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VIEWPOINT
Year : 2020  |  Volume : 57  |  Issue : 2  |  Page : 212-215
 

A wrong diagnosis


Department of Plastic Surgery, Chinmaya Mission Hospital, Bengaluru, Karnataka, India

Date of Submission10-May-2019
Date of Decision05-Jun-2019
Date of Acceptance07-Sep-2019
Date of Web Publication29-Apr-2020

Correspondence Address:
Neha Chauhan
Department of Plastic Surgery, Chinmaya Mission Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_418_19

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 » Abstract 


Cancer therapy is undergoing rapid advancements and many of the conditions that were incurable earlier can now easily be treated. Making a “correct diagnosis” is the first step in the ladder towards treating the disease. However, once diagnosed, “breaking bad news” to the patient and his family that he/she has cancer is still a big challenge as it is a life-changing event not only for the patient but their families as well. The following article narrates an incident dealing with the significance of diagnosing the condition accurately and that of “breaking bad news”. It gives an insight into the emotional ordeal that clinicians dealing with terminal-illnesses like cancer go through on a daily basis while trying to diagnose it and communicating it to the patient and his family.


Keywords: Breaking bad news, communication, diagnosis, empathy


How to cite this article:
Chauhan N. A wrong diagnosis. Indian J Cancer 2020;57:212-5

How to cite this URL:
Chauhan N. A wrong diagnosis. Indian J Cancer [serial online] 2020 [cited 2020 May 31];57:212-5. Available from: http://www.indianjcancer.com/text.asp?2020/57/2/212/283526




All knowledge attains its ethical value and its human significance only by the human sense in which it is employed. Only a good man can be a great physician” - Hermann Nothnagel.

It was a Wednesday… For sure!…I remember it correctly as that being the most hectic day of my week, gives me more blues than the notorious Mondays! I go for consultations to four hospitals that day and by the end of the day what remains is a bundle of tiredness, albeit with a feeling of triumph at having survived through the Herculean day of the week. Deep inside, I have started dreading Wednesdays.

As I hurriedly rushed to the cab with a half-eaten parantha in one hand and instruments case in the other, a call interrupted my breakfast. It turned out to be one of the surgery residents from the third hospital in line for the day. He said, “Sorry to bother you at this time, ma'am, but there is a reference for you in Ward D.” I replied, “There is no need to be sorry! It's my duty. Thank you. If it is not an emergency, may I see the patient at 4 pm when I come for the OPD?” He responded that it wasn't an emergency but the surgical team wanted me to see the patient that day itself.

By this time my hunger had vanished, the parantha lay in the corner of the seat and I was eager to know the case history. The resident told me that the patient had presented with a pus discharging swelling in the right axilla 4 days ago for which he underwent drainage and lymph node biopsy the next day. A day after the surgery, the patient had reluctantly shown them a wound on the right middle finger which had been there since two years. The wound hadn't bothered him much so he had not shown it to anyone at the time of initial presentation. The resident further added that the wound was black, involved the distal phalanx with nail erosion. I had been called for opinion regarding the management of that non-healing wound.

This conversation sent my mind racing, trying to hunt down the “correct diagnosis” and took me 17 years back in time. “Correct diagnosis”?!!…. Yes, that was my favorite game with my best friend during MBBS days. She would tell me the history and examination of patients that she had seen in her “evening wards” and ask me to diagnose the condition and I would do vice versa. What had started as a benign game in second year of M.B.B.S. of sometimes being right and sometimes being wrong turned into a serious affair by the time we reached final year. Each correct diagnosis would elate while the wrong ones would send chills down the spine. The constant thought those days was that I was about to become a full-fledged doctor soon. What would happen if in some instance I would not be able to diagnose and treat patients correctly? While I was still lost in the days of the “correct diagnosis” game, the cab suddenly stopped, breaking my chain of thoughts and I realized that I had reached my destination, thefirst hospital of the day. Gathering myself, I quickly alighted from the cab. I was 10 minutes before my OPD time and the conversation with the surgery resident flashed back again. The next few minutes of contemplation gave me a list of differential diagnosis but what topped the list was a rare diagnosis of “subungual melanoma with axillary lymph node involvement.” I was flabbergasted at my list of differential diagnosis because rare things usually fall lower down the list in differential diagnosis but here my mind and intuition both had set themselves on a rare diagnosis!! Fortunately, my state of surprise didn't last long as my patients started trickling in and I got engaged with them. After this, I rushed to the second hospital, finished my surgery there, and headed to the third hospital. I was more excited than usual and a bit nervous too! Though my M.B.B.S. best friend wasn't along, the affair with the “correct diagnosis” was still on, getting serious with every passing day. On what note would it end today? Would I be right or wrong? It seemed like a scene from the Nancy Drew series…A girl on an adventure in the search of the unknown, not knowing what fate has in store for her.

