their limits, physically and psychologically. It is too easy for some doctors to let the technology - the test results, the detailed diagnosis - speak for them. Physicians must acknowledge the patient (and the family) as well as the disease. But the patient and the family must show some understanding too. They cannot make unreasonable demands; each doctor has many patients and many questions from them. It is an unfortunate fact that a physician must limit his or her time. Of greater importance than the amount of time is the genuine compassion and concern that is communicated. D.M.
I read with mixed emotions the article by Ms. Davis-Barron and can empathize with her anger and frustration, having recently been through a similar experience. However, I find it unfair that she chose to mark the entire profession with one broad stroke of her pen. Ironically, it will be the compassionate physicians who are genuinely disturbed by the criticism, whereas the ones specifically addressed by Davis-Barron will likely not identify with the article. When my husband was terminally ill, I too was terribly distressed by the lack of compassion shown by some physicians, particularly during the early stages, when the shock of the diagnosis was most devastating. However, I met many more who could show sensitivity rather than being bearers of cold, hard facts. With their guidance and resources I was able to take more responsibility for my husband's care. The books, videotapes and other teaching materials mentioned in the article following Davis-Barron's ("Doctors can improve on way they deliver bad news, MD maintains" [ibid: 564566], by Evelyne Michaels) will 1890
CAN MED ASSOC J 1992; 146 (1 1)
definitely help those physicians who want to develop the "people skills" for dealing with sensitive issues. It is encouraging to see an emphasis now being placed on
withheld from patients only after very careful consideration. In some cases the family may not be aware of the true wishes of the patient. It is clear that in such situasuch skills. tions the doctor must determine J.G. the patient's wishes with compassion and sensitivity and come to a Doctor-patient (and doctor-fam- balanced judgement of when and ily) communication and the best what to tell the patient about the way of imparting information re- illness. garding diagnosis are central issues in Ms. Davis-Barron's article. Dianne Delva, MD It is fitting that the new book How Department of Family Medicine University to Break Bad News: a Practical Queen's Kingston, Ont. Protocol for Health Care Professionals, by Dr. Robert Buckman,' Reference is discussed in the article that 1. Buckman R, Kason Y: How to Break follows Davis-Barron's piece. Bad News: a Practical Protocol for I would like to make three Health Care Professionals, U of Toronpoints. First, the absence of a to Pr, Toronto, 1992 family physician from Davis-Barron's account is striking. Commu- Ms. Davis-Barron might comnication requires trust, which was plain to the media, the courts, generally lacking in this family's the provincial College of Physexperience. A family physician icians and Surgeons and Parliaknown to the patient and the fam- ment. She might threaten, revile, ily can play an important role at a abuse, denigrate, force, restrict, confusing and frightening time by refuse to pay, socialize and genanswering questions, clarifying erally harrass these offenders. options and giving support. It is a They might have to work longer pity that the family doctor, if for less under more frightening, there was one, was not included in legalistic and politically saturthe team. ated conditions. She could get Second, a decision not to tell them good! a patient that he or she has canThat should stop physicians cer requires sensitivity to the from being cold and hard and patient's wishes but also requires make them leisurely, open, warm that the issue of consent be care- and caring - or else! So obvious fully considered. Consent for really. the physician to give such information should be sought from a Franklin W. Furlong, MD competent patient. If this is Toronto, Ont. denied, then it would not be possible to offer treatment, since the patient would not have the information necessary to make a decision. In this case a plan Breaking bad news must be developed to treat the patient palliatively. s a 3rd-year medical stuA dent at the University of Third, it should be remembered that telling patients that Toronto I recently had the death is inevitable may - rather opportunity to practise breaking than destroy hope - allow them bad news to "patients" during an to put their affairs in order. The interviewing skills course taught information should therefore be by Dr. Robert Buckman (see LE 1 er JUIN 1992
