The anguished mother pounded the floor at Johns Hopkins Hospital, screaming, "Why, why, why?" Dr. John Wogan had just told her as gently as he knew how that her teenage son was dead, the victim of a stray bullet fired on the streets of Baltimore.
The next day the mother was dead herself, felled by a burst blood vessel in her brain that Wogan believes resulted from the terrible, sudden stress of learning her child was gone. Twenty years later the episode remains etched in the doctor's memory.
"The news itself is just devastating sometimes," says Wogan, now an attending physician in the emergency department at Greater Baltimore Medical Center in Towson.
Wogan has never encountered anything like the violence that erupted Thursday at Hopkins Hospital, when a spinal surgeon was shot by a patient's son.
But the shooting of Dr. David B. Cohen has caused health care providers around the region to reflect on those delicate interactions with patients and families. Reponses range widely, and it's hard to predict which emotions will emerge when a doctor must deliver news no one wants to hear.
"It does remind you that you are potentially in the same vulnerable position that physician was in," Wogan says. "The thing this will do is make people think about themselves and their safety, whereas before they would be exclusively thinking about the patient."
It's unclear what was said Thursday before Paul Warren Pardus shot Cohen in the abdomen after hearing news about his mother's condition. Pardus then entered his mother's room and fatally shot her and himself, police said.
However, the incident touched on an issue of great interest and concern to the medical community — the complexity of relaying emotionally rending news to patients and loved ones who might already be under stress.
"An incident like this does make one reflect on how we do it," says Dr. Mark Duncan, a veteran cancer surgeon at Johns Hopkins Bayview Medical Center. "It's probably one of the more important things we do in the job."
Duncan says he typically sits down with a patient's loved ones, offers empathetic touches on the hand or shoulder and answers every question that arises. Most of the time, recipients are accepting, even gracious.
"At the end of the encounter, the family will thank you profusely," he says. "Often far beyond what you think you merit. It's just the fact that you're there with them, that you care."
There is no indication Cohen handled Thursday's exchange inappropriately, and Cohen's former patients say they always found him to be compassionate and forthright.
"What impressed me about Dr. Cohen was that he was very straightforward in explaining what the problems were and telling us the inherent risks," says Joel Brandenberger of Rockville, whose wife had two spinal fusions. He said "it's still hard for me to imagine anyone wanting to do harm to him."
But the sensitive interaction between Cohen and Pardus — a doctor describing a medical condition to an anguished relative — is one familiar to many health care workers.
Dr. Bill Thomas, a professor at the University of Maryland, Baltimore County's Erickson School of Aging who has treated hundreds of critically ill patients, says some family members feel guilty for letting a loved one enter a difficult surgery that winds up going poorly.
Thomas remembers an older man who became his patient after a massive stroke. He met with the man's two daughters, whom he did not know well, to discuss options. Then he told them: "I think the best thing to do is just let him go."
"Dad was a professional featherweight boxer," one daughter replied. "He's been a fighter all his life. He would want to fight."
Though the patient died fairly quickly, the encounter taught Thomas the need to gauge an individual situation when making life-and-death decisions and to let family input steer his approach.
"I was giving advice without knowing the person," he says. "That was me thinking about neurology and not thinking about the man."
Thomas got an early lesson in what not to do. He was a medical student and had just watched a woman die on the operating table after a car accident. The surgeon appeared in the waiting area, said "she didn't make it" and walked away.
"He should've sat down, taken a deep breath and described in detail what happened," Thomas says. "He should have let the family know that she wasn't in pain when she died, that she wasn't afraid. Then, he should have said he'd answer every question they had."
Thomas believes the difficulty will grow as baby boomers reach old age and bad medical news grows more common. "We better get good at this," he said.
Patients and family members who have found their time-strapped doctors to be brusque or indifferent say the experience can compound their frustration or anger.
Michael Bennett, president of the Coalition for Patients' Rights, an advocacy group based in Maryland, says his bad experience with five Baltimore hospitals several years ago spurred him to join the coalition. He argues that doctors actually communicate less with patients than in past decades, something he attributes to an excessive fear of malpractice lawsuits.
"My dad went in with a respiratory virus that was becoming pneumonia," he says. "What should have been a three-day hospitalization turned into four months of unmitigated torture," Other than a call from one doctor, he didn't get "a single phone call, conversation, nothing, not a word."
At Johns Hopkins, medical students begin learning how to interact with patients right away. Twice a week over the first four months, they do role-playing with actors called "standardized patients."
Put simply, better doctor-patient interaction is better for patients, says Dr. Patricia Thomas, associate dean for curriculum at the School of Medicine and no relation to Bill Thomas.
Thomas recalls the time decades ago when, during her internship, she had to tell a Spanish-speaking woman that her husband's advanced lung cancer had taken his life. Though expected, the news, delivered through a translator, sent the woman screaming, thrashing and collapsing into relatives. It was the most emotional response Thomas had ever witnessed, and to this day she wonders if it was what she said, or how she said it.
Thomas also remembers the case of a middle-aged patient who was admitted with pneumonia and then suffered a heart attack that left her unconscious with evidence of serious brain injury. It fell to Thomas to tell the woman's family that she'd probably never wake up.
Each time she saw the family over the next few days, they peppered her with questions. Could their loved one hear them? Could she sense their touch? Thomas acknowledged she didn't know but encouraged them to trust their faith.
Eventually the family decided to turn off life support. Afterward, Thomas cried with them. To her surprise, they all hugged and thanked her, "in essence for my failure to cure their wife and mother."
Such exchanges are far more common than misunderstandings or emotional outbursts, says Duncan, the Bayview surgeon. Trouble is more likely in trauma situations, when a surgeon hasn't had time to build rapport with the patient or family. Sometimes he tries to have a nurse or another doctor at his side to avoid the chance of a one-on-one dispute.
The good news, Duncan says, is that the medical community has come a long way in recognizing the importance of communication with patients.
"It's easy to get excited about a six-hour surgery with all kinds of technical wizardry," Duncan says he tells young medical residents. "But lending comfort and understanding to someone who is not going to be cured is a tremendous opportunity to deliver care."