Delivering bad news to patients.

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Life changes in an instant.  This truth becomes more self-evident as we age, although even the young may have to learn hard lessons before their time.  We may be comfortably coasting along in a carefree manner only to have a single phone call or a text shatter our equilibrium.  Certainly, every reader of these posts has had this experience. 

I am referring here to an unexpected change of fortune.  It’s quite a different scenario if one has time to prepare for a disruption, such as knowing that you will lose your job in 6 months.  In this example, there is time to prepare and to forge an alternative pathway so that when the current job ends, in a best-case scenario, there will be a seamless transition. 

But life can change abruptly, grabbing us aggressively from behind.  We in the medical profession witness this more than most.  Every medical professional has watched what was expected to be a routine medical event emerge instead as a complex and serious situation.  In these instances, the physician is generally the first to receive the information and then communicates it to the patient. When I have been this doctor, I have been aware of the surreal time interval in between my receiving the medical report and my sharing it with the patient.  On a fantasy level, I want to lengthen this interval to delay imparting unfavorable medical news, but this is of course a measure of magical thinking on my part.  Life can be messy.

Life can change with a phone call.

(Alexander Graham Bell opening a long-distance phone line in 1892.)

How physicians deliver such news is extremely important and can deeply impact patients and their families.  All of us have experienced or witnessed when this has been done well, and also when it could have been done better.  At times, the inclusion or the omission of a single word might distort a patient’s understanding of the situation.  Such a patient might end up being more hopeful or more fearful than the facts warrant.  Words matter.

Communication between physicians and patients is the scaffolding of doctor-patient relationships. Delivering bad news takes special skill and has higher stakes.  You would think that during my many years of education and training that I was schooled deeply in this discipline, but I wasn’t.  I learned what I know by reading and having watched senior physicians and role models in action and incorporating certain practices and styles into my own professional armamentarium.  Conversely, I’ve witnessed communication techniques that I have elected to set aside.  This is how we all grow over time; we accept and reject as we develop our own preferences and styles.

This is not a one-size-fits-all medical task, such as doing a colonoscopy, refilling a prescription or measuring blood pressure.  The physician who will be imparting serious news needs to adjust the strategy depending upon the specific medical circumstances and the particular patient involved.  Some patients, for instance, want more information than others. Some patients can absorb more information than others.  Having an established rapport with patients in these circumstances is invaluable, but is not always present.  We do the best that we can.

How well am I doing at this?  I’m still learning and I believe that I have improved over time, at least I hope so.  It will remain for me a perpetual work in progress.

Next week, I will share a dialogue between me and a patient demonstrating my style in doing this important work.