implicates once again the highanimal-protein diet common in Western cultures. The renal tubular calcium losses associated with this diet have also been described frequently as causal in the process of osteoporosis.1,2 It has, however, been disappointing that dietary oxalates, normally poorly absorbed, continue to be considered the primary scapegoat to avoid if stone recurrence is to be averted. Despite the estimate that renal stones are at least 10 times more common now than they were at the turn of the century,3 consumption of foods containing oxalates has been declining this century, whereas animal protein consumption has dramatically increased.4 The ratio of animal to plant protein intake in the United States, about 1:1 at the turn of the century, is now more than 2:1.5 Further, with the unparalleled availability of packaged and processed foods today compared with the turn of the century, the sodium intake of Western populations now substantially exceeds minimum requirements.6'7 Finally, dietary fat, also in excess in Western diets and strongly associated with animal protein, promotes oxalate absorption.8 Hughes and Norman identify vegetarian diets as problematic, "since an increase in the intake of vegetable protein can lead to an increased excretion of oxalate." Yet a strict vegetarian (vegan) diet, with an emphasis on natural, unprocessed foods, is devoid of Shabbir N.H. Alibhai animal protein, low in sodium Richmond Hill, Ont. and high in fibre and water, conditions that should be considered optimal in the treatment of calcium stones. Vegetarians, despite their higher oxalate intake, have a Diet and calcium stones lower incidence of urinary stone disease9 and of a host of other T he excellent review by diseases. 10 Janey Hughes and Dr. As much as many of us Richard W. Norman (Can hate to consider it, maybe it is Med Assoc J 1992; 146: 137-143) time to look upon vegetarian on the primary preventive role of diets more seriously - given diet in calcium stone formation the many excesses of Western
"Doctors can improve on way they deliver bad news, MD maintains," by Evelyne Michaels [Can Med Assoc J 1992; 146: 564566]). In a particularly poignant interview, I remember having to tell a 22-year-old female university student acting as a patient that she had acute myelogenous leukemia. As I became flustered by the questions "Why me, doctor?" and "Will I die?" I began to realize just how difficult breaking bad news can be. It was far easier just to describe the various treatment options and their success rates in cold, precise terms. In another interview the roles were reversed, and I had the good fortune to play a patient whose "innocent" stumbling turned out to be amyotrophic lateral sclerosis (Lou Gehrig's disease). With the tables turned I began to appreciate the impact such devastating news might have and how important it was for the physician to be empathic and understanding during such a meeting. I wholeheartedly support the notion that a course of this nature is vitally important to training future physicians. Although it may be impossible to instil an appropriate level of sensitivity and understanding toward all patients in all medical students and although there are no right or wrong answers, courses like this one will certainly enhance our skills in breaking bad news.
1894
CAN MED ASSOCJ 1992; 146 (11)
diets, we could kill many "oxalates" with one dietary stone. Mark Fromberg, MD 14-65 Angeline St. N Lindsay, Ont.
References 1. Draper HH: Nutrition and osteoporosis. Can Med Assoc J 1991; 144: 889 2. Fromberg M: Nutrition and osteoporosis [C]. Can Med Assoc J 1991; 145: 390 3. Danielson BG: Renal stones - current viewpoints on etiology and management. Scand J Urol Nephrol 1985; 19: 1-5 4. Diet and Health: Implications for Reducing Chronic Disease Risk, National Research Council Committee on Diet and Health, Washington, 1989: 57
5. Ibid: 62 6. Nutrition Recommendations: the Report of the Scientific Review Committee, Dept of National Health and Welfare, Ottawa, 1990: 177 7. Recommended Dietary Allowances, 10th rev ed, Food and Nutrition Board, Commission on Life Sciences, National Research Council, Washington, 1989: 253
8. Williams H: Oxalic acid and hyperoxaluric syndromes. Kidney Int 1978; 13: 410-417 9. Robertson WG, Peacock M, Marshall DH: Prevalence of urinary stone disease in vegetarians. Eur Urol 1982; 8: 334-339 10. Position of the American Dietetic Association: vegetarian diets. J Am Diet Assoc 1988; 3: 351-355
