When a half-truth is the best medicine
Working in an emergency room, a young doctor finds that sometimes good treatment means keeping bad news to herself.
Everyone knows that parents worry about their children. It’s just how they’re wired. This is why, working in a busy emergency room, I am more often called on to justify myself when I think less should be done instead of more. Why am I not afraid that the 6-year-old who eats only Fritos and Twizzlers and has not pooped in six days has appendicitis? Because his belly doesn’t hurt when I touch it. Because I can feel the hard balls of stool backed up in his colon. But don’t I think he needs a CAT scan, just to be safe? No, I do not. I think he needs an enema.
In discussing a diagnosis with worried parents, I often find it helpful to talk through all the things I am not concerned about. I mention pneumonia to the parents of a child without a fever – and therefore without pneumonia – because I know their toddler’s cough has convinced them only antibiotics will help. Or I explain how unlikely it would be for a 10-year-old who fell after his friends tied his shoelaces together during gym to have bleeding in his brain. I try to defuse the anxiety in the room so that we can deal with things as they actually are.
But every once in a while I am faced with a patient I feel soul-wrenchingly horrible about, one I take a look at and know there is no way this family’s day is going to do anything but go from bad to worse. And when this happens, I find it hard to know exactly what to say.
For instance, the 4-year-old who had been happy and energetic a week ago but is now dehydrated and listless and has a hard mass in his abdomen that I am almost certain is cancer.
We’re about 40 miles away from Children’s Hospital Boston, with its cancer specialists, and this boy needs CAT scans of his head and chest and belly. He needs more testing of his blood. He needs a bone marrow sample from his hip. Before any of this, though, he needs to be put in an ambulance, and I need to tell his mother why.
There are no rules for how to do this. New doctors are not given a handbook that says how much of the truth we need to tell. We are not meant to lie to our patients, of course, even when lies might be kinder. But neither are we meant to inflict harm.
As we wait for the ambulance, I tell the mother that I am very concerned about her son, but that I am sure the doctors at this other hospital will figure out what is wrong. I say her son needs a specialist, but I don’t say what kind. I am as reassuring as I know how to be, which is what I think she probably needs at this moment, but I also feel guilty about the suspicions I conceal.
I find it difficult to engage in this kind of half-truth, but I also realize that sometimes it is the best thing I can do. In just a few hours, oncologists will examine my patient’s blood under a microscope and make an absolute diagnosis. The word “cancer” will be tossed around more than enough after that. There is nothing to be gained if I say it first.
So I hold my tongue. Instead, I put my hand on this stranger’s arm as her son is wheeled toward the door and I wish her luck. I wish her all the luck in the world.
Three months later, the boy and his mother return to the emergency room. He is transformed, smiling, no longer thin and wasted, and with a completely age-appropriate inability to sit still.
He had fallen off his bike, and his mother is worried about the constellation of small bruises dotting his bare skull. I review his most recent labs and see he is at no risk of serious bleeding. I speak briefly with his oncologist. Then I send him home.
“Do you remember us?” his mother had asked when they’d first arrived. She said it tentatively, almost as if embarrassed to suggest I might find her son remarkable enough to recall the unfortunate circumstances of the first time that we met.
I nodded and smiled. Honestly, not a week had gone by when I hadn’t checked her son’s chart, desperate to find any hint of good news. But she did not need to know that.
Instead, I said, “Of course I remember you.”
Meghan MacLean Weir is a pediatrician and the author of the new memoir Between Expectations: Lessons From a Pediatric Residency. Send comments to firstname.lastname@example.org.