Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, April 29, 2009

The Best Way to Break Bad News: It Depends

My father pointed out a recent article in Parade magazine to me the other day. He claimed it was because the woman mentioned is a family friend of my sister, but his motives may be suspect in that he's always on the lookout for things he thinks would help me in my profession. This is amusing, in that most of the time I am either already well aware of whatever it is he sends me, or I could have written the article myself. Thankfully, he has not yet sent me any of the articles I actually have written.

The piece in question was about the do's and don'ts of breaking bad news to patients.

Old news, Pop.

The basics about conveying bad news are pretty basic: do it privately, expeditiously, and compassionately. Beyond that, I would submit that the specific answer to the question about how to deliver specific bad news to a specific patient is pretty much the same as the answer to the vast majority of other questions that get asked in medical practice: it depends.

The woman quoted in the article appreciated the fact that she was given her cancer diagnosis over the phone. It allowed her time to get over the shock privately, so that when she saw the doctor she was emotionally better prepared to deal with the discussion. Fine for her. I commend her physician for taking the time to get to know her well enough to appreciate that this was the right approach for her.

Now if he were to say, "Oh, this is how I always do it," I guarantee that there are patients floating around somewhere permanently scarred by his callousness. "How dare he tell me on the phone! The least he can do is tell me something like that in person!" or similar sentiments, are certainly ringing out somewhere. The trick, as always, is to individualize the breaking of bad news to meet the specific needs of each patient.

I happen to agree that there are systemic factors that contribute to unnecessary delays in the conveyance of information. I don't care what lab or pathologist you're using: biopsy results do not take two weeks. Doctors who are "too busy" to communicate results the same day they receive them are doing their patients a disservice. Without a doubt, there is room to improve the expediency of these critical communications.

Compassion, though, is in the eye of the beholder.

Some patients want the facts and just the facts, thank you. Their version of the best way to receive bad news is straight up. No need to waste time with any of this maudlin emotional stuff. Just give them the information they need to make whatever decisions they need to make. Or, just tell them what they need to do. Even in this era of "shared decision making", there are surprising numbers of patients who don't want to be bothered with that kind of responsibility. I feel very strongly that the new "collaborative" paradigm does not serve these kinds of people well at all. We shouldn't be afraid to make decisions for patients who explicitly request that we do so. Still, there are people whose version of compassion is decidedly NOT of the touchy-feely variety.

Others want their hand held all the way. They want the physician to be there with them while they do their initial crying, because although they are upset, they are comforted by the doctor's presence. The doctor who responds the same way to this patient as he does to the previous ones will be seen as a cold and uncaring automaton who probably doesn't have any feelings of his own.

Doctors have two options: figure out what each patient wants and individualize their approach, or treat everyone the same and hope that they attract only patients who appreciate that particular style. The former is desirable; the latter, I have found, is more often the case in the real world.

There is a push to involve patients in this decision, for example asking (as does a poll in the above link to Parade) how they want to receive bad news. I think this approach is bunk, even though it may sound logical and well-meaning. Here's why: people may have definite ideas about this question, but find their feelings are remarkably different when they find themselves in the actual situation. More important, they may not even realize it. I'm not saying not to ask; just consider taking the answers with a grain of salt, if a skilled physician feels that a different approach would work better than what the patient said they wanted. (Granted this can be a no-win situation, as there would likely be a mixture of responses, all the way from, "Why didn't he do what I said? I know what I want!" to "I'm so glad he did it that way and not the way I said I wanted him to," and everything in between.)

Once again, the answer to the question -- in this case, "What's the best way to break bad news" -- is: It depends! That's why medicine is still an art.


At Wed Apr 29, 05:44:00 PM, Anonymous Anonymous said...

When I read that article, I couldn't figure out how I would want to receive the news. One doctor's approach was to schedule a follow-up appointment with EVERY patient who had a test or biopsy. I've been lucky enough never to have had a biopsy (knock on wood) and all the tests I've had to date have been rule-out situations in which the Bad Thing has been ruled out. It would make me crazy to have to schedule an appointment to hear that the Bad Thing was, indeed, nothing I needed to worry about. (That's what the doctor and I thought all along, anyway.) On the other hand, if a doctor called and said, "You need to come in so we can talk about the results of your test" -- I'm not stupid. I can see right through that. I already have the basic answer, and now it's all just an agony of waiting to find out how bad it is. So although it sounds heartless for a doctor to give bad news over the phone, in this day of outpatient testing it's hard for me to imagine there's a good way to really avoid it.

At Wed Apr 29, 06:49:00 PM, Anonymous Anonymous said...

I thought this was going to be a treatise on how to tell a patient they're going to end up Depends!

At Fri May 01, 05:07:00 AM, Anonymous Anonymous said...

What's also amusing is that I have a father who also alerted me to this article (or I alerted him; I forget which now), which includes the sentiment that "waiting for biopsy results is a form of slow torture." When said father asked how I was doing that Sunday, I said, "Fine, except for going through a form of slow torture."

He had no idea what I meant, and I had to remind him we were waiting on my husband's biopsy results from his colonoscopy.

But I guess it's not unusual for family members to forget about things like that, what with all the other things going on in their lives.

Kensington MD

At Fri May 01, 03:39:00 PM, Blogger John A said...

Of course, there's the "oops" method...

My doctor (OK, intern) sent me for blood tests, trying to figure out why my heart rate is so elevated. The next day, that department asked me to come for a retest because my potassium levels seemed very high, and what with my diabetes...


At Fri May 01, 05:32:00 PM, Anonymous Anonymous said...

A man goes on vacation, leaving a friend to house sit. After a couple days he calls home to check on how things are going. “Your cat died,” says his friend.

“Jesus! Couldn’t you have given me a little time to prepare, worked up to it bit?” replies the man.

“What do you mean?”

“You know, like ‘Your cat got up on the roof and there was a loose shingle...’”

“I understand. Sorry.”

A few days later the man calls again to check up. His friend says, “Listen, your mother got up on the roof and there was a loose shingle...”

At Fri May 01, 10:47:00 PM, Blogger Christian Sinclair said...

In classic Parade style, they took a whole article to really only discuss if bad medical news should be told over the phone or in person.

I was bummed I lost 5 minutes of my life reading the article to see if it really got into more details about good communication skills for clinicians.

I agree the method needs to be contextual and individualized for the person. But there are some good protocols out there like the SPIKES protocol. (free pdf article)


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