I mechanically climbed up the stairs oblivious of the surroundings, reached ward D, called out for the nurse incharge, asked her to bring the case file and a pair of gloves and reached “the patient of the day.” I call him so because I had spent maximum time that day thinking about his diagnosis. The patient, a simple middle-aged gentleman, told me that he had a thorn injury around two years back following which he developed a small wound on his right middle finger which had failed to heal. With hope in his countenance, he shared that after his axillary abscess drainage his pain was much relieved and he felt that his finger wound could be cured too. Hence, he had shown his wound to the primary consultant. His family was in Kerala and his only attendant was his friend.

As the conversation ended, I realized that I had after long made “a wrong diagnosis” but what was strange was that instead of a sense of failure, I had a sigh of relief!! What I had been imagining whole day to be a subungual melanoma was turning out to be just a chronic infection due to thorn injury or probably a fungal infection of nail.

However, a quick examination of his finger signaled that something was amiss. I called up the pathologist and asked for the patient's axillary lymph node biopsy report. She replied that it would take another 3 days for the final report to be given out but gross examination had shown that the lymph nodes had a tarry coating and were brownish black on cut-section. I shifted the patient to the operation theatre to take a biopsy from the finger. The incision revealed a black underlying tissue that almost put a stamp on my clinical diagnosis of being correct. Two days later the axillary lymph node biopsy and histopathology from the finger reported the diagnosis to be a malignant melanoma with axillary lymph node spread. Computerized tomography of abdomen and thorax revealed significant pulmonary lymphadenopathy. Positron emission tomography showed spread to the pulmonary system. With a heavy heart, I requested the surgery resident to arrange for a meeting with the family members of the patient in the evening.

Though I headed to the hospital browsing through the recent researches on breaking bad news, the biggest challenge was how to convey it to the family who had placed all their hopes and trust in us. Telling them that it was a rare cancer which had spread to lungs, had poor prognosis, and that there was very little that we could do for the patient was an arduous task. The staff had made arrangements for the meeting and the family had been briefed that the meeting was to discuss the reports and plan for further course of action. The patient looked intently in my eyes and with a very calm demeanor said that he would want his family to be there for detailed discussion while he just wanted answer to a single question, “How long would I live?” He added that he knew that he had cancer as he had overheard the staff discussing his diagnosis. He just wanted to know how much time he had with his wife and children. The question made me go numb in knees and I stumbled for an answer. Yes, there were multiple studies on the prognosis of malignant melanoma yet how exactly how could I predict how much time he had?! I could just utter “We will try our best.” He went out of the room after this and I explained in details to the family about his condition, expected prognosis (based on the available data) and that it would be best to take him to a cancer hospital for further management. As I broke the inevitable news, an eerie silence enveloped the room. Those fifteen minutes of silence seemed to last for eternity, when finally one of his brothers broke it declaring it to be the “will of God.” While speaking this, his throat almost choked and he broke down in tears. I spent almost 45 minutes with the family making them understand my limitations and that of medical science too. At the end of the meeting, they expressed gratitude for all my time in answering their questions. I was at loss of words and could just wish them all the best for further treatment.

On the way back home after this meeting, a myriad of thoughts, reflections, and an array of questions troubled my mind. I had indeed made the “correct diagnosis” even before meeting the patient and somewhere inside I should have been the same elated second-year M.B.B.S. student who had just won the “correct diagnosis” game. But strangely, there was sadness at being correct this time. Why was I praying against all odds those two days while biopsy was awaited that it turns out something else, something simpler and easier to manage? Why did I wish for a “wrong diagnosis” this time? Was I showing lack of scientific medical temperament by doing so? Or was I maturing as a person and a doctor over years to be able to empathize with him? Or was it just the fear of the difficulty in breaking the bad news that I had hoped against hope for a wrong diagnosis? Would I have felt the same way had the patient and his family been aggressive, non-trusting, and rude to me? Despite the turmoil of those four days, I slept well that night. Perhaps as we get involved in emotional healing of others we get healed ourselves!!

