Dealing with 'the shoe problem'

BBC writer Ivan Noble, who died last week, was hugely grateful to his doctors. But he felt strongly that the medical profession needed to work on its techniques for breaking bad news - what he called 'the shoe problem'. Here, one doctor, Stephen Kettlewell, explains that frankness is often the only considerate approach.

I'm a surgeon working in Scotland, and I was one of the thousands of people who sent messages to Ivan Noble having read his columns. Like all those people, I'm deeply saddened at Ivan's death, and send my condolences to his family.

I wrote to him in July last year after he had written about the difficulties in breaking bad news. He had written, memorably, that 'the shoe problem' needed addressing. 'When delivering bad news,' he wrote, 'a doctor really should be looking the patient in the eye, not staring at his or her feet.'

Cancer is cruel because it tells us something about the future - it gives you a vision of what is to come that you would not otherwise know about Stephen Kettlewell

His thoughts on the subject were a useful reminder that what may be another day at work for a healthcare professional is perhaps the most stressful day in the life of the patient. I agreed with him then - and still believe - that breaking bad news can be a very hard thing to do.

Perception

In my experience however, most patients seem to know that you are about to give them bad news as soon as you walk into the room. Many of my colleagues would agree with this, and I suspect that it must be down to body language or the patient's own perception of their problem.

I have to say that I could probably count on my fingers the number of times people have been completely surprised by what I have had to tell them - though I must say that when people have been surprised, they have usually been young.

I have learnt that patients often don't take in much of what they have been told. So I try to be as forthright as possible.

It's actually very difficult to look somebody in the eye and tell them that, yes, the results of the tests have come back and that they have shown we are dealing with a tumour.

On a human level, telling someone that their hopes and dreams will not come true and that they have an illness which no one in the world can cure is a profoundly tough thing to do.

Acceptance

It's well recognised that there is an 'acceptance curve' with bad news - any kind of bad news, actually, whether it's health or marriage or financial or something else. People will go through denial, anger, depression and may finally end up at acceptance. So we as doctors need to allow people to go through that curve.

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One thing I have tried in the past is to record the 'bad news' consultation on tape and give it to the patient who can then go over the details later, since most information given subsequent to the 'I'm sorry it's cancer' statement is forgotten.

Their minds are suddenly racing. But at least if they have a tape with them, they can take it home and, when they have had a few hours to absorb the initial information, they can hear the rest of the details again.

People assume the worst - they perceive cancer to be a life-threatening, often fatal, illness, and unfortunately that's largely true. This sometimes means that doctors sweep it under the carpet and aren't as clear with patients as they could be. It's not true across the board, and I think the norm nowadays would be to be as clear with patients as possible, but a lot of doctors do obscure what they are trying to say.

Having said that, I have seen patients with dreadful tumours who have made remarkable recoveries. I suspect this is one of the reasons some doctors are tempted to err on the side of optimism when giving bad news - simply because the person sitting in front of them could be the one patient in ten with that kind of cancer who will live beyond five years.

Empowering

Cancer is cruel because it tells us something about the future - it gives you a vision of what is to come that you would not otherwise know about.

It can, however, be used to empower patients.

A colleague had a patient, a young woman who had a cancer from which she was going to die. No doctor really knows how long a patient will live, so my colleague explained frankly how long she might live if her cancer went untreated, and how long she might live if she received chemotherapy.

But he also explained the impact that treatment would have on what time she had left.

The woman disappeared, but one morning her mother arrived at the hospital bearing a letter for my colleague. The letter was from the young woman, and it said that the fact my friend was receiving it meant that she had died.

But it also said that in the time since her diagnosis, she had travelled to all sorts of places round the world which she had wanted to visit. She thanked him for being so frank and honest - it had allowed her to make the most of the time she had.

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Add your comments on this story, using the form below.

