Giving the patient bad news

The patient, a young rodeo rider from rural Ohio, lies in a hospital bed, sick and in pain. The doctor has the results of his bone marrow biopsy and the news isn’t good: It’s Hodgkin’s lymphoma, a cancer of the lymph system which will require chemotherapy.

But that’s not all. In this excerpt from “The Country Doctor Revisited,” Lorence Gutterman describes what happens next:

I take in a deep breath, prepare myself for the next part. “But there’s another problem. You have AIDS.” I remain quiet but am unsatisfied that I’ve told him this without a family member or close friend in the room to comfort him after I leave. Carter turns away from me. I notice how thin his black hair is on the back of his head. In this moment, it’s not important how he got AIDS.

“Does Betsy know?” he asks.

“Not yet. Do you want to tell her or should I?”

“Ya tell her. God, I hope she’s okay.”

“She should be tested for AIDS.”

A slight nod and more silence. There are no right words to fill these spaces.

Sooner or later, virtually every doctor is forced to be the bearer of bad news. But although this is an important skill to have, few physicians receive formal training in how to convey difficult news to their patients.

The Journal of Cancer Education reported recently on a promising method of teaching this to medical students: videotaped practice sessions that allow students to role-play with standardized patients and receive feedback from the mock patients themselves.

Medical students who participated in the role-playing said afterwards that they felt more comfortable in their ability to deliver bad news. They especially benefited from the discussions with the standardized patients, many of whom were cancer survivors and familiar with the emotions – shock, denial, tears – that accompany difficult medical news.

The project was carried out at the University of South Florida College of Medicine. USF students who participate in an interdisciplinary oncology clerkship are required to complete two to three hours of training – first with other medical students and then with a patient actor – in how to convey bad medical news to patients. The mock interviews in the exam room are recorded and then analyzed to help the students identify their strengths and weaknesses and how they can improve.

The researchers wanted to know: What did students think of this teaching method? More to the point, did it help them increase their skills?

Overwhelmingly, students found it beneficial, the study’s authors reported. Although nearly all of them at some point during their medical education had seen bad news being delivered to a patient, only half had given the bad news themselves.

They found the feedback from the standardized patients especially valuable – more so than only receiving feedback from an instructor. The students also felt the role-playing exercise resulted in an overall increase in their knowledge of best practices for conveying bad news.

Giving bad news has always been one of the most difficult parts of medicine, and many physicians are highly uncomfortable with it or don’t do it very well. One study carried out in the United Kingdom, using audiotaped interviews with newly diagnosed cancer patients at a London teaching hospital, found that oncologists usually dominated the conversation, were more focused on the medical details than the patient’s emotions, and often failed to respond empathetically to the patient’s distress.

Another study, at Wayne State University in Michigan, evaluated medical residents on their skills in delivering bad news and found “a general lack of competence,” especially in their ability to converse in a way that was patient-centered.

Both of these studies were conducted in the 1990s, when the concept of patient-centeredness wasn’t particularly widespread. The curriculum at most medical schools has greatly expanded since then, incorporating more training to help medical students communicate better with patients and demonstrate more empathy.

It’s one thing, however, for students to practice and get feedback from their instructors and quite another to practice and get feedback from someone who’s actually been a patient, even if only a standardized patient.

The authors of the Journal of Cancer Education study concluded that although role-playing isn’t a substitute for a real-life encounter with a patient, it provides “a safe learning environment for the student. As a result, the students will have a solid background from which to begin developing good communication skills in the oncology setting.”