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Delivering bad news to patients is a highly sensitive challenge that, sooner or later, all physicians must face. Unfortunately patients aren’t always happy with how that news is broken. “Communication problems on the part of physicians have been cited as the most frequent complaint by patients, while inadequate communication, rather than medical negligence, is the most common cause of health care litigation,”1 said Rosa Braga-Mele, MD, MEd, an associate professor of ophthalmology at the University of Toronto.
How to Deliver Bad News
What steps can you take to communicate better with a patient when you need to deliver unwelcome news? Here are nine practical techniques that you can use.
Build a relationship. Early on, solidify your relationship with the patient, said Susan H. Day, MD, a pediatric ophthalmologist and chair of ophthalmology at California Pacific Medical Center in San Francisco. By building a rapport based on warmth and trust, you establish a good foundation for any difficult conversations that may be needed later on.
Demonstrate empathy. When delivering bad news, Dr. Braga-Mele puts a premium on the value of empathy—which is derived from the Greek word empatheia, for passion or suffering. “Your most important tools are your own feelings,” said Ivan R. Schwab, MD, professor of ophthalmology and director of the cornea and external disease service at the University of California, Davis. “Bad news comes to us all at some point, and if you deliver news to a patient using your own feelings, you will be a powerful support. Realize that you can never feel the way the recipient feels or truly understand their emotions, but you can comfort and support them as if you were at the threshold of doing so. To start, we should put ourselves in the patient’s position even if we have never received such news. For example—how would we feel if told we would be blind, forever?”
Understand the patient’s perspective. “We must constantly be aware of the patient’s, rather than the physician’s, grasp of a specific situation,” said Dr. Day. “As a patient asks basic questions—such as, ‘Will things get worse?’—we need to be clear what we mean by ‘worse,’ rather than assume the patient’s concept of ‘worse’ is the same as ours.”
Speak in plain language. Use vernacular, conversational language, advised Dr. Day; most patients will not be fluent in the vocabulary of peer-reviewed medical literature. “My sense is that we too often talk in medical terms, rather than in terms that our patients understand,” said Dr. Day.
Don't shield patients from the facts. The most serious mistakes in delivering bad news may be simply avoiding it altogether or, less drastic but more common, not fully relaying the severity of the situation, said Dr. Braga-Mele. “We naturally feel sorry for the patient in this moment and want to give them hope. Hope is good, of course—but only in the context of remaining truthful and realistic so that, moving forward, the correct care and support systems can be set up.”
Schedule enough time for your news and their questions. Dr. Braga-Mele pointed out that even the most attentive physicians don’t always allow sufficient time in their discussions with patients to methodically lay out all aspects of unwelcome developments. Dr. Day added that patients must be given a clear opportunity to ask questions, even if they aren’t the questions that the physician is concerned with. “Physicians may present the information accurately and yet completely miss what might be worrying the patient. One common example occurs when we tell patients their visual acuity will not be great. Their next assumption is often ‘Well, surely you can give me glasses to correct it.’”
Remain available for more interaction. After bad news is delivered, the patient’s ability to absorb subsequent information during that same visit is often lost. As the news sinks in and realities surface, the patient often benefits from further discussions, said Dr. Day.
Optimize the next visit. You can, for example, ask patients if they would like to bring a friend or relative on a follow-up visit, when matters will be addressed in more depth. Beyond helping your patient remember what was said during the visit, this additional person could potentially act as your advocate, helping you get your message across. (But make sure this third party doesn’t hijack the consent process.)
Encourage second opinions. When appropriate, another physician’s assessment is reasonable and could be reassuring.
Allow for hope. Even a glimmer of hope is better than none at all, said Dr. Day.
Bad News is Now Good Curriculum
|Several years ago, Dr. Braga-Mele and colleagues surveyed Canadian ophthalmologists about training in communication skills.1 “We found that the majority of physicians had been taught some communication skills in medical school,” said Dr. Braga-Mele. “But now there is a much greater emphasis on those skills structured into residency programs.”
Communication now a core competency of U.S. residencies. Dr. Day agreed that communication skills should be a key component of a young physician’s knowledge base, and she said those skills have become some of the fundamental “competency domains” in which all residents are periodically evaluated. “The accreditation process now explicitly requires that residents’ teachers nurture these skills. There are now formal techniques to address the specific area of delivering bad news. And the sensitive teacher will not only allow a resident to witness such communications but also observe as a resident takes primary responsibility for breaking bad news. The earliest lessons in communication actually begin years before residency; this learning really starts in medical school, from and with mentors.”
Which training format should be used? In Dr. Braga-Mele’s 2008 study, she found the most popular formats for teaching communication skills were, in order of decreasing popularity:
- interactive small-group discussions,
- video presentations of proper communication techniques, and
- practice scenarios using standardized patient actors—professional actors who can portray a scripted patient encounter convincingly and consistently.
“These exercises should continue throughout one’s career, either by spontaneous discussions among colleagues or in more deliberate, small-group sessions. Of course, I think we learn every day as we communicate with our patients and discover on the job what works most effectively,” said Dr. Braga-Mele. “Like all of our clinical diagnostic and treatment skills, patient communication is a lifelong learning experience.”
1 Zakrzweski PA et al. Can J Ophthalmol. 2008;43(4):419-424.
Being There for the Patient
“Reassure the patient that you will do all you can to help, including helping them plug into community resources,” said Dr. Schwab. “Keep the patient from feeling alone, and assure him or her that any potential rehabilitation that will help is possible. But, above all, patients must know that their physician will accompany them throughout the difficulties. In medicine, our greatest strength is the ability to accompany another person through life’s difficulties. You may not always be able to help, but you can always comfort.”
In the end, “Bad news is still bad news,” said Dr. Day, and it is best handled as a dialogue between the physician and patient. “Such a dialogue requires that the physician know with whom he or she is talking.” This entails taking into account such factors as the individual’s capacity to comprehend a big change, precedents for coping mechanisms that can be found in his or her prior life history, and the patient’s cultural propensities (see next month’s Practice Perfect, “How to Improve Cultural Competence in Your Practice”).
1 Simpson M et al. BMJ
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