Breaking bad news to patients
by Liz Hillman, Ophthalmology Business Staff Writer December 2017 issue of EyeWorld. Con permiso de EyeWorld.
Ophthalmology Business Staff Writer
Maehara: firstname.lastname@example.org Lee: email@example.com
“Bad news in the ophthalmologist’s office can be devastating, and the artful delivery of bad news can prove your compassion and ensure patient comfort with your continued care.” —Jeffrey Maehara, MD
Whether it’s a vision-threatening disease or a physician’s error, how you deliver bad news to patients can make a difference.
Providing compassionate care of the highest possible quality is what Paul Lee, MD, F. Bruce Fralick professor, chair of ophthalmology and visual sciences, and director, Kellogg Eye Center, University of Michigan, Ann Arbor, said all physicians aspire to do. One aspect of that, however unfortunate, requires physicians at one point or another to deliver bad news to a patient.
For ophthalmologists, this can range from a cataract surgery not reaching its desired refractive outcome to irreversible, blinding retinal diseases to cancerous tumors that could have an impact beyond the patient’s eyes.
“Being able to communicate both good and bad news to our patients, and if they wish, their loved ones, is an important aspect of taking care of patients,” Dr. Lee said.
Appropriate communications are part through these times is also an excellent of the National Academies of Sciences, Engineering, and Medicine’s definition of diagnostic accuracy, Dr. Lee pointed out. The Health and Medicine Division (previously the Institute of Medicine) defines diagnostic error as the “failure to a) establish an accurate and timely explanation of the patient’s health problem(s) or b) communicate that explanation to the patient.”1
“It’s not just being able to make the right technical diagnosis but being able to communicate that to the patient,” he said.
Beyond how the news directly impacts the patient, how these situations are handled by the physician and perceived by the patient can have implications for the physician and practice as a whole.
“Patients’ word of mouth referrals and their willingness to come perception of how well their physiback are heavily impacted by their cian communicates. It’s important for practice-building and retaining patients to have good communication with patients,” Dr. Lee said.
This could also have legal implications.
“Compassion is the heart of a patient-physician relationship,” said Jeffrey Maehara, MD, Maehara Eye Surgeons, Honolulu. “Bad news in the ophthalmologist’s office can be devastating, and the artful delivery of bad news can prove your compassion and ensure patient comfort with your continued care. It is critically important that patients feel secure with the fact that the physician is truly here to support them in every way through this period. Maintaining patient rapport
way to keep you out of court if legal action is a possibility.”
Discussing negative outcomes
Dr. Maehara said he does not think physicians in general are directly trained enough to break bad news to patients, nor are they “innately gifted at gentle delivery of such news.”
In a survey of 54 residents and attendings in the Department of Surgery at Baylor University Medical Center, Dallas, which was conducted to determine if a didactic program was needed to enhance these communication skills, 90% said they think being able to deliver bad news to patients is an important skill for a physician to have, but only 40% said they felt trained enough to do so effectively.2
“Experience and personal connection to patients may be responsible for some of the disparity in skills we see in this area,” Dr. Maehara said, adding that ophthalmologists in certain subspecialties, such as retina, might have more experience dealing with situations like loss of vision.
Learning how to communicate bad news, and communicate effectively in general, is being incorporated into medical school training, but a mentors and role models. “There’s that direct observational ability to do things in addition to classwork that’s going on in medical schools around the country today,” Dr. Lee said.
Observing patients for how they prefer to receive information is important as well. Dr. Lee said one needs to recall previous communications with the patient, picking up on clues as to what his or her preferred communication style may be. One should also act in accordance with your relationship to that patient. You may act on a more familiar level, for example, with a patient you’ve been treating for years compared to a patient you’ve only seen a couple of times.
“Certain people like things presented cer- tain ways,” Dr. Lee said. “There are some patients who love to have a detailed discus- sion about the various options they have, and other patients who when I am having an in-depth discussion of the options got more and more concerned. Part of that is to get a sense of how patients would like to get information.”
How do you learn this about a patient?
“A big piece when you first meet folks is to listen to what they have to say after an open-ended question and not interrupt them,” Dr. Lee said. “You’ll get a sense of how patients like to talk, and doing some re- flective listening is helpful so patients know you’ve heard what they’re trying to commu- nicate. Have appropriate body language or posture so patients know you’re paying at- tention. That’s particularly important for new patients in the world of electronic health re- cords, because so many electronic health re- cords are set up so that the doctor may not be looking at the patient when they’re put- ting information into the record.
