Tina Zhu
Today, as my colleague and I worked together on our upcoming teaching session, she brought up an interesting case that we saw recently along with the "think tank". Although this particular patient had a very striking cutaneous presentation, we were more perplexed by the art of disclosure that we observed during this encounter. The physical findings of this particular patient strongly (80-90%) suggested underlying malignancy to all of the medical professionals who were present. However, it was clear that the patient was unaware of these implications since the patient did not feel otherwise unwell except for the cutaneous findings. Although we did explain to the patient that there was likely an "underlying cause" for the presentation, there was no explicit mention of the C word during the physician-patient interaction. Instead, a full body CT scan was arranged urgently and the patient was told to return to clinic after the investigations.
I must admit, I initially agreed with the extent of disclosure that the team had chosen. I reasoned that if we had told the patient that there was a high possibility of malignancy without any concrete proof, such as imaging, we would just be causing undue anxiety for them. However my colleague disagreed. She maintained that we should have been more explicit when explaining the potential "underlying cause" to the patient so that the patient is not disillusioned into thinking that we were looking for something benign. After some back-and-forth discussion, I must agree with my colleague in that if I were this patient, I would have wanted a little more clarity regarding the medical significance of my symptoms. Although it is unclear whether this particular patient shared my views, since some patients do prefer to not know their diagnosis, potential or otherwise. In hindsight, there were probably moments during the conversation when we could have segwayed into a discussion regarding the sinister nature of the findings, but instead, we all tip-toed around the subject.
In the past, when we discussed the topic of disclosure in the classroom, it had always been a relatively black and white case of whether or not to disclose when a patient's family member requested to withhold the information. However, this particular case represented a much more gray area of disclosure in the face of diagnostic uncertainty. At what point, do we tell our patients that we suspect cancer even though further work-ups are still pending before we can be certain of the diagnosis? Is there a cut-off point depending on the strength of our suspicion? And how does the patients' wish for clarity factor into the equation? How do we even gauge what the patients' wishes are in the cases of diagnostic uncertainty? Should I begin each new patient consult with "How high should my diagnostic certainty be before I disclose that you may have cancer? Rank from 0%-100% certainty"? Ok, maybe I'm being a bit fastidious here, but you get my drift. Unless the diagnostic certainty is 0 or 100%, everything in between represent a massive area of gray regarding best practice in disclosure and there are definitely no evidence-based guidelines to help us navigate this unfamiliar arena. I guess this is what they refer to as the "art of medicine".
Thus far in my education, much of the learning focused on the science of medicine with lectures, readings, and exams. It is only recently, during clerkship, that I have started learning the art of patient interaction, through observation of staffs and residents, as well as reflective discussions with colleagues, both through structured educational activities and in informal settings. Personally, I have found the informal discussions, such as the one today, most enlightening and I must thank my colleague for sparking this particular reflection.
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