Delivering bad news
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7270.1233 (Published 11 November 2000) Cite this as: BMJ 2000;321:1233
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Bad news is called bad news because it is … bad news. Most doctors
are excellent communicators but they have to give complicated, difficult
or unpleasant news to people who are anxious or frightened, or feel guilty
or upset. The experience for patients or parents should be awful.
The writer of anonymous Personal View demonstrates several of the tensions
inherent in the doctor-patient relationship, which are exacerbated under
the circumstances described. [1]
Firstly, the arousal gap. Every phrase, silence and gesture is given a
meaning by the patient far beyond its intention. S/he complains about
being ushered in first. Had that not happened, presumably the complaint
would have been about being kept waiting. The patient found the direct eye
contact and silences unnerving. The alternative might also have been
criticised, “he avoided eye contact” or “he talked so I couldn’t think or
get a word in”.
Secondly, the writer thinks s/he is a mind reader and the doctor should be
one too. ‘I thought’ and ‘I felt’ and ‘he thought’ and ‘he seemed’. The
author complains about the ‘promised’ one month appointment being three
months (was it promised or just said?) and that the other people in the
room were not introduced. But why didn’t the author ask why the
appointment was longer or who the others were? The doctor should have
explained why the appointment was delayed, but there turned out to be more
important issues to talk about, and should have introduced the other
people in the room. The complaint might then have been, “he talked about
the waiting time and the other people in room when all I wanted to know
about was the biopsy result”.
Thirdly, the patient tells us s/he is a psychotherapist. I am unimpressed
when a parent plays the ‘professional card’. I tell them that when I take
my children to the doctor I go as a parent, not a paediatrician. I need
someone to think with their head, not their heart. In the same issue of
the BMJ a doctor who became a patient wrote, “Let the experts manage your
treatment … embrace the sick role. For the time being you are not in
control.” [2] Despite her/his training s/he clearly does not recognise
the anger, guilt, and fear which is motivating much of the what the s/he
describes including petulant remarks about omniscience, which belie
her/his claims for professional recognition.
The anonymous Personal View would have been a suitable piece for the BMJ
to allow the orthopaedic surgeon to give his side of the story.
Yours faithfully,
Dr Charles Essex
Consultant Neurodevelopmental Paediatrician
Child Development Unit
Gulson Hospital
Coventry CV1 2HR.
1. Anon. Delivering bad news. BMJ 2000;321:1233. [11 November 2000].
2. Hosking E-J. How to cope with time off sick. BMJ
2000;321(classified section, 11 November):2-3.
Competing interests: No competing interests
Sir,
I read Mr Nolan's response with surprise. The fact that his undergraduate
and postgraduate training have had no teaching on communication skills is
an indication of poor quality training.I congratulate him on his honesty
in making this admission of a gap in his learning and I hope he will take
steps to remedy this deficit.
There are two groups of reasons for learning good communication
skills. One is the fact that having good communication skills can help
avoid misunderstanding and conflict and so reduce the incidence of
complaints.
Good communication with patients, and in particular good preparation
of patients prior to surgery is known to improve outcomes and reduce post-
operative pain. Surely this alone should be enough motivation for any
surgeon to consider his communication strategies as well as his well honed
operating skills?
Good communication skills are also useful outside the consulting room
for example in teaching and making presentations. Their use also allows
people to be effective in committee work. In our personal relationships we
need good communication skills.
Finally using good communication skill is entirely enjoyable and
knowing how to communicate effectively will enrich every area of our
lives. It enables us to connect with other people and learn more about
them and so about ourselves. Communication skills can be learnt by anyone
and are a complement to any other abilities we possess.Indeed our other
abilities will be enhanced by good communication skills.
Communication skills are a basic part of medicine. As a profession we
need to ensure that all doctors are competent at communication.
Yours sincerely,
Peter Davies.
Competing interests: No competing interests
Dear Sir - I read with interest this weeks Personal View in the
Journal (No 7270 11 November 2000). Whilst I sympathise with his
experience in the inability of his orthopaedic surgeon to break bad news,
what did he expect?
In all my undergraduate and postgraduate training I have never been
taught how to approach this subject. Some individuals do manifest a
natural ability to be more sympathetic and others like the surgeon in the
article do not.
However does this really matter that much?
In the ideal world all surgeons would, as well as being technically
brilliant, be sensitive, gentle, caring and understanding individuals who
were adept at counseling. To some of us this may come naturally and to
others it may have to be taught. However I would rather have a surgeon
who had spent more time improving his operative skills than learning how
to be a psychotherapist.
Assuming that all qualities are not often found in one individual,
would the author of the article rather have a rude, insensitive but
competent surgeon or a gentle and sympathetic one who couldn’t tie his
shoelaces let
alone operate. I would speculate that most of the readers of the BMJ would
have no difficulty in deciding which one to chose.
