Dr. Judah Folkman died this week in Boston. News organizations used the occasion to report on his decades-long cancer research career. Given his status as a distant, non-celebrity, non-Nobel surgeon, you may be asking yourself why you, personally, should care about his death. Here’s why.
We were in our second year of medical school, feeling the growing pressure of clinical years just around the corner, when we would be thrown into the hospital system. For now, we had lectures in a large hall with 130 students sitting in chairs that sloped down to a stage. Professors came with presentations and handouts and complex diagrams. The immunology lectures were continuous strings of letters and numbers, with only the occasional verb, impossible to decode as human speech without months of training. Every tissue, every disease, every human physiologic function was discussed, down to the sub-molecular level. After hours of these lectures, the air would get stale and backs would ache and the squeak of weight shifting in chairs would become a metronomic beat marking out time that seemed to pass endlessly.
Then, one day, Dr. Folkman walked on stage. He asked us to put down our pens. He said he was going to teach us something that no one else would ever discuss, much less teach. I can’t imagine what he was thinking as he looked out on the sea of our faces. Give or take a few years, almost all of us were twenty-four years old. Almost all of us were single, ambitious, untouched by any of the major human experiences—no children, tragedies, severe illnesses or grief. The youth, the arrogance, the lack of world experience, all of it had to be a daunting, uninspiring sight. Dr. Folkman knew that in mere months, we would be keepers of information that would profoundly change lives. Pathology reports, cancer diagnoses, even the death of a loved one, those were all things we would be telling vulnerable people. Our actions and our words would be often unsupervised, particularly when disaster struck in the middle of the night.
He said he was going to teach us how to break bad news.
In retrospect, the undertaking of such a gargantuan task seems heroic. He only had an hour.
So what did he say? Did he discuss communications theory, or the quality of data about grief reactions, or discuss the role of ethics committees and liability protocols? What was the Judah Folkman set of instructions on how to break bad news?
After twenty years, I still remember it.
First, get a chair. Everyone must have a chair. When it comes to bad news, you must assert authority you didn’t know you had. Insist on having a private room. Move people out, clear a space. You can be a dictator. You get what you need by polite, quiet insistence.
Never give bad news standing up. Never, ever, ever give bad news in a hallway. As you’re getting the room, and the chair, people will become alarmed and ask you what has happened. You wait, saying you’d like to talk about it in private, please. You seat everyone. You take a deep breath, then you say it. And then, most importantly, you say you’re sorry.
You must keep in mind that only the first few words will be heard. After that, the mind shuts out the rest. Sometimes you hold a hand or pat a shoulder. Most of all, you wait. You wait some more. Often, like a trickle before the flood, there will be tears, then sobbing. Your job is to get tissues (if you have not thought to do so beforehand). If there is no crying, you let the silence stretch, no matter what else you have to do. If you have sadly forgotten to turn off your pager beforehand, you silence it if it rings. You can take these few moments for something this important.
Eventually there will be questions. You answer them with the facts you have, leaving out all interpretation, excuses, religion, or philosophizing.
Then, when tears or questions stop, you ask what you can do. You offer a phone. You offer to write letters to airlines, to contact bosses, to do whatever is reasonable and legal for you to do.
And, if the bad news is a death, you then ask for an autopsy.
At this point, as we listened twenty years ago, the auditorium was silent, no chairs squeaking, no pencils scratching, just a stunned sort of silence.
Dr. Folkman went on to explain the data on autopsies, how they are our society’s only way of knowing the truth about disease. He reviewed the accumulated data on the persistent huge discrepancies between what doctors thought was a final cause of death and what an autopsy found. He outlined the advances in diseases that had been made through autopsy information, and the ways in which “incidental findings” could turn out to be very important, especially for surviving family members. He stressed the importance of autopsies in helping us find and correct our medical errors.
Then he told us how to ask for an autopsy. He emphasized that we must remember that the family makes the choice, our job is merely to ask. He told us to say to the family that we ask everyone, because it was important to know what really happened in the end, even in the most obvious-seeming cases. Then he told us to say something that none of us expected. He told us to be sure and say that the autopsy wouldn’t hurt, that in fact, we’d make sure it didn’t hurt. Because that’s what grief-stricken people care about.
