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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  • buzzkillerjsmith

    Path, sweet. I did a year at UCSF back in the day and, quite stupidly, switched to family medicine. Biggest mistake of my professional life.
    You’re not going to replaced by a different type of “provider” soon. Go home at night and enjoy your silent glee.
    And don’t talk to pts. That’s the job of some other hammerhead–like me.

  • Guest

    “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.”

    Not all patients are stupid, though. Some of us are going to know you’re lying. Some will be happy with the 24 hours of false hope you’ve tossed their way, others will spend the next 24 hours wondering why the doctor lied to them, right to their face, and will spend the rest of their lifetimes never really trusting “the system” again.

    • PCPMD

      So you’d rather have a wet read that a biopsy *might* be cancer, spending the next 24 hours in mental anguish until the definitive results are back, rather than just hear the results the next day …

      • Observer

        I personally find not knowing to be much more “mental torture” than knowing without having a treatment plan. Just because the anguish of the uncertainty is bottled up inside doesn’t mean it isn’t still there. It’s not great to receive bad news, but at least I can start to get on with figuring out the next step instead of continuing the emotional limbo. Obviously if the pathologist doesn’t actually know yet then there’s nothing that can be said, and equally obviously there are people who cope better with each approach, but I do find it quite frustrating to not have important health information shared with me at the time it becomes known. I much prefer knowing the current ‘best guess’ so I can go do enough research to have an intelligent conversation about treatment with my personal physician. I would be curious to see some research about which of the two approaches is better for a group of patients. I know I’m not unique in my preferences, but I don’t know how prevalent those preferences are in the general population.

        • guest

          The problem is that no two patients are alike. For every patient like you who will calmly and rationally accept a preliminary notification of bad news and will proceed to do some thoughtful research so that a productive conversation can be held during the meeting with the treating clinician, whenever that happens, there are probably two or three patients who will not be able to tolerate that anxiety and will expect the treating clinician to drop whatever he or she is doing at that moment (as described above) in order to make himself available to try and provide on-the-spot reassurance.
          Obviously, you can’t run a medical practice that way. How would you like to be in the middle of an appointment with your doctor and have it interrupted by the doctor having to excuse himself or herself to try and soothe an unscheduled patient?

          • Observer

            I am hopeful that at some point soon the technology will be there to allow us to provide the results and take action right away, like some of the breast cancer centers that have same day mammograms and followup, with lumpectomy or mastectomy within two days from initial finding on the mammogram.

          • guest

            One does not diagnose breast cancer with a mammogram. A biopsy is needed. At times, an excisional biopsy may be performed, and then confusingly referred to as a “lumpectomy.” But it is still a biopsy, done for the purpose of diagnosing cancer and staging it. Our instant-gratification culture doesn’t like it, but waiting for biopsy results is just something that is a part of life at times.

          • Observer

            I can understand why you were confused by my vagueness, but the screening program I am referring to is set up so that a patient with a worrying mammogram result in the general population screening program will receive a same day biopsy (or one of several other other diagnostic procedures, which is why I was being so vague) followed by commencement of treatment within a week. This means the vast majority of patients with ultimately benign results don’t have to walk around thinking they may have breast cancer any longer than absolutely necessary.

    • guest

      I think the point of the entire piece is that the pathologist is not the appropriate person to deliver the news about the biopsy. That person would be the treating clinician, who in order to best organize the information for the patient, frequently needs a little time in order to make sure it is done well.
      Of course, in our society, where wishes for instant gratification are seen as entirely valid, and deserving of being met at all times, the idea that a patient should wait some small interval to hear a diagnosis is anathema. Even if the wait is in order that the doctor can be best prepared to have a thoughtful and productive conversation about the diagnosis and treatment options.

    • meyati

      If you know the biopsy report-it gives you a chance to think of the questions that you need to ask. It also prepares you for the brutality of many of the treatments. While I was a first time cancer patient, I knew it was cancer within a few days of the biopsy in the office. Mine was very rude-and new tumors popped up. Mine was so atypical that I couldn’t find anything on the Internet to give me a clue to what it was, but I knew it wasn’t good. The surgeon said, “Oh a cyst.” Boy was she surprised.

  • guest

    That’s not really bluffing, though, it’s just being professional. Since as a pathologist it’s truly not your job to share biopsy results with patients (as you saw during your fellowship, it can result in panic for the patient and disruption of your colleague’s day) maintaining an impassive demeanor in that situation is part of your professionalism.

  • Kernos

    As a pathologist, I agree with your routine, but still use judgement case by case. My main work is reading breast biopsies. My results not infrequently come when the PCP is out of town for days or longer. In such cases I will call the patient and communicate a diagnosis, especially if it is benign. It’s cruel to unnecessarily make a patient wait longer than necessary.

    I’m not as comfortable doing this if a biopsy is positive or unexpected. I try to call the PCP or an oncologist if one has been identified so they can pass on the info. Cell phones has made this easier. But as a last resort I will still inform a patient, rather than make them wait (It’s been up to 3 weeks). Having done family practice in the past perhaps makes me more comfortable doing this.

    Every time I have done this, the patient has been very thankful for my effort. I don’t think we should be rigid in our routines.

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