Friday, May 25, 2012

Doctor-Patient Disconnect

I've noticed that there are times when, despite best intentions, a patient and a doctor just don't connect.

Like the doctor thinks the patient is completely on board with what they're saying, yet they're about the opposite of being on board and are actually really upset.

An example of this occurred during my intern year, when I was on the medicine consult service:

We were consulting on this 40 year old guy on the ortho service with end stage liver disease and a recent above knee amputation following a trauma. His creatinine bumped a little (meaning his renal function got worse) and he's got major ascites from his cirrhosis, so they called us to figure out what to do with his fluids.

The patient needed a liver transplant, but couldn't get one due to his amputation. My attending Dr. Smith and I decided to calculate his MELD score, which is a score that determines the 3-month mortality of a patient with end-stage liver disease. His score gave him a mortality rate of 50-75% over the next three months. So basically, he had at least a 50% chance of dying in the next three months.

I knew that the patient wasn't even remotely aware of this. The amputation was due to a trauma, not diabetes or something like that. He had told me that his doc had been trying to get on a transplant list, but his liver disease "wasn't bad enough". He believed he was in the earliest stages of liver disease.

Dr. Smith said that we needed to give the patient a "prognosis report", meaning we should be honest with him that he has a good chance of dying soon and encourage him to go on hospice.

"I don't know about this," I told her. "I think he's going to be really shocked."

"You think the other doctors haven't been telling him this all along?" Dr. Smith challenged me.

"I mean, I saw him trying to do work on his computer this morning," I said. "I think he believes he's going to recover from this."

"I doubt he really believes that."

I said that he's a young guy with small children and he's not going to easily accept going on hospice. I know hospice is an underutilized service and I wasn't saying this guy shouldn't on it... I just felt like it was going to be a big surprise to him to hear all this.

"Are you saying he doesn't deserve to hear all this?" she asked me.

"No," I said. "I'm just saying he's going to be surprised."

We went to see the patient and Dr. Smith told him everything. She was completely blunt with him. She even talked to him about end of life issues like would he want to be on a vent, etc. The guy looked completely SHOCKED. He was just staring at the wall the whole time she was talking. I felt awful for the guy.

When we got out of the room, Dr. Smith said to me, "See? He didn't seem surprised, did he?"


"He's heard all this stuff before," she said. "He's just in denial."

Dr. Smith had done this hundreds of times (I assume), so part of me wanted to defer to her experience. But then the next day, the social worker came up to me and said, "You know that patient you talked to yesterday? He's completely shocked about what you told him and he's freaking out. He's really depressed. You need to come talk to him again."

I was like, "Goddamn it, I KNEW it!"

It was clear when I went back to the patient that he hadn't heard any of this before and he wasn't in denial at all. He was crying and asking me very legitimate questions.

I don't know how this disconnect happens, but I suspect it happens to all doctors. You think the patient is thinking one thing and they're actually thinking something completely different. And you only find out a few days later, when you've been reported to a patient advocate.


  1. Why is someone disqualified from transplant if they've have an amputation? If I misread something, I apologize? Thanks!

    1. Actually, I wrote this many years ago, but I think what I meant was that the patient had severe infection (osteomyelitis) that precipitated the amputation and that made him no longer a candidate. I can't remember all the details, but I know he had been taken off the transplant list, at least for the time being. For all I know, he eventually got the transplant.

  2. Do you know why the doctor did not think it might be good to make a plan with the social work team to talk to this guy with a social worker in the room, and his wife in the room?
    yes, i know, you are saying the doctor really believed this guy had heard all this stuff before.
    1. if he had heard from docs before and was still in denial, wouldn't that indicate he needed the help of social work and his wife?
    2.if he had not, why would he want to hear this for the first time in a room alone with two doctors he doesnt know well (i know they don't know him well, from the rest of your story), and then be left totally alone for the rest of the day and night, with no social worker, no family member, just alone in a room, in horror, at leaving his young kids?
    I am left stunned and horrified.
    If you bother to use psycobabble words like denial, then you should have the decency to make a psychobable plan, with people who have had some training. Your doctor was using the "denial" not a diagnosis, but as an excuse to do what she damn well pleased, which was not to "treat" the "denial", but avoiding the hard work of putting a team together to help this patient.
    Very inefficient use of hospital resources.
    liza bennett