He told us that we always, each time, had to do our very best when it came to breaking bad news. It was one of the most important skills for a doctor to have, and that if we messed it up, we would never, ever be forgiven. People remember the doctor who was a jerk to them, in their moment of grief, for the rest of their lives. The story about how the doctor told them their mother was dead while standing in a hallway, or the story about how the doctor ran out of the room to answer a page, or the story about how the doctor wouldn’t even let anyone make a phone call afterward—those are stories that are told and retold within families. That kind of experience affects every impression the family has about all of healthcare.
He was right. About everything. People do cry if you wait. People do care about whether an autopsy hurts. People do remember.
Dr. Judah Folkman’s death is a loss, but many people may not realize how great a loss. Judah Folkman, alone, in one hour, changed not only my life as a practicing physician but also the lives of every patient I’ve ever cared for, and their families. I, for one, went on to do my internship and residency in San Francisco during the holocaust years of the AIDS epidemic. Breaking bad news and talking about death weren’t abstract issues.
And it wasn’t just me, and my patients, and their families who were affected. Dr. Folkman changed the lives of all the patients and families cared for by all the students who sat in that auditorium that day, and all the patients and families of every student every year that he gave this lecture. Later, when I was a resident and then an attending, supervising UCSF medical students, I repeated Dr. Folkman’s instructions to them. And so on, and so on. When you think about these ripples of goodness from one man’s life, they expand further and further out and the numbers become amazing.
So you probably never thought about it, when you glanced at a news item reporting his death. There’s no way you could know. But if you’ve ever had a doctor who was decent to you when tragedy struck, if you’ve ever been given space and time and respect for your grief, you too may have been a beneficiary of the Dr. Judah Folkman legacy.
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Doc Gurley is a Board-certified Internist physician and the only Harvard Medical School graduate to have been awarded a Shoney’s Ten-Step Pin for documented excellence in waitressing. 
This is such a great story and a really wonderful lesson for all of us. I wish more people could read it.
Sir, thank you for this post. Dr. Folkman is (sadly only) a virtual mentor of mine, and I have been reading about him religiously for a while. I wish I had the opportunity to meet him in person. I only have heard about him from some of his disciples, like Jay Vacanti at MGH. Anyway, this story is one of those precious gems about him that should be shared with all those who enter the field of medicine. I hope you don’t mine if I post your entry on my own blog. His loss is one that is felt by the whole world. I will definitely take this lesson to heart in my own career/vocation.
Sincerely,
-Teddy Youn, MD ’09 Brown Medical School
I’m a 1st year medical student that actually came across this site while researching on an assignment on handling death and dying, and i thought that this would be really wonderful to share with the rest of my cohort. I hope you don’t mind if I posted this up on a medical students facebook group.
Feel free to post a link anywhere. For educational purposes, if you are copying the entire article, please include author attribution (say it’s written by me!), the date of the piece, the url and a copyright 2008. Thanks! I’m so glad you found it helpful.
Doc Gurley
Thank you for sharing Dr. Folkman’s and your insight — for 19 years, for the majority of the time, I was the one (the night nursing supervisor) who the doctors (and staff nurses) called to come and break the news to the families — for the doctors brave enough to stay and go thru it, they cemented the relationships with the families like you wouldn’t believe – I always learned more and would use this information for the next time — I would find that people would come up to me years later and remind me that I was the one who took the time for them. I thank you for your sharing this tough lesson.
I am a charge nurse who works on an oncology unit during the night shift. Often I am the one who will either call a family member or instruct my staff on how to properly tell a family member about the death of a loved one. I just want to thank you for this post. It is not only the doctors you can benefit from such valuable information.
Wow. What amazing nurses we are blessed to have, working hard and filling needs – thank you for all the lives you have touched with your care.
Doctor Gurley,
I am so glad I came across this tribune to Dr Folkman. What a legacy he has left us. You are absolutely correct that families remember and talk about how a doctor has treated them at a time of grief. I will not forget how my mother’s doctor, instead of consoling us, told us disapprovingly how she didn’t follow his medical advice, and implied that this had shortened her life. That was not what we needed to hear at that time.