[Dr. Norman responds.] We have our concerns about the oxalate, Especially when it wants to concentrate, But when the urinary levels are low, It is the other risk factors that must go. These are the patients who will not be contrarian If they want to become vegetarian. Richard W. Nonnan, MD, FRCSC Camp Hill Medical Centre Halifax, NS LE
lerJUIN
1992
I read with mixed emotions the article by Ms. Davis-Barron and can empathize with her anger and frustration, having recently been through a similar experience. However, I find it unfair that she chose to mark the entire profession with one broad stroke of her pen. Ironically, it will be the compassionate physicians who are genuinely disturbed by the criticism, whereas the ones specifically addressed by Davis-Barron will likely not identify with the article. When my husband was terminally ill, I too was terribly distressed by the lack of compassion shown by some physicians, particularly during the early stages, when the shock of the diagnosis was most devastating. However, I met many more who could show sensitivity rather than being bearers of cold, hard facts. With their guidance and resources I was able to take more responsibility for my husband's care. The books, videotapes and other teaching materials mentioned in the article following Davis-Barron's ("Doctors can improve on way they deliver bad news, MD maintains" [ibid: 564566], by Evelyne Michaels) will 1890
CAN MED ASSOC J 1992; 146 (1 1)
definitely help those physicians who want to develop the "people skills" for dealing with sensitive issues. It is encouraging to see an emphasis now being placed on
withheld from patients only after very careful consideration. In some cases the family may not be aware of the true wishes of the patient. It is clear that in such situasuch skills. tions the doctor must determine J.G. the patient's wishes with compassion and sensitivity and come to a Doctor-patient (and doctor-fam- balanced judgement of when and ily) communication and the best what to tell the patient about the way of imparting information re- illness. garding diagnosis are central issues in Ms. Davis-Barron's article. Dianne Delva, MD It is fitting that the new book How Department of Family Medicine University to Break Bad News: a Practical Queen's Kingston, Ont. Protocol for Health Care Professionals, by Dr. Robert Buckman,' Reference is discussed in the article that 1. Buckman R, Kason Y: How to Break follows Davis-Barron's piece. Bad News: a Practical Protocol for I would like to make three Health Care Professionals, U of Toronpoints. First, the absence of a to Pr, Toronto, 1992 family physician from Davis-Barron's account is striking. Commu- Ms. Davis-Barron might comnication requires trust, which was plain to the media, the courts, generally lacking in this family's the provincial College of Physexperience. A family physician icians and Surgeons and Parliaknown to the patient and the fam- ment. She might threaten, revile, ily can play an important role at a abuse, denigrate, force, restrict, confusing and frightening time by refuse to pay, socialize and genanswering questions, clarifying erally harrass these offenders. options and giving support. It is a They might have to work longer pity that the family doctor, if for less under more frightening, there was one, was not included in legalistic and politically saturthe team. ated conditions. She could get Second, a decision not to tell them good! a patient that he or she has canThat should stop physicians cer requires sensitivity to the from being cold and hard and patient's wishes but also requires make them leisurely, open, warm that the issue of consent be care- and caring - or else! So obvious fully considered. Consent for really. the physician to give such information should be sought from a Franklin W. Furlong, MD competent patient. If this is Toronto, Ont. denied, then it would not be possible to offer treatment, since the patient would not have the information necessary to make a decision. In this case a plan Breaking bad news must be developed to treat the patient palliatively. s a 3rd-year medical stuA dent at the University of Third, it should be remembered that telling patients that Toronto I recently had the death is inevitable may - rather opportunity to practise breaking than destroy hope - allow them bad news to "patients" during an to put their affairs in order. The interviewing skills course taught information should therefore be by Dr. Robert Buckman (see LE 1 er JUIN 1992