    1. I don't know why the patient was told this with no social support in the room, but I can't say it's the first time I've seen a doctor do that. I've actually seen it happen many, many times. One of the times that really stuck with me was in the ICU, a patient (awake but on a vent) was told he was dying by the attending with the entire team in room, none of whom he knew from Adam.

  3. Very sad. If the doctor didn't think social work was needed, at least she could have asked him if anyone had told him this before. Is it so hard to ask a simple question like that instead of assuming she knew his mental state? It really doesn't seem like a case of "best intentions," but not wanting to deal with it. I do admire that she believed the guy deserved some honesty, though.

  4. Situations like this are where gut instincts about a patient are crucial- Dr. Smith sounded sorely lacking in that area. That's the thing about instincts- you can't always put into words your justification for having them, but when you have the opportunity to really break down body language and little things about a person, you can usually pinpoint exactly all the things that clued your "gut" to kick in.(but really, who has time to do that?? just trust it, it saves time) Empathy is something that is very difficult to teach; either you have it or you don't- and without it? All the medical knowledge in the world doesn't mean crap.

  5. Which is why before breaking news you should always start with...Can you tell me what you understand is going on with...
    Takes 2 seconds and really prevents jaxk-a$$ doctor moments. You know what assumptions do...

  6. I totally agree. I was in hospital a few weeks ago and the doctor asked me what I knew about my condition before she expanded on possible out comes. It took her minutes but instantly made me feel I was in the company of a doctor that could listen and cared and presumably gave her a good idea of my level of understanding. I would have thought that would be one of the first important things you are taught as a student med?

  7. I have to say that I do admire the physician for having this discussion with the patient, and for being blunt and not sugar-coating anything. Maybe the delivery was off, but the intentions were good.

    As an emergency physician, I am constantly, constantly coming across patients in the absolute end stages of their illness who have no idea that they are going to die soon, and nor do their family members. This happens particularly often with cancer patients. So I end up having to have very frank conversations in a rushed ED regarding major decisions (intubation, ICU admission, chest compressions, etc) with families I have never met before and with whom I have no established rapport -- basically having to tell them that there is a good chance that their family member will die during this admission, with or without aggressive measures. They are ofcourse shocked to hear the state of their/their family member's illness, even though it is fairly clearly laid out in the oncologist's consult note (which, for some reason, he was not able to properly communicate to the patients). I understand the notion of wanting to give people hope, but false hope is extremely detrimental, and if more oncologists were willing to have these frank, unadorned discussions with their patients (and not soft-pedal prognosis discussions with vague vocabulary that will allow patients to hear what they want to hear), a lot of distress and confusion could be avoided, and people would be in a much better position to make end-of-life decisions and choose how they want to spend their last few days, not to mention allowing for better use of our health care resources.

    sorry for the rant, but I have a huge beef with oncologists when it comes to their prognosis discussions with their patients -- yes, it's not a pleasant conversation, but it's part of the job!

    ER MD

    1. Yeah, I get frustrated with the same thing. As a rehab doc, I should NOT be the one telling patients about their cancer prognosis. Yet we get patients all the time whose oncologists admit that the patient doesn't realize how sick they really are.

  8. The interesting thing is, they've done studies and statistically speaking, doctors who make patients feel listened to and take time to make sure they understand are significantly less likely to be sued for malpractice even if they actually were negligent. If they can't care about their patients enough to do the hard work of giving an accurate prognosis, they ought to at least care about not being sued.

  9. I had to have a similar conversation, by myself, with a patient's family member during a busy over-night shift in the ICU. It sucked. I still believe I shouldn't have been placed in that position - I was left trying to balance a patient who was at risk of bleeding out with a family member who was at risk of losing it. :p