How do you say it?

I am often the bearer of bad news. I don’t think I’ve ever been formally taught how to deliver bad news, but I’ve developed a style over the years, and I’m pretty good at it.

I work with medical residents every day in their outpatient clinics. Most of them have never had to deliver bad news. Some people are natural communicators, and some aren’t. Often, one of my residents just “gets it”—they have a great deal of empathy, can “read” the patient from moment to moment, and without any help from me, they can successfully give the news.

What does it mean to give bad news “successfully”?

In medicine, it means giving complex information in a short period of time, with proper emotional content, and in such a way that the patient takes it seriously, but doesn’t become so frightened that they forget the entire discussion. Once the word “cancer” comes out, little after that is retained. Over and over, I hear people say, “what was that thing you said I have?”

There is no substitute for young doctors giving bad news to their own patients, but it’s good to model behaviors and to pass along tips.

For example, if I have to tell someone they have HIV, I usually make sure to shake their hand, put a hand on their shoulder, sit near them, and keep my arms uncrossed. These signals set the tone for how they will view their illness. If you, as a doctor, seem physically distant, the patient will sense that, and may end up feeling stigmatized, isolated, and more afraid. Also, they may disappear out of fear, delaying further treatment.

Giving bad news has to be a flexible skill. All patients are different, and need to hear news differently. For example, I had a patient with a breast lump. She is a bright and straight-forward person, so I asked her, “Do you prefer a good surgeon who is warm and fuzzy and will hold your hand, or who will just get the job done?” She chose the latter.

I can only hope that my skills keep improving and that my residents keep learning. Unfortunately, there will always be people to give the news to.

6 thoughts on “How do you say it?”

  1. Delivering bad news does require a special skill, and I give you props for promoting that skill. In fact, delivering any news require skill. It is difficult for us non-medical people to absorb medical information. It is a little frustrating to be told about something complex and be sent home only with care instructions without a description of procedures done or conditions discovered. It is especially frustrating when the patient is told after surgery but won’t remember it because of the process of recovering from anesthesia. Meanwhile, there are written records made through transcription concerning impressions, diagnoses, descriptions of procedures performed and so on — but the patient is never given these records.

    So, yeah, what WAS that thing you said I have?

  2. PAL – have you ever considered the fact that “diagnosis” is not always an exact science and that your proclamations of doom and death may in fact speed the patient’s demise. I say this as an “insider”; many times when I have been looking after Alzheimer’s patients who concurrently get metastatic cancer. They don’t realize how “sick” they are supposed to be and just don’t die when they are supposed to – one lady with massive ovarian cysts and liver mets lived for another 10 years. Please remember when you make these predictions to patients that have the mental faculty to actually listen to what you say.

  3. when my friend was told about her breast cancer, she freaked. Normally level-headed and self-possessed, she was as freaked out by freaking out as she was by the cancer.

    The staff at the clinic were matter-of-fact, but compassionate, ready with a dish of chocolate, and a box of Kleenexs and generally got her though it really well.

    She’s on Tamoxifen now, and doing great!

    Now, about Eponymous…am I reading this wrong, or is he saying that doctors cause disease by diagnosing it?

  4. Almost a year ago I was diagnosed with an advanced basal cell carcinoma under the surface of my lower eyelid. Initially the doctor I finally got in to see said “No, looks like just a benign fatty cyst.” He sliced off the tiny projection that first made me aware something was wrong and said “Look, you can see the little pearl of fat there.” A couple of days later he called back and said “I have some interesting news.” Well, I like interesting. He said”That little tumor turns out to be malignant after all.” “Huh, if you thought it wasn a fatty cyst, how come you had it biopsied?” “Well, that’s what the book says to do, and I go by the book.”

    I started researching the situation on line.

    The second doctor said in alarm “That covers 9 mm of your eyelid! We’re talking disfiguring here!” That was upsetting, because I’m vain.

    I had it removed at UCSF, 6 hours away, Mohs surgery one day and reconstructive the next, and it looked pretty good. A slight notch remained on my lower lid, and they said that if I couldn’t live with it I could come back for another reconstructive. Three months later I did go back. They strongly felt I didn’t need the surgery, but I cried so they agreed to do it anyway, right there in a “dental” chair. They removed a piece of tissue to make it look better, and in a routine biopsy discovered that there was more cancer there. After the first surgeries they’d let me have the follow-up work done at home. This time they asked me to come in (another 6 hours each way), so I was a little suspicious but didn’t realize it. The tiny nurse who did the initial vision checks said “Usually they flag it in the file if there’s cancer, and I don’t see any flags.” She leafed through the file, then got up suddenly and left the room without saying “Goodbye” or “I’ll be right back.” This made me a little more nervous. The doctor came in and said “‘Ruth’ said you figured it out” (a flattering but untrue reference reference to my smarts). It hadn’t come to the surface of my mind yet, but I did understand and start asking questions. Again a flattering reference to my intelligence: “you figured it out.” Later I thought “Hey, I had to drive a total of 12 hours to find that out? You could have told me by phone.” He didn’t put a consoling hand on my arm, which would have made me feel condescended to, and he didn’t act alarmed.

    This time they had to do a two-hour frozen section. They initially said it had to be under general anesthesia, but I talked them into a local and happy juice. It was good to find that I had some influence on what took place.

    Now I have one eye for eight weeks – a pain in the butt, having no depth perception – but the only notifying doctor who upset me was the one who said in alarm “We’re talking disfiguring here!” I guess the doctors’ attitudes determined my ability to approach the problem with a problem-soliving orientation.

  5. I’d like to know if junior doctors actually get any training in delivering bad news? Its one of those skills which you hope should be taught, judging by the non-charms of some junior doctors I’ve worked with!

    I used to work in a cancer hospital where part of my duties including briefing the families on what to do after the patient died, regarding burial, paperwork, etc. I also had to deal with patients and relatives a lot during my day to day work.
    There was no training apart from sitting in on other people’s briefings, but what I did notice was how people react to information, and how not to break bad news. One of the best ways I found was to drop my voice a little and speak a little more slowly, which tended to calm relatives (the office joke was that it was my ‘funeral directors voice’). The other trick I learned is that when someone is hysterical, offer them some water. It is seemingly impossible for someone to sob uncontrollably and drink a cup of water at the same time – they have to concentrate on the water, which calms them down a little.

    Breaking bad news is a skill, as is talking to patients generally, and although its good to see doctors (at least in the UK) being given some instruction on how to do it, with so much else to cram into them, sometimes its not regarded as important as it actually is.

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