Kasey sits alone in the examining room, staring at the drug company calendar of a perfect Caribbean beach hanging above the doctor’s desk, but not seeing it at all. She is very frightened.  After three years of treatment for cancer, she is in trouble.   Kasey feels fine: no shortness of breath, no cough, no pain.  Still, she is there to get the report on her CT scan, and she knows that something terrible is going to happen.  Kasey is about to visit the bad news doctor.

In all the time she has been coming to the medical group, Kasey has never met Dr. Cassle.  At one time or another, each of the other four doctors and two nurse practitioners has talked with her, examined her, treated her.   When she passed Dr. Cassle in the hall, he never made eye contract.  He looked stern, even depressed.  He saw fewer patients than the other doctors and he has a reputation for long visits with each, often running behind.  He is older, greyer, sadder: a grumpy grandfather.

A year ago, Kasey had seen, for the second or third time, a patient leaving an appointment with Dr. Cassle in tears.  In fact, the whole family seemed devastated.  That was when Kasey figured it out.  Dr. Cassle’s job in the practice is to inform patients when things take a turn for the worse.  Pull the plug on hope and prognosis.  Start talks about palliative care, hospice, end-of-life and give each patient a slight nudge toward the great beyond.  Dr. Cassle is the bad news doctor.

Therefore, when Kasey had shown up for her appointment with her usual doctor, and been informed that she was scheduled instead to see Dr. Cassle, her heart sank into her stomach and she almost threw up on the desk.  She knew that whatever was on the new x-ray was not good.  So, as she sits in that cold prison with its sterile calendar Kasey is trying to get control, but finds herself fixed on how ridiculous and worthless are the words “get your affairs in order.”

After too long, which is probably only minutes, the handle turns slowly, very slowly, and the door gradually creaks open.

Dr. Cassle walks in, a single sheet of an official looking document in his hand.

The door closes.  Silence.  Too much silence.  Finally, the doctor speaks.

“Good morning, Kasey, I don’t think we’ve met before, I am Steve Cassle.”

“Hi,” is all Kasey can muster.  Still she takes his handshake; firm, warm, dry, and feels slight comfort in his easy half smile and direct gaze.

“Sorry to screw you up this morning, but your doctor had an emergency, so I am covering some of his patients.  How are you doing?”

Kasey is confused.  What was going on?  “I’m fine. I guess.”

“That’s great.  Nothing new I should know?  No new medical care or problems?”

“No, I have been doing really well.”

“That’s excellent.  Are you sure nothing is going on?  You look worried.”

“I guess I am worried about my CT scan.”

“Your CT scan is fine. We looked at your chest and abdomen.  It looks great.  No problems.  You are well healed and there is no sign of cancer or any other problem. “

“Really?”

“Yes, definitely.  Why were you so concerned?”

“Well, I thought that was why you were seeing me this morning, instead of my regular doctor.  I thought you were going to tell me that the cancer has come back.”

“Absolutely not.  That was just a last minute scheduling problem.  And I can tell you this: If there is important news to tell a patient, like maybe there is a problem, your primary doctor will be the one to tell you.  He knows you the best and would always want to take responsibility for important changes in your case.  We would never, unless it was a true emergency, let you learn bad news from someone you don’t really know.”

”But, I thought you were the bad news doctor.”

It is Dr. Cassle’s moment for confusion.  He smiles. “Well, some days it feels like that.  But, we all take care of our own patients, through good and bad.  Why did you think that giving bad news was my job?”

“I really don’t know.  I guess cause we had never really talked.”

“Well, I am glad that the first time we talked, I was able to give good news.”

Reputation is a frail thing: a mixture of good and bad acts, appearance, projected assumption, subjective thought and the prejudice of others.   Because we cannot actually meet and talk with every person, every doctor, we rely on reputations to guide us.   Still, sometimes, maybe often, it can lead us astray.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.