Friday, August 30, 2013

Poker Face

As a pathologist, I am one step removed from the patient.  This is comforting for the most part.  I render my diagnosis and another clinician communicates it to the patient.  It is best this way - I have no treatment options in my own doctor toolbox to give meaning to the words I communicate.  I learned this the hard way - in fellowship training.

Once I was doing a fine needle aspiration on a small sub centimeter mass behind a patient's ear.  The patient had a history of melanoma, and they were very anxious.  After I aspirated some cells I looked at them under the microscope.  I had a good sample.  It was pretty obvious, despite needing stains to prove it.  Metastatic melanoma.  I sighed internally and turned around.  The patient asked, "Well, what is it?  Is it melanoma?"  I was nervous, still in training, and I hesitated a second too long.  The patient melted into tears, guessing the answer by my lack of words.  I communicated some soothing words and did not hesitate to ask a nurse to call the oncologist two floors above.  Wisely flaunting routine the doctor arranged to meet the patient immediately to discuss treatment.

I learned from that experience.  Now I tell the patient up front that we won't have results for at least 24 hours, although at least half the time I have a pretty good guess at the results when I triage the sample on site to see if it is good enough material for a final diagnosis.  The clinicians appreciate our discretion, and as I said, it is best overall as we usually need special stains or additional material from a cell block for a definitive diagnosis.  And most importantly, we cannot offer treatment options.  This leaves us and the patient at a huge disadvantage if we jump the gun.  Giving a diagnosis without a next step is mental torture.  I sure wouldn't want to be on the receiving end of that.

As a long time member of the community in the hospital where I practice, I encounter situations, not infrequently, where a family member of a patient will text me or facebook message me and ask if I can look at/triage/let them know when the results are out/ of a biopsy of a family member.  I am always happy to help but at a loss for many reasons I mentioned above, not to mention that to communicate results to someone other than the patient, even a family member, is a major HIPAA violation.  I try to offer support and information but fall short of giving away any information about the actual diagnosis - letting it fall naturally in the clinicians hands to communicate themselves.  I know this is for the best, and appropriate, but when your friends are in need diversion can't help but feel deceitful.  I have actually called clinicians, during working hours, letting them know that my report is out and I have a patient or family member calling me.  The clinicians are always gracious and helpful, despite my natural reticence to add to their workload.  I have usually fielded many calls from them about patients in their office - wanting a preliminary diagnosis or a personal phone call when the final results are out - so I understand it works both ways.  And once the diagnosis is out, I am more than happy to discuss it with a patient.  Although that doesn't happen very often it is a rewarding experience.

Sometimes I wish I was back in college when a poker face was just that.  A poker face.  Texas holdem.  Seven card stud.   I wasn't good at it then, bluffing is not my strong point, but I have developed a fantastic one in my field.  It's a skill I didn't anticipate having to master when I chose pathology.


  1. Funny- I was thinking about posting about "Poker face" as well- from the primary care doc perspective. Sometimes, when I am sitting face-to-face with a patient, and I feel personally strongly, or even passionately, about something they are doing, or a decision they are making, I need to wear my "poker face". And I am not good at it. More than once I have let slip disapproval, or even some form of judgment... It is an area I am working on. But how to both be empathetic and real, and then hide those inevitable negative emotions? I guess I need to write about it, and ask the forum.

  2. Enjoyed hearing that I'm not the only specialty - thanks Monique.


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