When I was diagnosed, my consultant told me over the phone in a very brusque manner. Still, I guess at least he didn't the have dilemma of whether to look me in the eye or look at his shoes! Your mind does race after hearing the dreaded word "cancer" and, by the end of that 90 second call, I didn't know if he said I had Hodgkin's, non-Hodgkin's or what the hell I had (I'd not really heard of either of them). However, since that initial call (which I definitely wouldn't recommend as a way to tell someone), my consultant haematologist, the chemo nurses and the care I have received have been second to none. I'm now 5 1/2 years down the line and, every time I go back for my check-ups, my doctor tells me that the type of cancer I had always returns. I actually now call him Dr Death as he's always doom and gloom but I will always want him to be totally honest with me (however hard that may be for both of us).
Tina, London

My husband and I were told by a sonographer (ultrasound technician) at our 20 week scan that our unborn son had a problem with his brain. Not only was she unable to remember the name of the condition (!) but she wouldn't or couldn't look at us, and we got the distinct feeling she wanted us out of the room as soon as possible. The consultant we saw hours later was not much better, but at least she gave the condition a name. Every time we asked what this meant it was a 'Dismal outlook'. We both left with an impression that nobody wanted to associate with us, as if our child's condition was contagious. Thankfully we found a UK Charity called Antenatal Results and Choices (ARC) who, in addition to supporting parents, offer training to medical professionals on how to give bad news.
Debby, Surrey, UK

I was one of the lucky ones. My consultant looked me straight in the eye and said "Well Mrs H there is definitely a tumour, I will need to take a biopsy and wait for confirmation - but you and I know exactly what it is, don't we? I will get a bed booked for you in anticipation of the results." Breast Cancer was diagnosed and I was admitted within three days. In the ante-room of the operating theatre he looked in, smiled broadly and said "Well, Mrs H at the moment you have a Cancer ¿ but in 20 minutes it will be gone!" I believed him! After radiotherapy and chemotherapy I was fine. That was ten years ago.
Patricia, UK

A couple of years ago I sat with my brother while he got news of his second brain tumour. The doctor was unable to say the words "cancer" or "tumour" (relying on "abnormality") and was so embarrassed that it was terrible. A second doctor, who specialised in cancer, was dead straight and factual and it was so much easier.
Ian, UK

I really wish that more doctors would present the pros and cons of chemotherapy as you've described. My experience of my late mother's treatment, and now my mother-in-law's treatment, is that doctors simply assume that everyone should have chemotherapy, even when there's no hope of a cure, and little hope of a significant remission. They even seem to go into 'hard selling' as if it were a time-share option. The option of trying to make the most of your last few months without endless hospital appointments and crippling side-effects is not even discussed.
J Ellis, Bristol, UK

I am impressed by your forthright comments. I know that, much as I would dread hearing bad news, I would want to know the facts if a serious illness happened to me - and hear them from my consultant rather than looking them up on the internet later on. I have found that hospital doctors tend to simplify things - one said "ok, funny noise coming" and when I said "Look - I do have a degree you know!" he started to explain in detail, which was what I needed to hear! Knowing the facts is very important to me in how I can deal with something, but I accept some people will just not want, or be able, to listen. The tape is a very good idea.
Flash Wilson, East London, UK

I agree about Doctors/Consultants being reluctant to be frank. My wife was recently found to be suffering from cancer and I was with her at each consultation. The Consultant, who was clearly not able to handle the situation, took three meetings to hedge around the point, and only got as far as 'cancerous cells have been detected', despite being in possession of CT and MRI scans that clearly showed the extent of the problem. We only got shown these, and had the situation fully and frankly explained when we met the Oncologist for the first time. However, the Oncologist combined kindness and frankness in a highly professional manner that improved our attitude to, and understanding of, the illness. We now know what we are facing, we know the Oncologist is honest and capable. Life has become a little easier, and we have confidence in them. We were not at all impressed by the Consultant's attitude or their methods which caused weeks of needless delay and uncertainty.
Chris, UK

The consultant who spoke to my mother re her cancer condition opened with the statement "Well, have you been told how long you've got left?". My mother was slightly taken aback by this blunt approach but it had a devastating affect on my niece who accompanied my mother to the hospital appointment. I agree bad news is not easy to break for some doctors however, nearly 11 years after my mother died I am still angry that she was asked such a straight question when she was completely unaware that her cancer was terminal.
Andrew, Edinburgh

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