implicates once again the highanimal-protein diet common in Western cultures. The renal tubular calcium losses associated with this diet have also been described frequently as causal in the process of osteoporosis.1,2 It has, however, been disappointing that dietary oxalates, normally poorly absorbed, continue to be considered the primary scapegoat to avoid if stone recurrence is to be averted. Despite the estimate that renal stones are at least 10 times more common now than they were at the turn of the century,3 consumption of foods containing oxalates has been declining this century, whereas animal protein consumption has dramatically increased.4 The ratio of animal to plant protein intake in the United States, about 1:1 at the turn of the century, is now more than 2:1.5 Further, with the unparalleled availability of packaged and processed foods today compared with the turn of the century, the sodium intake of Western populations now substantially exceeds minimum requirements.6'7 Finally, dietary fat, also in excess in Western diets and strongly associated with animal protein, promotes oxalate absorption.8 Hughes and Norman identify vegetarian diets as problematic, "since an increase in the intake of vegetable protein can lead to an increased excretion of oxalate." Yet a strict vegetarian (vegan) diet, with an emphasis on natural, unprocessed foods, is devoid of Shabbir N.H. Alibhai animal protein, low in sodium Richmond Hill, Ont. and high in fibre and water, conditions that should be considered optimal in the treatment of calcium stones. Vegetarians, despite their higher oxalate intake, have a Diet and calcium stones lower incidence of urinary stone disease9 and of a host of other T he excellent review by diseases. 10 Janey Hughes and Dr. As much as many of us Richard W. Norman (Can hate to consider it, maybe it is Med Assoc J 1992; 146: 137-143) time to look upon vegetarian on the primary preventive role of diets more seriously - given diet in calcium stone formation the many excesses of Western
"Doctors can improve on way they deliver bad news, MD maintains," by Evelyne Michaels [Can Med Assoc J 1992; 146: 564566]). In a particularly poignant interview, I remember having to tell a 22-year-old female university student acting as a patient that she had acute myelogenous leukemia. As I became flustered by the questions "Why me, doctor?" and "Will I die?" I began to realize just how difficult breaking bad news can be. It was far easier just to describe the various treatment options and their success rates in cold, precise terms. In another interview the roles were reversed, and I had the good fortune to play a patient whose "innocent" stumbling turned out to be amyotrophic lateral sclerosis (Lou Gehrig's disease). With the tables turned I began to appreciate the impact such devastating news might have and how important it was for the physician to be empathic and understanding during such a meeting. I wholeheartedly support the notion that a course of this nature is vitally important to training future physicians. Although it may be impossible to instil an appropriate level of sensitivity and understanding toward all patients in all medical students and although there are no right or wrong answers, courses like this one will certainly enhance our skills in breaking bad news.
1894
CAN MED ASSOCJ 1992; 146 (11)
diets, we could kill many "oxalates" with one dietary stone. Mark Fromberg, MD 14-65 Angeline St. N Lindsay, Ont.
References 1. Draper HH: Nutrition and osteoporosis. Can Med Assoc J 1991; 144: 889 2. Fromberg M: Nutrition and osteoporosis [C]. Can Med Assoc J 1991; 145: 390 3. Danielson BG: Renal stones - current viewpoints on etiology and management. Scand J Urol Nephrol 1985; 19: 1-5 4. Diet and Health: Implications for Reducing Chronic Disease Risk, National Research Council Committee on Diet and Health, Washington, 1989: 57
5. Ibid: 62 6. Nutrition Recommendations: the Report of the Scientific Review Committee, Dept of National Health and Welfare, Ottawa, 1990: 177 7. Recommended Dietary Allowances, 10th rev ed, Food and Nutrition Board, Commission on Life Sciences, National Research Council, Washington, 1989: 253
8. Williams H: Oxalic acid and hyperoxaluric syndromes. Kidney Int 1978; 13: 410-417 9. Robertson WG, Peacock M, Marshall DH: Prevalence of urinary stone disease in vegetarians. Eur Urol 1982; 8: 334-339 10. Position of the American Dietetic Association: vegetarian diets. J Am Diet Assoc 1988; 3: 351-355
[Dr. Norman responds.] We have our concerns about the oxalate, Especially when it wants to concentrate, But when the urinary levels are low, It is the other risk factors that must go. These are the patients who will not be contrarian If they want to become vegetarian. Richard W. Nonnan, MD, FRCSC Camp Hill Medical Centre Halifax, NS LE
lerJUIN
1992