“If you have a new patient and you’re typing in information as they speak but you’re not looking at them, patients don’t feel that you’re paying as much attention as they’d like.”
In these situations, Dr. Lee said he will en- gage with the patient in direct conversation. When the patient offers information that he thinks is important and limited to what he can remember, he’ll say, “If you’ll excuse me for a second, I’m going to enter this into the com- puter, then I’ll ask you some more questions.”
At the 2017 Women in Ophthalmology (WIO) Summer Symposium in August, Dr. Lee gave a presentation on delivering bad news, “Breaking Bad: Empathetically Delivering Bad News to Patients,” where he said that it’s important to “be the doctor who com- municates information; don’t delegate it to a team member, resident, fellow, or colleague.
… Don’t be the person who says, ‘I think you’re going to be OK, but go see Dr. Smith.’”
It’s also important to prepare the patient preoperatively for com- plications and surgical risks.
“It’s a whole different ball game if you’ve talked to the patient about what could happen,” Dr. Lee said. “I’ve had my fair share of com- plications, and having spent the extra couple of minutes ahead of time, the patient remembers, ‘You did say that could happen.’ That changes the what can we do? Minutes here can save hours and days and weeks if it ends up in court.”
Dr. Maehara offered similar thoughts. “This is where an ounce of prevention goes a long way. Set- ting realistic expectations when we first meet a patient or encoun- ter a new consequential problem can significantly ease the transi- tion to bad news,” he said. “If we are taking a ‘final shot’ at some- thing, we should make this clear to a patient. It is always better to underpromise and overdeliver.”
Dr. Lee said when a negative out- come is the result of a physician’s mistake, it’s important to be up- front about it.
“Patients sue to get information because they feel they’ve been stonewalled. We’re in this as a team; let’s be honest and tell them what happened,” Dr. Lee said at the WIO meeting. “The results of doing so are good for patients and good for physicians and the health systems, based on experience at the University of Michigan.”3
Delivering bad news to patients
• Do it yourself; don’t delegate to a team member.
• Recall from previous interactions how the patient might prefer to receive such news, how much detail you should get into, etc.
• Suggest having a family member or friend present for extra support. • Focus on positive attributes of the situation.
• Schedule a follow-up appointment a week or so after delivering bad news to check on how the patient is doing.
When a patient acts emotionally
In addition to considering how you deliver bad news to patients, physi- cians need to consider their response to patients’ reactions.
“Having an appropriate, compassionate reaction is something I try to do with folks,” Dr. Lee said. “For example, if they’re crying, offer them a tissue. De- pending on the relationship, help reas- sure them. If they’re angry, let them ex- press themselves and work with them on how to address their concerns.”
Dr. Maehara said in addition to being supportive and explaining that these emotions are normal, it can be helpful to provide examples of how things could be worse and emphasize positive attributes that remain, even if it’s the other eye.
In these situations, Dr. Lee said it’s of- ten helpful to have a patient’s loved ones engaged in the conversation. A close friend or family member can pro- vide support to the patient receiving negative news as well as a second set of ears to help process the information.
In tense times, Dr. Lee said it’s import- ant to ask patients to repeat back what they’ve heard so the physician can be sure they fully understand the situa- tion.
“When breaking bad news, it’s often overwhelming for the patient, so it is best to ensure family members are pres- ent and to summarize where the patient was before, the unfortunate events that have occurred, and what positive things remain,” Dr. Maehara said.
Scheduling a follow-up appointment af- ter delivering bad news might not help soften the blow, but it provides reas- surance to the patient.
“A 7- to 10-day follow-up appointment to check on how the patient is doing is not a bad idea and reinforces that the patient is not alone despite a perma- nent condition,” Dr. Maehara said.
- The National Academies of Sciences, Enginee- ring, and Medicine. Institute of Medicine. Impro- ving diagnosis in health care: Quality chasm se- ries. September 2015. www.nationalacademies. org/hmd/~/media/Files/Report%20Files/2015/ Improving-Diagnosis/DiagnosticError_Report- Brief.pdf.
- Monden KR, et al. Delivering bad news to patients. Proc (Bayl Univ Med Cent). 2016;29:101–2.
- Boothman RC, et al. A better approach to medical malpractice claims? The University of Michigan ex- perience. J Health Life Sci Law. 2009;2:125–59.