scientific evidence to support such screening.^2,3 As our case illustrates, a great deal of extra investigation along with significant anxiety for the patient, cost, and morbidity, may be required to prove that an incidental finding on CT screening is exactly that.

There is no way of determining how many persons have had such scans; one company claims to have performed over 15,000 scans.⁴ With heavy media and Internet exposure emphasizing glowing individual reports of the benefits of this screening, public demand for these procedures is likely to increase. Family physicians should be aware that their patients may have had or are considering such testing. Self-referred CT screening among the general population raises far more questions than answers. Controlled clinical trials are needed to assess the risks, benefits, medicolegal issues, and total costs involved (including false-positive and false-negative findings). We believe that family physicians should actively discourage self-referred CT screening until better information is available.

ALLEN L. PELLETIER, M.D.
ANGELA P. POTTER, M.D.
University of Tennessee College of Medicine
St. Francis Family Practice Residency Program
1301 Primacy Parkway
Memphis, TN 38119

REFERENCES

1. Landers SJ. Full body scans: buying peace of mind. AMNews. September 3, 2001. Retrieved May 1, 2002, from: www.ama-assn.org/sci-pubs/amnews/pick_01/hlsa0903.htm.
2. Lewis C. Full-body CT scans: what you need to know. FDA Consumer Magazine. U.S. Food and Drug Administration, November-December 2001. Retrieved May 1, 2002, from: www.fda.gov/fdac/features/2001/601_ct.html.
3. The American College of Radiology Statement on Total Body CT Screening. September 27, 2000. Retrieved May 1, 2002, from: www.acr.org/departments/pub_rel/press_releases/total-bodyCT.html.
4. Davis R. The inside story: reporter takes uncertain plunge into his own body. USA TODAY. Aug. 25, 2000. Retrieved May 1, 2002, from: www.usatoday.com/life/health/general/lhgen075.htm.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.