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Doctors who deliver bad news should do it better

Many patients are unhappy with what they've heard and with the unfeeling way the information was presented. Doctors should be trained to take emotions into account.

March 09, 2009|Valerie Ulene | Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. The MD appears once a month.

When a close friend went in for exploratory surgery recently, her doctor told her there was nothing to worry about. In fact, he was so unconcerned, he planned to perform the surgery laparoscopically -- that is, with only minor openings. But during the surgery, he found cancer. By the time the operation was over, he had abandoned the original approach in favor of a much larger incision, removing her uterus and ovaries as well.

The surgeon delivered the news to my friend's husband as she was wheeled into the recovery room. The doctor was brief; he reported that he had found cancer -- and then excused himself, saying he had another surgery. My friend got the news from the surgeon as she was recovering from the anesthesia. He reassured her that cancer had been found but removed. Then he walked away.

The couple were left reeling, with no answers to their questions or information to allay their fears.

Their experience isn't unique. Many patients are unhappy with the way bad news is broken to them by their doctors. Patients often leave these conversations devastated by what they've heard and by the seemingly callous way the information has been presented.

Doctors' ineptness is understandable -- to a degree. They're not heartless or unfeeling (most of them anyway), but rather doing the best they can in extremely difficult situations. They're focusing so intently on the problem at hand that they ignore the emotions that go along with it.

"As doctors, we're taught to fix things," says Dr. Robert Buckman, an oncologist and author of "How to Break Bad News," a medical textbook for healthcare professionals. "But patients are more than just their medical conditions; there's a person that needs to be dealt with too."

Empathy not only reassures patients that they're in good hands, but it also helps them process the information provided. So patients need their doctors to be understanding.

"They want their doctors to care about what happens to them," says Dr. Anthony Back, professor of medicine in the division of oncology at the University of Washington. That feeling of caring from a doctor can cement the trust necessary for good care.

Yet communication skills are glossed over in medical school and residency training, and most physicians are never taught how to deliver bad news -- although it's a regular part of most doctors' jobs. "It's a practical technique that it doesn't take most people long to master," Buckman says. "Doctors just don't receive the formal training they need."

But even instruction and practice don't make delivering bad news easy, and some doctors fall short simply because they're uncomfortable doing it.

They can try to soften the blow by being less than candid or direct, attempting to avoid a prolonged conversation or even offering an unrealistically optimistic prognosis. In one study, only 16% of doctors talking to their patients about a diagnosis of cancer actually used the word "cancer" in their conversations.

Sometimes, doctors will also ignore any emotions their patients might express in response to bad news. "When patients' emotions erupt, doctors don't know what to do," Buckman says. Although most would offer tissues to a crying patient, many are too uncomfortable in this situation to openly acknowledge the obvious distress.

That's a mistake. Experts in doctor-patient communication stress the importance of acknowledging patients' emotional response. "Do it and they never forget you. Don't do it and they never forgive you," Buckman says.

So, doctors, it's time to step up to the plate. Recognize that having difficult conversations is part of doctoring, and that learning how to deliver bad news well is important to patients' physical and mental well-being. And, patients, help them out -- these conversations aren't easy for them either. (See the accompanying story for tips.)

As for my friend, she had the opportunity to speak with her surgeon one more time: He informed her about her pathology results over the phone and referred her to an oncologist.

The oncologist oversaw the subsequent radiation and chemotherapy; my friend is now doing well and considers herself cured.

Looking back, she's convinced that her surgeon caused her more distress than he would have by discussing her disease. Although the last thing she had wanted to hear was that she had cancer, not talking about it was worse.



How patients can prepare

Be prepared for the possibility of getting bad news after a biopsy or similar screening. Here's what experts recommend:

* If you're having an important test or diagnostic procedure, know ahead of time how you're going to get the results -- by phone or in person.

* Don't assume that everything is going to be fine; make arrangements to discuss the results with your doctor.

* Have somebody go to the visit with you. Choose a person who can act as an advocate and help gather information. Chances are, if the news isn't good, you'll forget much of what you hear and another set of ears will be invaluable.

* Before that visit, write down any questions that come to mind and bring them with you. After receiving serious news from a doctor, it's often difficult to come up with thoughtful questions on the spot.

* Don't be afraid to ask questions or, for that matter, simply ask for a quiet moment if that's what you need.

* Let your doctor know how much (or how little) you want to hear at that first visit. Doctors won't know what you're prepared for unless you tell them.

* Sometimes the next step is simply giving yourself time to digest what you've heard and scheduling another appointment with the doctor to talk further.

-- Valerie Ulene


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