Thursday, January 14, 2010


A friend of mine, successfully treated for primary brain cancer ten years ago, has been closely monitored since. The medication she was taking to lower her cholesterol can affect the liver, so she received regular liver enzyme tests. A couple of times the tests were abnormal. When her doc took her off the med, the tests came down. Now she hasn't taken that medication for two months, she’s in fine health, but her liver tests mysteriously rose again.

A likely cause is a plain old error. An appreciable number of blood tests—some studies show one out of six—are flat-out wrong, for a variety of reasons: the machine wasn’t correctly calibrated that day, the technician didn’t prepare the sample properly or mistakenly tested the wrong blood sample, that sort of thing. My friend’s test, then, needs to be repeated.

Her doctor was occupied, so she saw the physician’s assistant about the report. She asked, “What do these abnormal tests mean?”

“Well, we don’t think you have hepatitis, so it might be liver cancer or maybe cirrhosis, something like that.”

My friend, stunned and at the same time furious at the P.A.’s insensitivity, responded with an obscene curse. Maybe she truly does have a serious liver ailment (which I doubt) and maybe she doesn’t, but as a vulnerable, emotional being, she deserved to be informed of the possibilities more gently.

I applauded her for her appropriate response, but it was only a first draft. What she needs to do is to expand it from the F-bomb to a complete, comprehensible, educational message. The P.A. might have come away from the encounter erroneously thinking, “Wow, she’s really angry. I guess I’d be angry, too, learning I have liver cancer.”

Keep in mind that there’s nothing within medical practice that offers practitioners feedback about their communication quality. Malpractice lawyers teach till they’re blue in the face that most litigation comes not from outright mayhem, but from a suboptimal relationship, meaning poor communication. To this P.A., better communication could mean telling the patient she might have liver cancer. Obviously, this is inadequate.

I perennially suggest that we give regular feedback to our practitioners. Unless they receive a praising card or a detailed critical letter, they have no idea whether the quality of their presence is helping or injuring patients.

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