Bad news and a patient you don't know
Mr Smith, a patient you have never met, comes in and says he would like to know the histology report on the lesion removed by one of the partners. His computer record shows it is an incompletely excised malignant melanoma. The partner is away. Dr Melanie Wynne-Jones advises.
How do you feel?
This is the antithesis of how we are trained to break bad news1,2,3,4. The situation has been sprung upon you and is about to be sprung upon Mr Smith; checking his record before the consultation would have given you a last-minute warning.
You have no idea what Mr Smith is expecting, or what he already knows or suspects, nor whether he has brought or would wish to bring someone with him for support. You do not have an established rapport to help you and you have had no opportunity to research what the next course of action should be or to set aside protected time (you may already be running late). In addition, you may be challenged about the absent partner's actions.
How and what are you going to tell Mr Smith?
If you are lucky, you may be able to click away from the report before Mr Smith has read it, giving you some control over how he is given the information.
Start by finding out what he does know or suspect, perhaps by asking 'What did Dr X say he thought it was?', 'What did you think?', or 'Did Dr X say whether you might need further treatment?'. This highlights the importance of pre-operative counselling and documenting what it comprised; Mr Smith may already have been warned that Dr X was concerned about the lesion, making your task easier.
Whether he suspects or not, you will still have to negotiate the process of delivering the bad news in incremental chunks, checking both that Mr Smith understands what he is being told and how much he actually wants to know at this stage. He may not be ready for all the information but it is vital that he understands the urgency of further treatment and that he is given the opportunity to ask questions. You must also be alert to his feelings or distress and offer to discuss these areas (overt criticism can be acknowledged without endorsing it, with the suggestion that it can be discussed later if he so wishes).
A further problem is that you may not be entirely certain about how the next steps should be organised; you may need to sort this out immediately by telephone. However, a promise to contact Mr Smith later in the day may be more practicable and gives him (and his relatives) additional support, plus another chance to ask questions.
This is likely to be a stressful consultation for you as well as Mr Smith; take a break or debrief with your trainer if you need to. This may also benefit your remaining patients, even if you are already running late.
How could this have been avoided?
The practice should consider conducting a significant event analysis. Issues will include:
· Practice policies for identifying and removing suspect lesions should Mr Smith have been referred to a dermatologist under the two-week rule?5
· How pre-operative counselling is carried out and recorded.
· Whether the practice audits its minor surgery service. Are all removed lesions sent for histology? How skilled are the doctors who perform it; do they need refresher training?
· How patients are notified about serious abnormal results. They may be told to make sure they find out their results, but medicolegally this is ultimately the practice's responsibility6. Consider, too, how results are tracked through the system. Is the practice certain this result could not have slipped through the net if Mr Smith had not inquired?
· Handing over clinical responsibility: how do partners arrange for ongoing problems and loose ends to be safely tied up in their absence?
The discussion may reveal several communication, operational and training issues. A summary document should be circulated, agreed, acted upon and reviewed at a later date.
How should suspected melanomas be managed?
Thickness at time of surgery is a crucial prognostic factor for melanoma and patients and doctors are regularly exhorted to act on suspicious symptoms and signs. But GPs may have difficulty in distinguishing melanomas from benign pigmented lesions, even when using algorithms and instant cameras7, especially if the appearance or site of the lesion, age of the patient or lack of pigment (the rare amelanocytic melanoma) are atypical.
Skin cancer referral guidelines5 recommend patients with suspected melanomas are not biopsied in general practice; patients should be referred with the lesion intact to the specialist. Suspected melanomas are defined as pigmented lesions on any part of the body that have one or more of the following features:
· Growing in size or changing shape
· Irregular outline
· Changing colour or mixed colour
1. Buckman R. How to break bad news: a guide for health care professionals. Baltimore: Johns Hopkins University Press, 1992
2. Faulkner A. Clinical review; ABC of palliative care: communication with patients, families and other professionals.
3. Kaye P. Breaking bad news a 10-step approach. EPL Publications,1995
4. Faulkner A, Maguire P (eds). Talking to cancer patients and their relatives. Oxford Medical Publications, 1994
5. Cancer referral
guidelines 2000 www.doh.gov.uk/pub/ docs/doh/guidelines.pdf
6. GMC good medical practice 2001.
7. English DR et al. Evaluation of aid to diagnosis of pigmented skin lesions in general practice: controlled trial randomised by practice. BMJ 2003;327:375-8
· Breaking bad news should be done in accordance with good practice and not 'on the hoof' unless unavoidable
· Suspected malignant melanomas should be referred under the two-week rule to the local specialist service
· GPs offering a minor surgery service should audit their performance
· Practices should have robust protocols for ensuring
are acted upon