It’s not deep

Highly commended in ‘The patient that taught me’ category, Dr Toni Munno on a case of delivering bad news close to home 

It’s not deep   

The teenager was critical of how I had broken the bad news to her.  An MRI for back pain had shown a sacral abnormality. She was now on the sarcoma pathway at a specialist centre. 

It’s not deep. What she meant was don’t be so bleak about it, stop making everything so black. I thought back to what I had said and how I had said it. I felt bad. 

What made it worse was that this teenager was my daughter.  

The day before I received the MRI result, I had been teaching medical students as part of a series of sessions on clinical communication skills. The topic that day was breaking bad news. I had taught that workshop for years and knew the content well. Now here I was, 24 hours later, planning how to tell my daughter the outcome of her scan. I thought it might be better coming from me rather than delaying and waiting to see the specialist again.   

To break bad news as a dad would be raw and painful. But, at least I had a structure to guide me as well as years of experience. With the students, you map the process as a series of blocks and assure them that with an empathic ear, time and practise the stages weave together: establish the patients starting point; bridge the gap with chunks of information; consider a warning shot; recognise and allow for emotion.  

It’s not deep.  

That was her reaction. 

That criticism wasn’t to do with dad-daughter awkwardness but something more fundamental with how I had gone about delivering the news. I realised it was about tone and emphasis; in my discomfort I spooled back over years of professional conversations and began to hear the echo of the same pattern: an omission, an absence. The absence of hope.  

‘Don’t forget to offer hope’ had come up at the tutors’ meeting a few weeks earlier when we had mapped the new role-play scenarios to our teaching model. The comment was a snatched and urgent interjection made by one participant as we all signed off. ‘Offer hope’ was an afterthought to the meeting – seemingly disconnected to our model and resources. I didn’t give it much thought: at best it sounded like a platitude, a banal instruction to ‘be nice’ or ‘be kind’ – and at worst it sounded like a device to make it easier for the deliverer of bad news to pull back from being honest.  

I could now see that ‘hope’ was more than that. Much more.  

A determination to ‘be honest’ had burdened my approach with such weight that my preferred route through that path of information and emotion – the hushed voice, measured words, the pregnant silences, the tilt of the head – had created a black hole of intensity. A hole with no light and in which there was no space for hope. Too deep. 

My daughter had taught me that hope illuminates that darkness and from it, we get closer to that precious and fundamental part of our role: to alleviate suffering. 

(PS my daughter is doing very well. She has just turned 18, has read this article and is happy for it to be published along with my name.) 

Dr Toni Munno is a salaried GP in Bedford.