How To Convey A Difficult Diagnosis To A Patient

   Most aspects of being a small town podiatrist are easy and pleasant. My patients almost always leave feeling better than when they arrived. Most are grateful and express it with their thanks or occasionally by leaving a batch of freshly baked cookies. I arrive home most evenings with my emotional cup full to the brim. Tonight, I came home on empty.    Earlier this week, a vivacious woman in her mid-30s came to the clinic for help with a mole on the sole of her foot. Her doctor had been concerned when she found it during a routine yearly physical. The lesion was less than 1 cm. It was uniform in color with a geographic character. If I had found it on my foot, I probably would have measured it and ignored it. She explained that her doctor was concerned and wanted it removed for biopsy.    I blocked the area and removed the lesion using a double elliptical incision. I sent the specimen to the lab, anticipating a benign report. I arranged to see the patient a week later in order to review the report and take out the sutures. We had an enjoyable visit and reminisced about when she was a child. Her parents had been friends of my wife and I. This is the part I have enjoyed about working in my hometown. Most patients are connected in some way to my past.    Her chart with a yellow pathology report was lying on my desk this afternoon. The words “malignant melanoma” and “Clark’s level 3” and “incompletely excised” jumped out at me. I have been through this a handful of times during 30 years of practice. There never seems to be a right way of letting a patient know her world is about to change.    One thing I have learned is to have a care plan in mind before I call the patient. In this case, I phoned a friend who is an orthopedist and an oncologist at the Seattle Cancer Care Alliance to arrange for assistance with the care of this young woman. I chatted with him for a few minutes and then presented my patient’s case. He agreed to accept her.    Calling the patient was the hard part. I called her at work and asked if she could come to my office to review the result of her biopsy. She asked if it had to be today. I told her, “Yes. It’s important.” She showed up an hour later and brought her sister along. She suspected she would need the support.    I sat them down in a quiet room and told my patient she needed to thank her family doctor for saving her life. I then told her she had a malignant melanoma. There was the immediate moment of shock with both women. I let the news sink in and the shock wear off. Then I explained the seriousness of her diagnosis. I also explained that a Clark’s level 3 melanoma was treatable and that early evaluation and treatment would give her the best chance to survive the illness.    Waves of shock seemed to roll over the two sisters until they were just able to sit and cry. I took both of their hands, sat silently and waited for them to settle before I went on to explain the plans I had made for her continued care. Finally, they both stood and hugged me. They thanked me for calling them in and got the information on the Seattle cancer center. They left the clinic in a state of emotional shock.    I placed a call to the family doctor to let her know the biopsy result and the plans for continuing care. She was grateful that the hard part had been done and her patient had been accepted by one of the best cancer surgeons in the country. Since the hard part was over, I returned to the easy part of my job. The next patient was annoyed because she had waited 30 minutes for a toenail procedure. I explained to her that I am just getting slow in my old age.    I arrived home this evening with my emotional cup empty. I told my wife about my difficult day and my cup was again half full. I sat down tonight to tell my readers about the hardest part of being a doctor and my cup is once again full. Thank you. Dr. McCord is a Diplomate with the American Board of Podiatric Surgery. He practices at the Centralia Medical Center in Centralia, Wash.