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When a patient gets a “double whammy,” deliver the bad news the way you would like to hear it.

Fam Pract Manag. 2008;15(6):42

Author disclosure: nothing to disclose. Patient names have been changed.

My neighbor AJ, who is a patient of mine and an avid fisherman, called to say he had some salmon for us. “Come on over, I've just finished cleaning them,” he said.

Being prone to seasickness and loving fresh salmon, I was glad AJ always caught fish … and shared them with his friends. We already had a freezer full, but you never can have too much salmon, or so my wife says. After loading me up with fillets, AJ said, “You know, my leg has been hurting me pretty badly. The pain starts in my hip and travels down to my knee. Sometimes I can barely walk.”

“I'm sorry,” I said. “How long has it been going on?”

“Four months,” AJ said. “I was waiting for salmon season to end before I made an appointment with you.”

AJ was a year overdue for his physical besides, so I insisted he come in. He was there the next week, and he had all the signs of a nerve root compression – a diminished knee jerk, a calf circumference discrepancy and decreased strength in the affected leg. The only other positive finding was asymptomatic microscopic hematuria. I scheduled him for an MRI, urine studies and a CT.

AJ was worried, but I reassured him that most of the time my hematuria workups were negative, although it wasn't uncommon for me to find kidney stones, and that I rarely found a tumor. AJ's MRI results weren't a surprise: “Left lateral L5-S1 disc protrusion causing severe narrowing of the left L5 neural foramen with probable nerve root compression.” His abdominal CT report read: “Multiple renal cysts. Several small liver cysts.” AJ had polycystic kidney disease (PKD). It was a double whammy.

On his return visit, I tried to put the results in a favorable light, but an overzealous X-ray tech had already told him about the cysts and he had spent the entire week on the Internet thinking he was going to soon be on dialysis – or worse. Thinking how much I hated techs who played doctor, I said, “The good news, AJ, is that your back can be fixed and you probably have the mild form of polycystic disease.” After all, he was 50 years old and he was asymptomatic. “If we control your blood pressure and follow your renal status, you should be OK,” I said. I offered to set him up to see a nephrologist and a neurosurgeon as well. AJ left the office visibly shaken.

I felt bad and wished I could have given him better news. I love giving good news. Patients are always worried, even when they come in for routine care. After doing an annual exam, nothing gives me greater pleasure than being able to tell a patient that I could find nothing wrong.

But bad news is something else. Delivering bad news is always difficult, but it used to be a lot harder for me, until I figured out a better way to do it. Sometimes bad news isn't all bad, or it's not nearly as bad as patients think. I discovered that if I framed the news the way I'd like to hear it if it were happening to me, then I could get through the conversation without becoming totally drained.

AJ had back surgery several months after our visit and was relieved of his pain. His renal function has remained stable, and he was recently gratified to learn that both his boys tested negative for the PKD gene. “You see,” I told him at a recent visit, “it wasn't nearly as bad as you had imagined it might be.”

“Yeah, doc,” he said, “it worked out OK, but it sure was a lot of bad news for one day.”


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