Though I haven't yet found the exact answer to my hoping for “a wrong diagnosis,” I realize that while a correct diagnosis is always welcome, a wrong diagnosis doesn't hurt at times. The medical profession combines the best of virtues of humanity and as doctors we must strive for the well being of our patients. As we grow in our practice, ego takes a backseat, boundaries of wrong and right blend, and what remains is the desire that our patients heal well, even if we are proven wrong!

The incident also brought to fore the uncomfortable but commonly encountered situation in cancer care—that of “breaking bad news.” It's difficult terrain which till now has received very little attention at medical school curriculum.[1] Bad news is defined as any news that adversely and seriously affects an individual's perception of his or her future. Though around 93% clinicians regard being able to deliver a bad news with composure a very important skill, only 40% feel they are sufficiently trained for the same.[2] Breaking bad news is devastating both to the patient and his family. In countries like the United States, the law states that while delivering a bad news, a patient must be told as much as he/she wants. The communication should convey the true information regarding patient's condition while taking care not make the patient and his family hopeless. A study by Wallace et al. reveals that “breaking bad news” not only affects the patient and his family, but also evokes strong negative emotions like guilt, sadness, pain, stress, and heartbreak in approximately 50% clinicians.[3] During their careers, the oncologists encounter approximately 20,000 occasions where they may have to deliver the bad news.[4],[5] Studies have shown that prolonged exposure to the stress of delivering bad news due to inadequate training can lead to a constant state of stress to the clinician and cause early burnout in them. The clinicians need training to be mindful of their emotions while delivering a bad news to avoid it affecting their own health while being able to deliver the whole truth to the patient with empathy. The Medical Council of India(MCI) has taken a step towards this endeavour in their most recent change in medical graduation curriculum (implemented from the 2019 batch) with the introduction of Competency Based Undergraduate Program.[6] This program introduces Attitude, Ethics and Communication (AETCOM) competencies. Five modules spread over 34 hours forfirst year students, 8 modules (37 hours) for second year, 5 modules(25 hours) for third year and 9 modules (44 hours) for final year students have been introduced, aimed at teaching the roles and responsibilities of the doctor and key competencies like scope of doctor-patient relationship, communication with the patient/family, bioethics, healthcare teamwork, patient rights/autonomy, empathy and acquiring a non-threatening and non-judgemental attitude towards all patients. Module 4.4 of this syllabus specifically dedicates 5 hours of training in empathy and art of communicating the treatment/care option for terminally ill patients like those suffering from cancer. This module is designed to be taught to the fourth year medical graduates. A number of protocols like SPIKES, ABCDE, and BREAKS have been designed to deliver bad news[7] which can be easily employed (but are beyond the scope of discussion in this article). I hope that these measures introduced by the MCI would enable the future generation of medical graduates to be better equipped in empathy and art of communication with the patients especially the ones with terminal illness.

To conclude, in the best interests of patients and the doctors, it would be worth investing time teaching empathy and the art of communication specifically that of “breaking bad news” as a part of medical curriculum, besides the skills of diagnosing a disease.[1]



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Supe AN. Interns' perspectives about communicating bad news to patients: A qualitative study. Educ Health 2011;24:541.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Monden KR, Gentry L, Cox TR. Delivering bad news to patients. Proc (Bayl Univ Med Cent) 2016;29:101-2.  Back to cited text no. 2
    
3.
Wallace JA, Hlubocky FJ, Daugherty CK. Emotional response of oncologists when disclosing prognostic information to patients with terminal disease: Results of qualitative data from a mailed survey to ASCO members. J Clin Oncol 2006;24:8520.  Back to cited text no. 3
    
4.
Fallowfield L, Lipkin M, Hall A. Teaching senior oncologists communication skills: Results from phase I of a comprehensive longitudinal program in the United Kingdom. J Clin Oncol 1998;16:1961-8.  Back to cited text no. 4
    
5.
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—A six-step protocol for delivering bad news: Application to the patient with cancer. Oncologist 2000;5:302-11.  Back to cited text no. 5
    
6.
7.
Narayanan V, Bista B, Koshy C. BREAKS' protocol for breaking bad news. Indian J Palliat Care 2010;16:61-5.  Back to cited text no. 7
[PUBMED]  [Full text]  




 

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