The author of the article is a psychotherapist and was looking for
qualities in his surgeon that he delivers in his own professional
activities. However he forgets that sensitivity is the very essence of
his work whilst surgery is the very essence of ours. Not all surgeons can
counsel and even fewer psychotherapists can operate.
Paul C Nolan MD FRCS FRCS(Orth)
Consultant Orthopaedic Surgeon
Competing interests: No competing interests
EDITOR - Was the juxtaposition of articles on the same
page in the iith November BMJ an intended irony? 1,2. At first glance the
articles seem opposed. The Personal View describes a surgeon’s apparent
lack of awareness of his patient’s feelings and needs when breaking bad
news, the
Soundings seems scathing about enquiring too closely
(perhaps insistently?) about patients’ feelings. Yet they have common
ground: trying to give each patient space to begin making meaning out of
suffering according to their
needs, rather than the blanket prescription which is
often delivered, such as “the counselling” at any and all scenes of
trauma.
Carola Mathers,
Consultant Psychotherapist,
South West
London and St. George’s Mental Health NHS Trust, Sutton Hospital, Surrey.
1 Anonymous, Personal View, BMJ 2000;321:1233
2 Barraclough, K. Soundings, ibid.
Competing interests: No competing interests
Sir, I am writing to agree with Dr. Davies that GP training has
preceeded hospital based training as regards communication skills
assessment. However, I must also state that this problem has been well
recognised by the Royal College of Surgeons and many medical schools.
My undergraduate training at St.Bartholomew's Hospital included
specific teaching and assessment of communication skills including
videotaped consultations. When I recently sat my postgraduate surgical
exams one fifth of the clinical examination was given to the communication
skills section. I have also just completed a Care of the Critically Ill
Surgical Patient course run by the Royal College of Surgeons and on this 3
day course 3 sessions were devoted to communcation skills scenarios with
an actor playing various roles.
Having been supposedly taught more communication skills than most and
in particular probably more formally than this consultant orthopaedic
surgeon I feel that it is a difficult subject to teach. I also feel that
the most important role that this surgeon had to play was diagnosing and
treating the patient correctly and this must not be forgotten. Patients
expectations are ever increasing and to change this surgeons particular
practice may be impossible. We must continually endeavour to provide an
appropriate service for our patients and there is certainly room for
improving many doctors communication skills. It may be a case of teaching
old dogs new tricks but at least medical schools and the Royal Colleges
are trying to improve the training of their new graduates.
Competing interests: No competing interests
Sir,
I read this piece with sadness. At one level the doctor involved has
succeeeded in diagnosing and treating a malignant sarcoma. He has
exhibited great skill and technique and the end result in terms of cure
and with reasonable retention of function is good. The surgeon has won a
victory and cured the cancer. Surely we should be celebrating with the
surgeon?
And instead we see the results of failing to communicate with the
patient. The surgeon appears not to realise that language is a sharper and
more dangerous instrument than any scalpel. By his use of language he has
caused a wound to appear that need never have been made. This is an
iatrogenic injury and should be regarded as badly as any other unecessary
side effect of medicine.
To receive my certificate of approval to work as a G.P. I had to
demonstrate basic competence in communication skills by means of a series
of videotaped consultations. So far as I know none of the hospital based
specialities have this requirement in their training programmes. This is
despite the fact that all doctors are communicating constantly with their
patients and each other.
In the light of cases such as the one described in this article it is
surely time for teaching and formal assessment of communication skills to
be a key part of undergraduate and postgraduate medical education in all
specialities.
Yours sincerely,
Peter Davies.
Competing interests: No competing interests
Let us bear in mind that talent for human communication is unequally
present in different people. It is not a prerequisite for becoming a
surgeon. Still, the art of it can be taught, so that people with limited
natural talent, can acquire minimal proficiency. Perhaps professional
organizations could pay more attention to this need, offering courses in
communicating with patients and families, and encouraging members to avail
thamselves of such courses.
Competing interests: No competing interests
Training in delivery of bad news
I sympathise whole heartedly with the author of the article. I think
the newer generation of doctors have received better training, whether
this is adequate or not, only the generation after will be able to tell,
i.e. the people who give and those who receive bad news.
For me, a medical SHO, the best training was a 6 month slot in
Oncology, which presented me with umpteen opportunities to 'deliver bad
news', and hopefully the people I have delivered the news to feel that I
did a reasonable job, though I have vivid nightmares of the ones where I
didnt do anything right. I think it should be a prerequisite for all
training rotations, to have a little Oncology in their training.
I think something to remember is never to say "Bad news, I'm good at
giving it", because however much one improves, one is never good enough.
Unfortunately, one only learns with a few mistakes, for alas! they
are the stepping stones to success (and I, as do most others, apologise
for those stones I have stepped on)
Competing interests: No competing interests