The power of honesty

In our hospital medicine group, I’m known as the early rounder. I’m in the hospital by 6:30 a.m., pre-charting, coming up with plans, and being ready to calmly handle the stream of pages at 8 a.m.

One recent morning I had an unwelcome surprise. I saw a patient in his 30s on my list without much past medical history, but there was a note from the night team that the patient was wondering if he could go home and pursue an outpatient workup. In the chart, I read that two weeks ago he began having intermittent fevers, and got an outpatient CT scan of the abdomen and pelvis that demonstrated a “possible chronic abscess.” He was appropriately directed to go to the ED by his primary care physician. Repeat CT scan of the right lower extremity on admission got a better look at the “chronic abscess” and the differential changed from abscess to malignancy. In fact, during their 36-hour wait in the ED, he even managed to get a biopsy sent for cytopathology. Surgery was consulted and recommended MRI soft tissue/tumor protocol to assess for malignancy.

I walked into the room around 8 a.m. and introduced myself. The patient immediately asked if he could go home to make it to a CrossFit class. I paused, and asked if he would be willing to await the MRI so we could help differentiate if this mass was an infection or cancer as it would change what follow-up they needed.

The patient’s face dropped. “Cancer! No one told me that! Are you sure?”

I pulled up his EHR and showed the multiple mentions of “malignancy” in notes and imaging.

“I didn’t know malignancy meant cancer!” he said.

The patient was understandably distraught. I sat with him, asked if there were any questions, and then said I would be back at 10 a.m. on the dot. I rounded on the patient every couple hours to let him know he wasn’t alone.

When the MRI result came back, it was highly suspicious for malignancy. In partnership with his primary care doctor, I was able to get it presented at tumor board three days later.

Lessons learned

The patient had been in the hospital for 48 hours before I met him. He saw three ED doctors, two surgery residents, and one hospitalist. I was trying to figure out how such an important piece of information wasn’t shared with the patient and did some detective work.

1. The patient had access to his EHR, but didn’t know what the word “malignancy” meant, which was the word used in the chart.

2. The surgery residents didn’t disclose that cancer was on the differential as they were worried the patient wouldn’t handle it well.

3. The admitting medicine doctor believed the patient would be very anxious to learn malignancy was in the differential, so they told him the MRI was for underlying pathology.

By the time I saw the patient the next morning, I truly was the first person to mention “cancer.” This encounter caused me to reflect on my practice. Was I too forward? Should I have first asked what the patient knew about their situation? Should I have waited for the MRI result like everyone else?

Here’s what I took away from this experience: 

1. Learn what a patient knows about their hospital course before jumping into the plan, even if they want to get to the plan right away.

2. Always use patient-friendly language.

3. Disclose the differential to the patient, especially when it’s highly likely. They may feel anxiety at the time of disclosure, but waiting too long and ordering tests without informing the patient of the reasoning can result in loss of trust.

Throughout the day, the patient expressed that they were scared, but also told me that they appreciated my presence, honesty, and clear communication. He said he wished the prior providers had been more forthcoming. I was privileged to have earned the patient’s trust and navigate them through the first steps of a difficult diagnosis.

Luckily for this early bird, a lesson was learned; trust was earned.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.