The news was devastating. The doctor had to tell a 39-year-old single mother of two that her leukemia had returned after a year in remission.
The patient sat quietly while absorbing the news, then began to weep.
“I can see you weren't expecting this,” the doctor said. “This must be very upsetting.”
“How will I tell my children?” the patient asked. “Will I get well?”
This scenario wasn't real; it's a role-playing enactment in an MD Anderson workshop that teaches doctors how to deliver serious news to patients.
Led by Daniel Epner, M.D., professor of Palliative, Rehabilitation and Integrative Medicine, and Jennifer McQuade, M.D., instructor in Melanoma Medical Oncology, the “Difficult Conversations” workshops originated in 2010 in response to research that showed many physicians are uncomfortable with delivering challenging news.
“Nobody likes doing it,” Epner says, “but at some point during their practice, most oncologists will need to convey some unwelcomed news about a patient's medical situation.”
Practice makes perfect
Patients must be told when their cancer recurs, their treatment stops working, or when it's time to plan for end-of-life care.
“Even telling someone with an excellent prognosis that they have cancer can be distressing,” Epner says. “It’s difficult news to deliver, and even more difficult to hear.”
Doctors acknowledge the importance of such discussions, yet many lack confidence about how to say what needs to be said. And they’re unprepared to handle the emotional reactions of patients and family members that may follow such conversations, such as crying, getting angry, demanding to know why, or denying the seriousness of the situation.
Workshop attendees prepare for these scenarios by acting out the roles of doctor, patient, and patients' family members with instructors. In a safe learning environment with close supervision, participants have discussions that occur when people are seriously ill. At the end of each scene, they review what went right and wrong, and where improvements might be made.
“Our goal is to teach doctors how to deliver the message in the most effective and compassionate way possible,” McQuade says, “without creating confusion or additional distress for patients.”
A key to successful communication, she says, is avoiding the use of medical jargon.
“Don't say ‘You have a nuclear grade 1ER/PR positive spiculated 4-centimeter lesion,’” she advises. “Instead, say ‘You have a fairly good-sized tumor in your breast.’”
Knowing when not to talk
After hearing disheartening news, patients need time to respond.
“Often, there's a long period of silence while the patient tries to process the information,” Epner says. “As much as most doctors want to speak to fill the void, I advise them to be quiet. Give the patient space.”
Epner uses these silent moments to imagine himself in the patient's shoes, then validates their emotions with empathic statements such as, “This must be very upsetting for you,” or “I can see you're worried about what lies ahead.”
“Empathy is key,” he says. “Continually imagining yourself on the other side of the conversation will help you be as understanding and respectful as possible.”
Understanding the effect of overwhelming news
Studies show that bad news overwhelms the brain with emotion, so it can't absorb new information right after a shock. Epner is careful to keep the patient engaged as he broaches how to proceed with treatment. He asks “Are you with me so far?” and “What questions do you have?”
He also carefully clarifies the desires of patients who have a terminal diagnosis before discussing next steps.
“Understandably, physicians don't want patients to lose hope,” he says, “so they start listing all the additional tests or experimental treatments that can be tried.”
By first asking patients how they envision their future, doctors can avoid the clinical vacuum in which treatment plans too often are made.
“Some people want to pull out all the stops and try every drug or procedure we can offer,” Epner says. “Others want to forego medical interventions so they can spend a year of uninterrupted, treasured time with family instead of two years in and out of the hospital.
We need patients to understand that it's their life, and their choice.”
Epner says patients need assurance they won't be abandoned, but that their physician will continue to accompany them throughout their illness.
“Most people want to know the truth, no matter how upsetting it proves to be,” he says. “They want to have conversations about end-of-life care, but often don't end up having them, because these conversations are intensely emotional for both the patient and the health care team.”
It’s the doctor's job to help the patient redefine hope, he says. If the hope was that the cancer would be cured, and if that's no longer possible, patients can hope instead to celebrate another anniversary, see a grandchild born, reconnect with old friends, or take that trip they’ve always dreamed of.
“The focus should be on living, not dying,” Epner says.
Communicating in the e-health era
For many patients, there's an unwanted visitor in the exam room — the doctor's computer.
Today, electronic health records are the norm, and doctors frequently enter data into a computer as they interview their patients.
But a study led by Ali Haider, M.D., assistant professor of Palliative, Rehabilitation and Integrative Medicine at MD Anderson, reveals that most patients would like to give the computer the boot.
For the study, Haider and colleagues showed two videos of doctor-patient interactions to 120 patients with advanced cancer.
The first depicted a doctor talking with a patient, using only paper and pen. The second showed the same doctor entering the patient’s data into a computer during the doctor-patient conversation.
Study participants filled out a questionnaire rating the doctor's communication skills, professionalism and compassion after watching each video. Nearly three-quarters of patients preferred the doctor in the face-to-face video over the doctor using the computer.
“To be sure, electronic health records have benefits, including legibility, electronic prescriptions, and centralized location of information,” Haider says. “But the computer is definitely a third party in the exam room, and it does change the dynamics of doctor-patient communication.”
Haider says the findings call to mind different options that could be evaluated in future studies.
For example, doctors could attend training sessions to learn how to conduct their computing in a way that guides and encourages conversations, rather than shutting them down.
Exam room furniture could be rearranged, or laptops on wheeled stands could be used, allowing patients and doctors to sit side-by-side to review data on screens.
Some hospitals and clinics are employing medical “scribes” — professionals who remain in the exam room and enter the patient’s data into the computer during the medical appointment. This frees doctors to provide their patients with eye contact and undivided attention.
“People hearing bad news and facing serious decisions need to know that the doctor who's caring for them also cares about them,” Haider says.