Reflections in a Head Mirror

If you can't explain it simply, you don't understand it well enough.
-Albert Einstein    


Holiday music plays in the background as I scan my Cancer Center clinic schedule for the day. Most of the names are familiar. There will be three or four new patients that I have never met, a few that are coming to the office for postoperative wound checks, a few that are returning for routine cancer survivor visits, and a few that have noticed alarming new symptoms. Over the course of the day, about 20 people will pass through the office. Their medical problems will vary but each one hopes to hear good news.  

Preparing for the day, I review scans and laboratory tests. Indeed, some of the reports will allow me to share happy moments with patients.

"The biopsy showed only scar tissue; there is no cancer!"

"The new scan shows that everything has gone completely back to normal."

"Surgery was completely successful; we removed all of the cancer and you need no more treatment"

"You have been cancer-free long enough that we do not need to schedule any more appointments."

These are wonderful moments!

Other reports, however, carry ominous warnings. I anticipate these discussions. Although there is no one "right" way to share bad news, I try to remember: Be honest. Be gentle. Preserve hope. Listen. Answer questions. Don't hurry.

"There are new findings on the scan that explain your pain."

"We found more cancer in the operating room than we expected."

"The treatments did not control all of the cancer."

"There are options for care."

"Even though we cannot cure the cancer, we will do all we can to help you and your family."

"We will not abandon you."

"I am so sorry."

During the day, I move from exam room to exam room. Good news here, bad news there. In one room, there is a sense of pure delight and celebration. The holidays will be merry! In the next, there are tears and a gradual realization that the world has been turned on its head. What will we tell everyone? By the end of the day, I will have fallen woefully behind during the complicated visits and then caught up a bit during the routine ones.

As the last patient heads to the parking lot, I move on to the next task. Clinic is not truly complete until I have prepared a computerized report for each visit — a note succinctly distilling the history, examination, reports, diagnoses, and plans. My task is to translate moments of joy and horror into a written form that will become part of the medical record.

Notes for the "good news" visits are a pleasure to write. I work on these first.

Preparing the notes for the bad news visits, though, is often very difficult. There are many things that I cannot understand and for which I know no words. At the moments when I find myself struggling with a note, I often realize that I am incapable of comprehending the issues with which the patient and family are dealing.

Medical records have a variety of purposes. They record what has happened. They document what needs to be billed. They help caregivers communicate. And, sometimes, while I am trying to capture a critical moment in writing, they can even be a means of healing all by themselves.