Spoke w/ a junior resident about a tough case. He asked: How do you tell someone they have cancer? How do you comfort them?

I won't pretend to be an expert but explained to him my approach and I'll share one element for #medtwitter users who might find it helpful. A :

1st- this is a huge topic. @SAEMonline has some great resources on breaking bad news. But each situation will always be different. There are so many variables and so much nuance- all of it way beyond the scope of a few tweets.

2nd- a cancer dx (or strong suspicion for it) shouldn't ideally come from the ED. Unfortunately, at my safety net hospital it is not uncommon. This reflects many issues with our healthcare system (cancer care in particular)- also way beyond the scope of this thread.

Worth quickly noting: ED cancer dx is associated with later stages and increased mortality. This study from @MontefioreNYC is illustrative:

https://pubmed.ncbi.nlm.nih.gov/29108643/ 

@IanSolsky @MontefioreSurg

But say you've given a (likely) cancer dx and in addition to coordinating next steps- outpt f/u, sometimes admission, more testing- you want to offer some minor reassurance (NOT false hope or foolhardy prognostication). What is there to say?

First, I like to stress to patients that they did the right thing coming to the ED 𝒕𝒐𝒅𝒂𝒚. Even if it's wide spread and we wish they'd come in sooner. The pt also could've waiter longer and didn't.

Cancer can make people feel powerless. I want to reinforce their agency.

Second, I talk about our specialists and the road they took to become experts. That I'm going to consult/refer to someone who is very smart and knows infinitely more about malignancies than I do.

And I'll spell it out. I'm entrusting someone with your care who...

Was an excellent high school student. Then an excellent college student. Who busted their behind and went to medical school for 4 years. Then studied internal medicine for three years where they spent countless hours confronting problems like yours.

Then they did a fellowship for 𝒂𝒏𝒐𝒕𝒉𝒆𝒓 three years to develop expertise treating cancer. And many go on to complete even more specialized training and research. A 𝒎𝒊𝒏𝒊𝒎𝒖𝒎 of ten years of training after college to even have the opportunity to care for you.

(A similar convo plays out for surg onc.) Ultimately, I am not just referring a pt to someone who knows more about cancer than I could begin to imagine. I am sending them to someone who has devoted their 𝒍𝒊𝒇𝒆 to understand and combat this disease.

And if you're going to have someone helping you to navigate a challenging time and scary disease, that is 𝒆𝒙𝒂𝒄𝒕𝒍𝒚 who I'd want on my team.

Of course, this isn't meant to ameliorate cancer diagnoses. But if conversations like this can offer even a small measure of reassurance- or make the next steps in cancer care seem just slightly less intimidating- I'd argue it's a worthy endeavor.

But I'm also interested to hear if anyone else on #medtwitter has unique approaches to these sorts of conversations in the ED. I would love to get any insights you all have to offer.

Photo credit: @JeffStapleton