Thanks again; you have made my day. God bless you, Mary Scott, RPh, CGP
As a hospice nurse with many years of experience, I thank you profusely for this article. Like you, I mourn the loss of a mentor like Dr. Folkman. So many physicians struggle with this difficult task of breaking bad news and Dr. Folkman is absolutely correct that the manner in which this is conducted profoundly colors the experience for patients and families. I think that the component of remaining present after conveying the news is most important. It’s also the hardest. To stay with them in the face of their emotional response is uncomfortable, to say the least. And yet, to walk away conveys true abandonment, just when the situation seems most dire. Again, thank you for this article and let’s all try to share it with anyone who will listen!
As a Child and Family Therapist I thank you for this article as well. In my time working with adolescents with substance abuse issues on an inpatient basis I have been faced with a similar problem to that which is addressed in this article. I have kids who are locked up in a detention center who have lost a loved one, and often they cannot leave to attend a funeral. Or they have a family member who has been in a serious accident, or been diagnosed with cancer, a girlfriend who has had a miscarriage. In all cases the family comes to me asking what would be the best way to break this news to their child, and even if it should be done while the child is in this environment (the fear being how much the child will sit in their detention cell and just ruminate on the situation without any perceived support). I do not believe in family secrets and for a parent to sit through a visitation knowing something tragic has happened while pretending everything is fine is detrimental in almost every case. I always let the parent ultimately make this decision even if I do not agree with it professionally. When the decision is to tell the child the biggest issue for me is how long to stay and how long to let them have private family time within the context of a situation where I simply cannot leave the child unattended. I am always careful to notify detention staff and to assure the family that I will be available if their child wishes for extra time with me. I thank you for this advice because it gives me a better idea of how to walk through this difficult situation.
[...] as a physician, believe in being more, rather than less, forthright with patients. Read my How To Break Bad News post for more on this [...]
Thank you for this insightful and moving tribute.
Thank you for this insightful and moving tribute. Dr. Folkman must have been quite a wonderful teacher. Compassion is a lost art for many, I hope that those who absorbed his well taught lesson continue to teach it to others, as you have.
WOW!! I can see why you choose this as a “best” post. Thank God for people like Dr. Folkman and yourself, you’re what is keeping the medical system alive at the moment, because too many people aren’t showing concern or empathy. Thank you for this post, thank you for passing on the wisdom of what Dr. Folkman taught you and thank you for caring.
I came across your website via a gluten free/chronic illness blog and I am so glad I found it. Really, your (or your lecturer’s) advice is good for everyone. Listening and waiting for people to absorb information is such a hard thing to do. Thankyou for your beautifully written entry.
-Emma
A beautiful tribute to wisdom and to a wise man. Thank you.
Doc Gurley,
It is you who have chosen to so carefully, eloquently, and compassionately tell this story that I thank. The qualities of Doctor Folkman you relate can be so much more broadly applied to other situations between medical personnel and the humans beings they interact with.
I only wish the surgeons and PA who deceived me into agreeing to what I didn’t understand was exaggerated surgical overtreatment for a “probable” cancer would read your message and be touched by it. They would have the opportunity to realize the life-long consequences of inhumane attitudes towards patients on the medical conveyor belt and to learn how transform themselves into humanists.
So much anguish can be so easily averted…
Thank-you.
[...] How to break bad news [...]
Hi!
I am a senior resident in Community Medicine in Nigeria and i came across your message while looking up materials for my Part 2 proposals.
Thank you for the hindsight into the proper way to break bad news.
Incidentally in the University College Hospital,Ibadan ,Nigeria where i work most times the task is left to the nurses and we try to justify this decision with thte fact that the nurse has probably spent more time with the patient and family.
I am however of the opinion that it shold be the doctors duty to do the job so thanks for a research idea !
Finally i am sorry about the loss of your mentor(see i am learning already)
[...] Doc Gurley remembers an influential mentor in “How to Break Bad News”. [...]
And now, as a medical student, I too have been influenced by Dr. Judah Folkman.
Funny I am just doing a uni paper in ICU nursing and todays subject was end-of-life care, including breaking bad news. I do not think anybody has ever managed to put it that clearly and beautifully how to approach this difficult subject with families. Thank you for the wonderful insight
When my mother died, we had one doctor who clearly knew how to give bad news, and one who either didn’t know or didn’t care. Thank goodness for the one who did, and for the nurse who saw us through the end.