News organizations used Dr. Judah Folkman’s death to report on his decades-long cancer research career. Given his status as a distant, non-celebrity, non-Nobel surgeon, you may be asking yourself why you, personally, should care about his death. Here’s why.

We were in our second year of medical school, feeling the growing pressure of clinical years just around the corner, when we would be thrown into the hospital system. For now, we had lectures in a large hall with 130 students sitting in chairs that sloped down to a stage. Professors came with presentations and handouts and complex diagrams. The immunology lectures were continuous strings of letters and numbers, with only the occasional verb, impossible to decode as human speech without months of training. Every tissue, every disease, every human physiologic function was discussed, down to the sub-molecular level. After hours of these lectures, the air would get stale and backs would ache and the squeak of weight shifting in chairs would become a metronomic beat marking out time that seemed to pass endlessly.

Then, one day, Dr. Folkman walked on stage. He asked us to put down our pens. He said he was going to teach us something that no one else would ever discuss, much less teach. I can’t imagine what he was thinking as he looked out on the sea of our faces. Give or take a few years, almost all of us were twenty-four years old. Almost all of us were single, ambitious, untouched by any of the major human experiences—no children, tragedies, severe illnesses or grief. The youth, the arrogance, the lack of world experience, all of it had to be a daunting, uninspiring sight. Dr. Folkman knew that in mere months, we would be keepers of information that would profoundly change lives. Pathology reports, cancer diagnoses, even the death of a loved one, those were all things we would be telling vulnerable people. Our actions and our words would be often unsupervised, particularly when disaster struck in the middle of the night.

He said he was going to teach us how to break bad news.

In retrospect, the undertaking of such a gargantuan task seems heroic. He only had an hour.

So what did he say? Did he discuss communications theory, or the quality of data about grief reactions, or discuss the role of ethics committees and liability protocols? What was the Judah Folkman set of instructions on how to break bad news?

After twenty years, I still remember it.

First, get a chair. Everyone must have a chair. When it comes to bad news, you must assert authority you didn’t know you had. Insist on having a private room. Move people out, clear a space. You can be a dictator. You get what you need by polite, quiet insistence.

Never give bad news standing up. Never, ever, ever give bad news in a hallway. As you’re getting the room, and the chair, people will become alarmed and ask you what has happened. You wait, saying you’d like to talk about it in private, please. You seat everyone. You take a deep breath, then you say it. And then, most importantly, you say you’re sorry.

You must keep in mind that only the first few words will be heard. After that, the mind shuts out the rest. Sometimes you hold a hand or pat a shoulder. Most of all, you wait. You wait some more. Often, like a trickle before the flood, there will be tears, then sobbing. Your job is to get tissues (if you have not thought to do so beforehand). If there is no crying, you let the silence stretch, no matter what else you have to do. If you have sadly forgotten to turn off your pager beforehand, you silence it if it rings. You can take these few moments for something this important.

Eventually there will be questions. You answer them with the facts you have, leaving out all interpretation, excuses, religion, or philosophizing.

Then, when tears or questions stop, you ask what you can do. You offer a phone. You offer to write letters to airlines, to contact bosses, to do whatever is reasonable and legal for you to do.

And, if the bad news is a death, you then ask for an autopsy.

At this point, as we listened twenty years ago, the auditorium was silent, no chairs squeaking, no pencils scratching, just a stunned sort of silence.

Dr. Folkman went on to explain the data on autopsies, how they are our society’s only way of knowing the truth about disease. He reviewed the accumulated data on the persistent huge discrepancies between what doctors thought was a final cause of death and what an autopsy found. He outlined the advances in diseases that had been made through autopsy information, and the ways in which “incidental findings” could turn out to be very important, especially for surviving family members. He stressed the importance of autopsies in helping us find and correct our medical errors.

Then he told us how to ask for an autopsy. He emphasized that we must remember that the family makes the choice, our job is merely to ask. He told us to say to the family that we ask everyone, because it was important to know what really happened in the end, even in the most obvious-seeming cases. Then he told us to say something that none of us expected. He told us to be sure and say that the autopsy wouldn’t hurt, that in fact, we’d make sure it didn’t hurt. Because that’s what grief-stricken people care about.

He told us that we always, each time, had to do our very best when it came to breaking bad news. It was one of the most important skills for a doctor to have, and that if we messed it up, we would never, ever be forgiven. People remember the doctor who was a jerk to them, in their moment of grief, for the rest of their lives. The story about how the doctor told them their mother was dead while standing in a hallway, or the story about how the doctor ran out of the room to answer a page, or the story about how the doctor wouldn’t even let anyone make a phone call afterward—those are stories that are told and retold within families. That kind of experience affects every impression the family has about all of healthcare.

