Breaking bad news to patients when they are alone [PODCAST]

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“Today, we got called on a patient in the ICU who recently had a new brain mass removed surgically. The specimen came back positive for an aggressive brain tumor known as glioblastoma multiforme. We discussed his diagnosis and prognosis with him at bedside alone, with his wife and daughter on speakerphone given visitor restrictions due to the current coronavirus pandemic.

Unfortunately, this type of situation is rather familiar to us. We are used to breaking bad news, comforting patients during their times of need, and then shifting to our usual survival tactic of orchestrating a treatment plan. While many aspects of this exchange were similar, there were unique variables that grabbed my attention, given our current circumstances.”

Azam J. Farooqui is a hematology-oncology physician.

He shares his story, global health perspective, and discusses his KevinMD article, “Breaking bad news to patients when they are alone.”

This episode is brought to you by Saykara, the first voice-powered ambient virtual assistant.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Azam Farooqui. He is in his last week of hematology-oncology fellowship, going to be an attending next week, and he wrote the KevinMD article “Breaking bad news to patients when they are alone.” Azam, thank you so much for being on the show.

Azam J. Farooqui: Of course. Thank you for having me.

Kevin Pho: So tell me a little bit about your story and your journey to where you are today.

Azam J. Farooqui: Yeah, so, just some background: I was actually born in the Midwest, in Chicago, grew up in the suburbs of Cincinnati, moved back to Chicago, and did med school at Rush, which is essentially in downtown Chicago. I actually met my wife there. We couples matched to residency in internal medicine at Indiana University in Indianapolis, and we actually couples matched again in our fellowships. I’m obviously finishing up heme-onc, and she’s finishing up GI. We’ve been in St. Louis for the past three years at St. Louis University, and like you mentioned, we’re finishing in the next week, and then we’re actually moving to Arizona to both begin our attendinghood. So we’re very excited.

Kevin Pho: Well, thank you, and best wishes on your future endeavors.

Azam J. Farooqui: Of course.

Kevin Pho: So we read a lot about how patients are dying alone in the ICUs in the pandemic because of visitor restrictions. Now you’ve actually seen it for yourself. You’ve experienced it, and you wrote about it. So let me start by reading the first paragraph of your article. You write, “Today, we got called on a patient in the ICU who recently had a new brain mass removed surgically. The specimen came back positive for an aggressive brain tumor known as glioblastoma multiforme. We discussed his diagnosis and prognosis with him at bedside alone, with his wife and daughter on speakerphone given visitor restrictions due to the current coronavirus pandemic.” So tell me the story behind that article and why you decided to write it.

Azam J. Farooqui: Yeah, it’s funny. Actually, I started writing as kind of a stress relief when I started fellowship. Heme-onc is obviously an incredible field, and I’m very happy to be a part of it, but as you can imagine, it can be very heavy at times. I’ve constantly, since medical school, been looking at ways to channel stress and achieve a balance within life. And it’s funny, I wish I actually had started writing in residency, but in fellowship, my first year, I started just documenting very emotional patient cases that really struck a chord with me.

It’s interesting, because I hadn’t written in a while. Really, the reason I wrote this little piece and kind of wanted to document this story was because it was kind of right at the height of the COVID anxiety that was overwhelming our hospital, my friends and family, all of us. So it was really kind of more of a stress relief, just to kind of get that on paper.

I mean, the story overall is a very common phenomenon. In oncology, we break bad news all the time, and we see very unfortunate stories on a daily basis. I kind of find that each individual oncology story is almost a mini tragedy in its own and, honestly, could have been its own article. I think that one really stood out to me because that was one of the first patients I saw amid all of the COVID hysteria, and it just was something that I took home and wanted to get out. We’ve been checking on that family ever since, and they’re doing quite well.

But it was definitely a very reflective time, in that I think before that, I had definitely taken family for granted to an extent, as far as our patients’ family, because they’re honestly an enormous asset to us and our patients. And so their absence was felt enormously by us, the ICU providers, and everybody, and even to this day we’re still feeling it as COVID continues.

Kevin Pho: So what kinds of things are you and your staff doing within the hospital during a pandemic to make these patients feel less isolated?

Azam J. Farooqui: Yeah, that’s a great question. At the beginning, just like I’m sure you and many of us have experienced, there’s been a lot of learning. It’s been a learning experience literally since day one. We’ve already done a great job just kind of navigating around the social isolation that’s happened, and the fact that a lot of testing and imaging has had to be either shifted or changed as far as our surveillance goes for our cancer patients.

