In the fall of 1970 Philip Tumulty, a Johns Hopkins’ internist, gave a lecture to the 3rd year medical school class at Johns Hopkins. His lecture was published in the same year in the New England Journal of Medicine under the title of “What is a clinician, and what does he do?” (Tumulty PA. What is a clinician and what does he do? N Engl J Med. 1970 Jul 2;283(1):20-4.) In this classic piece, this eminent physician of his era claimed that the primary role of the clinician is to “manage a sick person with the purpose of alleviating the total effect of his illness”. 

This paper, probably better than any other paper I have ever read gets to the essence of what a patient needs from an expert clinical caregiver; it lays out eloquently and robustly the characteristics of a good clinician and what is involved in excellent clinical care of patients. As Tumulty says, it is not a diseased body organ that shows up for physical diagnosis and treatment; rather, it is an anxious, fearful, wondering person concerned about her personal life, including her family, work, friends as well as her hopes and dreams. This means the clinician must be a thoughtful and systematic fact finder, a careful listener, a keen analyst of the facts and a prudent planner regarding which tests and treatment options make the most sense for this particular patient. Moreover, Tumulty rightly assumes that these skills should be embodied in the clinician as natural traits that the clinician genuinely enjoys performing. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

Giving bad news is a difficult thing to do. Receiving bad news is hard, too, but is perhaps a close second to hearing a complicated, vague version of the same set of facts. In healthcare, the failure to disclose pertinent facts in clear, uncomplicated language and verify the information is understood is harmful to the recipient of this information, but also to the provider, who must often untangle the resulting misunderstandings later on.  Families and patients who find they are asking "Why didn’t someone tell me?" may be on the receiving end of an attempt to give bad news.

I tend to think of these vague communication moments as 'dodges.' Rather than stating "I believe your Aunt Lila’s condition will not improve and we need to talk about what kind of care she would want" is instead a listing of diagnoses, medications, lab values, and a review of body systems, surgical options, and statistical probabilities. This type of encounter shifts the focus from the overall prognosis to the details, which though factual, obscure the big picture of a patient who is not expected to recover. Avoiding a frank disclosure of the fact that a patient is doing poorly doesn’t help the patient, and does not help anyone make informed decisions. But it serves a purpose in the moment. Sidestepping the straightforward presentation of bad news may avert or postpone the experience of delivering upsetting news and witnessing the emotional suffering of others who hear it. I get it. It is stressful and distressing to be the source of often devastating news. Yet, we must keep in mind that the news itself is the source of the upset, and the bearer of the news need not feel morally culpably for the facts. The old adage applies, 'it’s not what you say, it is how you say it.' We owe it to medical providers to give them adequate practice and training in delivering bad news as well as opportunities to observe experienced practitioners talk with patients and families when critical conversations are held.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.