He was right. About everything. People do cry if you wait. People do care about whether an autopsy hurts. People do remember.

Dr. Judah Folkman’s death is a loss, but many people may not realize how great a loss. Judah Folkman, alone, in one hour, changed not only my life as a practicing physician but also the lives of every patient I’ve ever cared for, and their families. I, for one, went on to do my internship and residency in San Francisco during the holocaust years of the AIDS epidemic. Breaking bad news and talking about death weren’t abstract issues.

And it wasn’t just me, and my patients, and their families who were affected. Dr. Folkman changed the lives of all the patients and families cared for by all the students who sat in that auditorium that day, and all the patients and families of every student every year that he gave this lecture. Later, when I was a resident and then an attending, supervising UCSF medical students, I repeated Dr. Folkman’s instructions to them. And so on, and so on. When you think about these ripples of goodness from one man’s life, they expand further and further out and the numbers become amazing.

So you probably never thought about it, when you glanced at a news item reporting his death. There’s no way you could know. But if you’ve ever had a doctor who was decent to you when tragedy struck, if you’ve ever been given space and time and respect for your grief, you too may have been a beneficiary of the Dr. Judah Folkman legacy.

Jan Gurley is an internist physician who works with the San Francisco Department of Public Health. She blogs at Doc Gurley: Posts from an Insane Healthcare System.

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7 Responses for “The New Doctor’s Desk Reference: How to Break Bad News (For Doctors)”

  1. sm2012 says:

    Dr. Gurley,

    Thank you for this post. I didn’t appreciate the value of mentors when I was younger. After many years of surgery training and practice, I now often find myself remembering my Chairman. I think of his words. At the time, I just thought he was a taskmaster and aloof. But now, I remember – how he thought out steps to a procedure and had triple back up plans, how he rounded with the team every day at 6am unlike most physicians much less most chairmen, how he ran a department, operated 4 out of 5dys of the week, and simultaneously oversaw research, the finances of the group, teams of residents and attendings and medical students. I try, usually unsuccessfully, to emulate him, and to pass on the lessons he taught us.

    Dr Folkman obviously made a huge difference for you. And in an area that so few people ever discuss. I can only imagine what SF was like just as HIV awareness was starting.

    I’ve been taking care of cancer now for several years and I am often struck by the lack of relatability and empathy I see in many physicians. And even more, their inability to deliver bad news. They put it off or deliver a watered down version of truth that doesn’t help patients or their family members to make the decisions they need to. To me, this is an unkindness. But they feel they have done their technical duty. There is a way to give bad news, while trying to give hope and show love. I wish there were more physicians like Dr Folkman around to teach all of us the softer, but critical, skills that we need to truly serve the people we care for.

  2. Jim Salwitz says:

    I had the honor of first hearing Dr. Folkman speak when I was in medical school in 1977 and attended a conference in Boston on cancer research. I remember distinctly that even though his subject was his early animal work on tumor neovascularization, he had a remarkable way of personally connecting to his audience about the importance and potential of his discoveries. He talked not only about microscopic blood vessels, but about miracle cures and hope. Dr. Folkman was a renaissance man who saw as his responsibility not only to disperse information but to excite others to pursue excellence not only in the lab, but at the bedside.

    I believe that doctors have that same broad responsibility. We are bound not only to perform procedures and dispense pharmaceutical marvels, but to guide patients and their families in dealing with disease. Giving bad news “well”, is part of that charge. If we are compassionate we give each patient and family the opportunity to carry on through adversity. If we fail at those vital moments families are doomed to struggle to find the path to healing. A doctor’s job is to help sufferers take the first steps down that difficult road.

    jcs

  3. Suji says:

    This is an inspiring story. I’m not a doctor but I’m certainly aware of this. I salute all the doctors around the world!

  4. Dear Doctor Gurley,

    Thanks for writing this. It should inspire every physician.

    I took the liberty of passing it on to Dr. Folkman’s brother, David. He said “this was so typical ‘Judah.’” He was deeply moved.

  5. Dr. Gurley, I like your tip on never breaking the bad news in the hallway and waiting for everyone to be seated in a private room, but unfortunately this is rarely the case for most doctors.

    I often see doctors break the bad news inside the patient’s room but never asking anyone to get seated. I think whatever position we take it’s still hard to break the bad news to any family member.

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