Learning to give bad news

Bad news awaited the patient as she recovered from surgery… but the first person to enter her hospital room while she anxiously waited for the pathology report wasn’t the doctor, it was a medical student.

Could this situation have been handled better? Kyle Amber, a fourth-year student at the University of Miami Miller School of Medicine in Miami, Fla., writes about the experience in a recent issue of Academic Medicine, the journal of the Association of American Medical  Colleges:

“Is it cancer?” she asked, as if completely unfazed by the three hours she waited to be seen at this busy clinic that treats patients with poor access to care. All I could reply was, “The resident will come into the room in a few minutes to discuss the findings with you.” Let down, she nodded and told me she understood. Even as I attempted to comfort my patient, I knew it would take quite some time before a resident would be able to see her in this busy teaching clinic. An hour after I had left the room, the resident walked into the room, introduced himself to the patient, and told her that the pathology demonstrated a widely disseminated Stage IV cancer.

If the patient is about to receive bad news, the first person in the room should not be a medical student, he concludes. “This is no way to deliver bad news.”

Breaking bad news to patients and families is one of the most difficult tasks for a doctor to undertake. It’s stressful, and few physicians ever look forward to it or truly become comfortable with it. Yet at some point during their training, they have to confront it.

How do you teach this skill to medical students? There’s a fair amount of debate in medical academia over whether empathy can be taught. Students can learn and practice communication skills, however, that help increase their comfort level as well as their competency. The evidence also suggests that training can help instill awareness and behaviors that make it less likely for bad news to be delivered in ways that are insensitive or devoid of compassion.

At one time, doctors received little if any formal training in how to communicate bad news. They mostly learned by watching more seasoned mentors carry out this task. Hopefully they saw good examples, but maybe they didn’t. These days, medical schools are recognizing it’s an important skill for students to learn and most training programs have incorporated it in their curriculum.

But there seems to be an unwritten rule that medical students should never, ever be the bearer of bad news in a real-life clinical setting. That responsibility lies with more senior colleagues who are directly involved in caring for the patient.

It’s tough, then, for a medical student to be placed in the position of being with a patient who has been waiting for hours to hear the outcome of her surgery, yet be unable to do anything about that patient’s most immediate need – the need for information. Sometimes a student’s most memorable lesson is about how to handle things differently next time.

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