Bluffing wasn’t a skill I was expecting to master in pathology

As a pathologist, I am one step removed from the patient. This is comforting for the most part. I render my diagnosis and another clinician communicates it to the patient. It is best this way — I have no treatment options in my own doctor toolbox to give meaning to the words I communicate. I learned this the hard way — in fellowship training.

Once I was doing a fine needle aspiration on a small sub centimeter mass behind a patient’s ear. The patient had a history of melanoma, and they were very anxious. After I aspirated some cells I looked at them under the microscope. I had a good sample. It was pretty obvious, despite needing stains to prove it. Metastatic melanoma. I sighed internally and turned around. The patient asked, “Well, what is it? Is it melanoma?”

I was nervous, still in training, and I hesitated a second too long. The patient melted into tears, guessing the answer by my lack of words. I communicated some soothing words and did not hesitate to ask a nurse to call the oncologist two floors above. Wisely flaunting routine the doctor arranged to meet the patient immediately to discuss treatment.

I learned from that experience. Now I tell the patient up front that we won’t have results for at least 24 hours, although at least half the time I have a pretty good guess at the results when I triage the sample on site to see if it is good enough material for a final diagnosis. The clinicians appreciate our discretion, and as I said, it is best overall as we usually need special stains or additional material from a cell block for a definitive diagnosis. And most importantly, we cannot offer treatment options. This leaves us and the patient at a huge disadvantage if we jump the gun. Giving a diagnosis without a next step is mental torture. I sure wouldn’t want to be on the receiving end of that.

As a long time member of the community in the hospital where I practice, I encounter situations, not infrequently, where a family member of a patient will text me or Facebook message me and ask if I can look at/triage/let them know when the results are out of a biopsy of a family member. I am always happy to help but at a loss for many reasons I mentioned above, not to mention that to communicate results to someone other than the patient, even a family member, is a major HIPAA violation.

I try to offer support and information but fall short of giving away any information about the actual diagnosis — letting it fall naturally in the clinicians’ hands to communicate themselves. I know this is for the best, and appropriate, but when your friends are in need diversion can’t help but feel deceitful. I have actually called clinicians, during working hours, letting them know that my report is out and I have a patient or family member calling me. The clinicians are always gracious and helpful, despite my natural reticence to add to their workload. I have usually fielded many calls from them about patients in their office — wanting a preliminary diagnosis or a personal phone call when the final results are out — so I understand it works both ways. And once the diagnosis is out, I am more than happy to discuss it with a patient. Although that doesn’t happen very often it is a rewarding experience.

Sometimes I wish I was back in college when a poker face was just that. A poker face. Texas hold ‘em. Seven card stud. I wasn’t good at it then, bluffing is not my strong point, but I have developed a fantastic one in my field. It’s a skill I didn’t anticipate having to master when I chose pathology.

Gizabeth Shyder is a pathologist who blogs at Mothers in Medicine

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