Tune into patients' 'emotional channel' to deliver bad news
From the April ACP Observer, copyright © 2006 by the American College of Physicians.
By William Bunch
No physician likes to deliver bad news—but oncologist Anthony Back, MD, has made something of a second career out of it.
Now with the University of Washington and the Fred Hutchinson Cancer Research Center in Seattle, Dr. Back started making rounds as a young oncology fellow in the 1980s, and realized he'd received no training in how to communicate bad or complicated news. While he wasn't the first physician who felt unprepared for this critical task, he decided to do something about it.
He started by reading everything he could find on the subject. Then, he applied for and received a $1.4 million grant from the National Cancer Institute to develop better techniques for breaking bad news. For the past several years, his lab has been an off-season ski resort in Aspen, Colo., where dozens of young oncologists have taken a four-day immersion course, held twice a year, with local actors playing the role of cancer patients. Findings from the research project—which is called Oncotalk—will be published soon, and Dr. Back is trying to find funding to continue the program.
According to Dr. Back, physicians need to acquire a hierarchy of communication skills, beginning in medical school and going through subspecialty training. "What we do in Oncotalk—teach fellows how to give news about a cancer occurrence and talk about why chemotherapy hasn't worked—isn't appropriate for medical students, because students don't deliver that type of news," he said. "We need a whole developmental sequence to appropriate communication."
ACP Observer recently spoke with Dr. Back:
Q: Because physicians aren't well trained to discuss bad news, what is the impact on patient care?
A: There's been a negative impact. Patients either don't understand what we tell them as much as they should or don't feel the doctor took the time to help them understand. That has led to broad mistrust between patients and doctors, and is one reason why patients don't follow their doctor's recommendations or seek out alternative and complimentary types of care.
'We end up talking with patients about only narrowly technical things, and that makes us less satisfied with our work.'
—Anthony Back, MD
There is also a negative impact for physicians. We end up talking with patients about only narrowly technical things, and that makes us less satisfied with our work. That type of conversation isn't meaningful and it's not what we went into medicine for.
Q: What are some broad communication techniques?
A: Start by assessing what the patient knows or understands already. This can be as simple as asking, "What have the other doctors told you so far? I want to make sure I'm starting in the right place." You're asking for data about what their level of comprehension is and their level of coping.
Patients who tell you, "nobody's told me anything" could mean they really haven't been told anything. But they also might mean they were told something but were so upset they didn't retain it. Those are valuable data telling you where to start—at square one.
A second rule is to consider the patient as a TV with two channels. One is the cognitive channel, which is what patients understand, and then there's the emotional channel. What are the patients experiencing, how are they coping, what's the emotional data you're getting from them?
The most common pitfall I see is that physicians concentrate on the cognitive channel and totally skip the emotional one, thinking it's irrelevant or will take too much time. If you don't tend to that emotional side, you'll actually spend much more time. Patients will come back with more questions, more phone calls, because they were too overwhelmed to process what you told them.
Q: What are common mistakes physicians make?
A: When patients have a CT scan or test result that shows something serious, they can get really angry. Physicians often get defensive and say, "I've done all the right tests, why are you so upset with me?" The fact is, patients are angry because they're scared, and physicians need to acknowledge that. They need to say something like, "I can see this wasn't what you expected and you're upset."
Physicians should also avoid telling patients not to worry, especially in the context of a life-threatening illness. That is like telling them, "your concerns really don't count," which isn't helpful.
The other phrase to avoid is, "everything will turn out fine." For most patients, big diagnoses are life-changing events, and it's trivializing for a doctor to pretend that everything is going to be fine.
Q: Is body language important?
A: Yes it is. I had a patient who told me her doctor, when he had to give bad news, would literally back away from her into the corner of her hospital room.
Make sure you're facing the patient, maintaining a comfortable distance and sitting at the same level with the patient. You also need to be in a setting that's appropriate for the seriousness of the discussion.
Q: Is it OK for physicians to talk about how they feel regarding the patient's bad news?
A: I think it's reasonable for the doctor to express feelings aligned with the patient's. If a treatment doesn't work, I think most patients would be comforted if the doctor said, "I'm disappointed, too." Most patients would see that as a sign their physician cares.
But if the doctor is saying, "gee, this reminds me of a situation I had with my mother," the patient will think, "what does this have to do with me?"
Q: Should physicians try to cheer patients up during the conversation?
A: There are times where it's important to make sure the patient feels hope, but there are times where it's important to be realistic. I don't think being a doctor is all about being a cheerleader. It's about guiding patients through this experience.
Q: What can physicians do to hone their skills?
A: Find colleagues they can talk to and share experiences with, talk things over and get feedback from. People get better with training and practice—but don't acquire these skills listening to a lecture. You need some kind of interactive workshop and feedback because communication is more than just a cognitive skill.
William Bunch is a freelance writer based in Philadelphia.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
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