'When the Sorrows Come': Dealing With Bad Days

David J. Kerr, CBE, MD, DSc, FRCP, FMedSci


March 13, 2018

Hello. I am David Kerr, professor of cancer medicine at the University of Oxford.

For those of you who have seen me on Medscape before, you are used to me waffling on about some aspect of gastrointestinal cancer, some aspect of science, of molecules, of biomarkers, whatsoever. Today I am going to talk about something a wee bit different.

Fridays are our clinic days, and yesterday I think we had a bit of a hard time of it. As Shakespeare said, "When the sorrows come, they come not single spies, but in battalions."[1] We just had a bit of a busy day in terms of breaking bad news to patients. All of us have those days. Usually they are spaced out, but sometimes they just come as a small tidal wave of misery, and this made me think again about how we communicate with patients.

I have been a cancer doctor for more than 30 years, and I think I can say with some proof that I am an experienced, good, and maybe even a bit of a gifted communicator. Is it not interesting, though, how often our patients say "thanks" at the end of the consult when we have broken the worst of news? It always makes me think of Raymond Carver—my favorite American author—who was famous for his short stories and poems, and who was called "the American Chekhov."

If we had to categorize Carver, he would be in the school of American realism. He died of lung cancer at age 50, after years of too much alcohol consumption and heavy smoking. He wrote a beautiful poem titled "What the Doctor Said."[2] A memory like a sieve cannot recite it, but I would really like to read it for you. Excuse my funny Scottish accent.

"What the Doctor Said," by Raymond Carver:

He said it doesn't look good

he said it looks bad in fact real bad

he said I counted thirty-two of them on one lung before

I quit counting them

I said I'm glad I wouldn't want to know

about any more being there than that

he said are you a religious man do you kneel down

in forest groves and let yourself ask for help

when you come to a waterfall

mist blowing against your face and arms

do you stop and ask for understanding at those moments

I said not yet but I intend to start today

he said I'm real sorry he said

I wish I had some other kind of news to give you

I said Amen and he said something else

I didn't catch and not knowing what else to do

and not wanting him to have to repeat it

and me to have to fully digest it

I just looked at him

for a minute and he looked back it was then

I jumped up and shook hands with this man who'd just given me

something no one else on earth had ever given me

I may even have thanked him habit being so strong

It is a funny paradox, is it not, and one that is so ingrained in a patient-doctor relationship that we are thanked for breaking sometimes disastrous and miserable news.

So, there you are—a difficult Friday and a wonderful poem. If there is one thing to take from this, read some of Raymond Carver's poetry. It is fantastic. Read his epitaph; read what is written above his grave about being called beloved.*

Thanks for listening. It is not quite our usual talk—I know that. For those of you who would like to comment on anything, of course, please do so, but do read Raymond Carver.

Thanks for listening, as always. For the time being Medscapers, ahoy.

*Editor's note: Raymond Carver's epitaph is from his poem "Late Fragment," published in the collection A New Path to the Waterfall.


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