As of right now, our hospital’s COVID numbers have been decreasing steadily. Again, with our state opening up a little bit more in Missouri, those numbers might surge back, so we are prepared for that. But we initially eliminated visitors attending visits for our patients. We’ve started to kind of allow certain ones in if they’re screened properly. We usually try to get patients on speakerphone with all of their appointments. We’ve actually been using Zoom quite a bit just to do video conferences as well, so if patients can make it, we’ll usually Zoom in with them and their families, which is wonderful.

But there’s still that absence when they’re not in the room. It’s interesting, even on Zoom: Like an inpatient visit, I feel like you just get a lot more out of the patients. You feel a lot more with them. So it’s not the exact substitute that we would like, but it’s definitely making things a little bit easier at this time. So we’ve been doing that, and it’s been going pretty well. I think the patients have gotten used to it now, too.

I think the new diagnoses are still really tough. I mean, a cancer diagnosis is honestly earth-shattering, just because the word cancer has such a heavy connotation to it. That alone, I feel like people will really stop listening once you say the word cancer. So sometimes the family members are really there to help absorb that information, translate things to them when they get home, kind of be the voice of reason, kind of explain things to them that they might have misinterpreted, and just kind of be an emotional crutch and support for them, too. So I think that absence is really strongly felt, and I can sense that there’s a lot more anxiety and tension in some of the visits without a family member directly there.

When they’re on the phone, and I kind of expressed this in the article, it’s funny: Technology is wonderful, but when there’s a bad connection or a call gets dropped, you can feel the frustration within the family member on the phone, just being like, “I can’t hear you guys.” And actually, with wearing masks now, just the other day I had a family member saying, “Can you please take the mask off or put the phone right up to your face, because I really want to get down everything you’re saying to my mom right now.” So I think it’s just a challenge that we’re constantly working through. It’s definitely made us way more appreciative of our family members when they’re there, and of taking the time to really make sure that they’re involved.

And actually, sorry, the other thing that we’ve been doing is, I find that I’ve been calling family members individually a lot more than I was before. A lot of times they’ll be in the visit, and you’ll be talking to patients, and they’ll be listening in. But because of COVID, I’ll actually say, “You know what, I’m going to call your sister as soon as you leave here.” And in some ways, I’m actually getting a lot more of a personal connection and conversation with them. So that’s actually a learning lesson that I hope will continue even after COVID, where I’ll try to direct some of the care and discussion with really key family members from here on. So I’m just trying to find the silver linings in this, and I think those are a few of them.

Kevin Pho: Sure. Is there anything that you know now that you wish you knew back before the pandemic started?

Azam J. Farooqui: Yeah, I mean, that’s a great question. I think just having an understanding of how it was going to affect our cancer patients has been huge. So it’s interesting: My wife’s in gastroenterology, and so we have these parallel experiences that we’ve been comparing, and a lot of her visits were able to be changed into telemedicine right off the bat. A lot of cancer patients still have to come in, whether it’s for a chemotoxicity checkup, whether it’s to come to infusion to get chemotherapy, whether it’s to get surveillance imaging, or even a concerning finding that we need to work up. And so they have a lot more touches within the health care system that are really necessary.

And while I would say that it’s essential care, we’ve had to kind of navigate through and figure out what’s really necessary or not. I wish that I had a better grasp of that before the pandemic, like which chemotherapy can we delay, or what imaging scans can we spread out to wider intervals? What I will say is that the national organizations, like the American Society of Clinical Oncology and the American Society of Hematology, ASCO and ASH, have done an excellent job creating webinars and free educational sessions for providers on every tumor type, to say, “You know what, in breast cancer, maybe you can space out mammograms to this interval to kind of give yourself a few months.”

Obviously, knowing that ahead of time would have been a lot more helpful, because there were a lot of questions coming our way from our cancer patients, like, “Is my treatment going to be affected? Is my immune system going to be so much lower that I’m going to be at higher risk? So should we stop?” So that created a lot of tension at the beginning. It’s gotten much better with time, and a lot of our patients would have done pretty well. We haven’t had too many hiccups with their treatment. So those are all things that, again, were impossible to know before the pandemic. But God forbid if we have another pandemic, I feel like we have a lot of protocols that we’ve already created, which is awesome.

Kevin Pho: Well, you’ve given us so much great advice and insight. So I was wondering, is there one tip, the most important tip, that you give to other physicians who want to maintain that doctor-patient relationship with the pandemic emphasizing virtual visits, when they may not be able to see their patients in person as much? What’s that one tip that you could give to other clinicians?

