I have not been able to get Ms. K out of my mind ever since making teaching rounds with a resident team earlier this week. Ms. K is a 63-year-old woman who came to the hospital because of “odor coming from my left breast.” Upon further questioning, it became apparent that she had first noted a mass in her breast approximately 18 months ago but chose not to seek help from a physician. She had not gone regularly for medical care and told us she could not remember when her last mammogram was. “I put myself in God’s hands,” was her reply to us when we asked her questions; she only wanted to know what could be done to “take the odor away.” She had no pain, no weight loss, and was fully functional.

On examination, Ms. K’s diagnosis was obvious. She had a large, rock-hard mass in the left breast that had broken through the skin and was necrotic and foul-smelling. She had large, firm, immobile lymph nodes in her left axilla and a 6 x 8–cm rock-hard mass in her right axilla. The patient’s chest x-ray showed a pulmonary nodule as well. Not being the patient’s physician, I was cautious as to what to say. I did speak to the house staff team prior to entering the room about the need to move swiftly to get a biopsy for a proper diagnosis and recognition of the receptor status in case the oncologist wanted to start chemotherapy. The oncology team should be involved as soon as possible. I discussed with the team the need for Ms. K to see a surgeon, not only for a biopsy and catheter placement if chemotherapy was to be done, but also to determine whether surgery might improve her quality of life. Even if a cure may not be possible for the patient’s underlying cancer, my experience was that the tumor may need to be removed for maximal quality of life for the time she had left. A debridement of the necrotic tissue might also be appropriate and offer her some relief from her suffering. The oncology team would be in a better position to express whether they thought chemotherapy and/or radiation might help improve Ms. K’s quality of life. I did mention that one of her physicians needed to sit with her privately and discuss what they thought was going on, and what the plan would be if she was agreeable.

As we walked into the room, I heard one of the resident physicians tell the patient in no uncertain terms that she had cancer. I was shocked, yet did all I could to hide my emotions. I could see the startled look on Ms. K’s face as she continued to ask, “What can you do for the odor?”

Just then, a surgeon who apparently had been called by one of the ER physicians to see the patient came to the bedside. Once again the patient asked, “What can you do for this odor?” The surgeon quickly responded, “There is nothing we can surgically do for your cancer. You need to have chemotherapy and radiation.” He said that she should wait to have the biopsy until the oncologist came to see her, as he would do the biopsy and put in a catheter for her infusions at the same time. Ms. K said that she “would have to think about things” and asked the surgeon again, “What can be done for the odor?” After repeating “nothing surgical,” he left the room.

I found myself at a loss for words as I tried to explain to the patient that she was “in good hands with your doctors, and one of them will come back soon to talk with you privately about what they think is going on and what options there are.” Ms. K looked up and said, “I am in God’s hands…I will need to think about things.”

Telling the truth in all circumstances is not always the best thing to do, especially when it is not done with compassion and with recognition of the unique background and interests of every patient. I am not saying one has to lie or misrepresent, but rather physicians need to find the “right” way and circumstance to discuss life-changing information with their patients. I know that my conversation with the resident physician after we left the room would be remembered and hopefully help mold future interactions with similar patients, but for the surgeon, senior and confident in his style, I am sure many more patients will be the product of his abrupt nature and all-too-direct approach.

Ms. K did not ask for a diagnosis, what the physician thought was going on, or what could or could not be done for the cancer; she was seeking help for an obvious and disturbing odor. I only hope that someone has since spoken to her about this and heard her plea for help. Listening to what someone says, knowing when to remain silent yet empathic, and being able to deliver “bad news” in a skilled and compassionate manner are skills I wish more physicians would cultivate.