Article from the Boston Globe’s On Call Magazine, May/June 2005

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

Communicating with patients, families, or clients about upsetting or unexpected issues is a challenge for all healthcare professionals. In some instances, such as relating a grim diagnosis or prognosis, the news may be sad. At other times, providers may have to correct a service error, such as forgetting to call a client with lab results. “Problems happen all the time,” says Carin Smith, DVM. Smith is a speaker and consultant in Peshastin, Washington, who works with healthcare professionals on developing effective and appropriate communication techniques. “Probably once a week, something happens that gives providers a knot-in-the-stomach feeling.”

Steven R. Grossman, MD, PhD, director of the Gastrointestinal Cancer Program at UMass Memorial Cancer Center in Worcester, agrees. As an oncologist, he talks with patients and families about their diagnosis, prognosis, and treatment options. Often, the news he has for his patients is not encouraging. Grossman says that how health providers communicate sad news is as important as the news itself. To illustrate, he compares two ways in which the same medical information may be shared. In one mode, the physician speaks with the patient and family in a clinical manner, relating only the facts. In the other, the physician adopts a more empathetic approach. Obviously, Grossman says, the way in which this news is delivered is something that families are likely to remember for many years.

Smith and Grossman agree that few healthcare professionals are trained to communicate bad or sad news well. To help, they share the following experiences, examples, and lessons learned.

Develop a Rapport

Like many healthcare professionals, Smith and Grossman must find a way to quickly establish a rapport and a trusting bond with patients, families, or clients they’ve just met. Grossman does this by greeting everyone and finding out how much information people already have. To do this, he uses open-ended questions such as “What is your understanding of what you have?” While one person might say, “I think I have cancer and you’ll tell me the rest,” another may talk about the Internet printouts they brought with them to the appointment.

“Ramp up” to the News

Getting started can be the hardest part of communicating difficult news. Smith suggests that health professionals “ramp up” with a prefatory statement of some kind. If the news is unexpected and sad, you might begin by saying, “I’m really surprised and sad to tell you that.…” However, she cautions not to spend an overly long time ramping up, as the other person may sense that you are withholding crucial information.

Communicate the Information People Need in Ways They Understand

The standard of care for Grossman is to openly discuss diagnosis, prognosis, and treatment options with his patients. Within this standard, however, he uses his clinical judgment to decide how to present this information. While one patient may want to know mostly about prognosis, another may be much more eager to discuss treatment options. Regardless of the news, Grossman always finds something positive to say. For instance, he might focus on comfort and quality of life for a person without treatment options.

Another important principle to keep in mind, he says, is to not assume patients know and understand medical terminology. It’s important to choose words and use teaching methods they understand and can relate to. Grossman does this by matching his language to the patient’s words. For example, he might talk about a “cancerous tumor” with a scientist and a “spot on the colon” with someone unfamiliar with medical terminology. Likewise, Grossman might describe metastases to a layperson by saying, “The cancer broke off and got to the liver.” He also finds it helpful to communicate by drawing pictures, using metaphors, and showing patients their imaging scans in a light box.

Apologize and Amend

When news is about something that went wrong or could have been avoided, Smith suggests that health professionals consider apologizing. While saying “I’m sorry” can have legal implications, she says, current research shows there are benefits to doing so. She recommends that health providers ask at their organization about acceptable practice with regard to apologies.

Making amends can also be helpful. Smith says that one way of doing this is letting the other person know what will be done differently as a result of an error. For example, saying, “I am sorry we were late calling you with the lab results. Here is what we will do so this does not happen again.”

Follow-up

Patients and their families quickly become overloaded after hearing sad or bad news. When this happens, they are not likely to retain what you are saying. To help people who are reeling from bad news, Grossman summarizes the most important two or three key points and then brings closure to the conversation. He follows this by making plans to talk again with the patient. For instance, Grossman might say, “I know this is a lot to think about right now. Let’s find another time to discuss your other questions.”

Practice

When an interaction is particularly difficult, Smith suggests that providers learn from their experience. One way is by talking with their colleagues about what could have been done differently or better. Another way is to set aside time, in a department meeting or workshop, to practice communicating bad or sad news. Smith uses simplified, yet realistic, scenarios of difficult conversations in her workshops. She divides participants into two groups — one taking the role of the client/patient and the other being the health provider. The groups switch roles in a second scenario. By taking turns, participants learn valuable lessons about what it is like to be in the other person’s shoes.

The Final Word: Listen

Communicating well is more than just talking at someone. Listening and sitting in silence are equally — if not more — important. Daniel Egan, MD, in his article “Can You Learn How to Break Bad News?,” writes about sitting in silence after telling a woman her husband just died. Instead of having to listen to her physician talk, the woman uses the silence to process the news, cry, and share a story about her husband. Of this experience Egan writes, “Something that traditionally has been one of the worst parts of this job became one of the most important and moving patient interactions I had ever had.”

How to Find Out More

Steven R. Grossman, MD, PhD, is director of the Gastrointestinal Cancer Program at UMass Memorial Cancer Center.

Carin Smith, DVM, is president of Smith Veterinary Consulting, and works with medical professionals on communication issues. She maintains a Web site at www.smithvet.com.

In print and online:

• Egan D. “Can You Learn How to Break Bad News?” Medscape Med Students. 2005 7(1). www.medscape.com/viewarticle/498845_print
• Smith CA (1998). Client Satisfaction Pays: Quality Service for Practice Success. AAHA Press (American Animal Hospital Association), ISBN 0941451712.