Azam J. Farooqui: Yeah, again, great advice, too. It’s funny, because I’ve gotten so many tips myself from my mentors and peers, so it’s just passing along their advice and wisdom. But I really feel like it’s easy to stress, and it’s easy to get overwhelmed, and that’s the case for providers, and it’s even more so for a patient with cancer. So one of the things I found is that a lot of the patients are coming to us to be that stabilizing factor: with questions on COVID, trying to clarify things that they’re seeing in the news, because misinformation is unfortunately a big issue right now; to clarify treatment; and to get reassurance on their treatment.

So I feel like just maintaining calm, trying to maintain a voice of reason, and kind of providing a level of reassurance to our patients is huge, whether that be to kind of take the extra mile to make an extra call or two to talk about the scans, or make an extra call to their family member who’s a key stakeholder in their care and really wants to know what’s going on. I think just providing extra stability to them at this time is key. And I really feel like we have the means to do that, because we’re armed with knowledge. Fortunately, I think the health care system, for the most part, has rallied greatly to the COVID cause. So just kind of using all the tools and resources we have to advocate for them has been key.

So I think just kind of maintaining calm, and realizing that you’re a stabilizing force, not only within cancer but in a lot of these patients’ lives, to get valid information, is key. So continue the education, continue to reassure them. I think that has been probably the biggest asset for me so far.

Kevin Pho: So let’s take a step back. I was wondering if you could share something that you’ve been curious about or something that you’ve been passionate about recently.

Azam J. Farooqui: Yeah, again, that’s a great question. I actually feel like one of the biggest things that I’ve been really passionate about, and I guess curious and excited about, relates to COVID, but also to a lot of the other tensions that are going on in our country right now, with racism and all the other things surrounding the George Floyd killing. I feel like I’ve seen the medical community become a lot stronger in their advocacy and activism in the community, and I feel like that’s awesome.

It’s funny, I was just at a White Coats for Black Lives protest, a peaceful protest, yesterday, and I remember my wife and I were there. We were both commenting on all the medical students there, all the short white coats. They stick out like a sore thumb, which is a good thing, and honestly, I loved it. I feel like, seeing this generation of doctors, and I mean, I’m technically still a young trainee, but I guess I’m still in that older generation, I just see a lot of activism happening. I feel like I’ve been seeing a lot of doctors rallying to each other’s side, with COVID especially, and then now even with this new movement. I think that’s been really great, and it’s been inspiring for me and my wife to kind of get more involved and to educate ourselves more on what’s going on with both COVID and a lot of the other public health emergencies going on in our country. Seeing everybody’s excitement and seeing our physician community kind of rising with those challenges has been awesome.

I feel lucky every day that I’m in a field of work that’s inherently altruistic. Just the nature of medicine is to help others, and I just feel like this has been a great reminder that that’s really what we’re here for. A lot of times in medicine, we get caught up in the red tape and a lot of the other clerical and administrative duties, but in some ways, this really intense year has kind of stripped some of that away and kind of looked at what’s really important in our health care system and with us as doctors. So I just hope that that continues and we can actually make changes within the health care system and society moving forward.

So I hope with all this activism, physician voices get louder. I hope that we get more involved in politics and advocacy-related issues. And again, that’s also why I really respect and appreciate what you’ve been doing with KevinMD.com and these interviews, because I was just watching the interview you had with a young fourth-year medical student who wrote a piece on undocumented and immigrant workers, and that’s incredible. So thank you for giving us more of a voice and for getting our names out there, because I feel like that’s all going to be really helpful in the next year or so.

Kevin Pho: Oh, thank you so much for sharing that. So my final question: What’s your take-home message for my audience?

Azam J. Farooqui: So my take-home message, I think, as far as it relates to my article, is again: This is a super stressful time. Continue to practice compassion. Continue to be aware of what’s going on with your patients’ lives, with your nurses’ lives and your other ancillary staff in your clinics, as well as yourselves. Writing for me was a great tool that I added to my repertoire of life balance and fellowship, so keep striving to find those types of things. And just take care of yourself, and take care of patients.

I think we’re going to all get through this pandemic together, and there’s still quite a bit of work that has to be done. But if you see something, if there’s something that really strikes you, write it down, communicate it, and talk about it with your community, your family, and the people in your life that you care about, so that you’re connecting and engaging on that higher level. I think that’s really the biggest thing that I’ve been learning through this pandemic to get through it, and probably my biggest take-home.

Kevin Pho: Well, those are excellent tips. Thank you so much for sharing your insight and wisdom. On the show, we have Azam Farooqui. He’s a hematology-oncology fellow, soon to be an attending. He wrote the KevinMD article “Breaking bad news to patients when they are alone.” Azam, thank you for being on the show.

Azam J. Farooqui: Yep, thanks so much.

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