Breaking Bad News: Then and Now
Humanistic qualities and realistic outlook
Despite all the amazing advances in medicine, things can still go wrong with a patient. A 1-in-10000 occurence is never the same as zero, and it is a fact that we have to face in this field. We have sophisticated risk prediction models based on extensive research and careful calculations, and they do help both doctor and patient, but at the end of the day, they produce predictions — nothing more.
When things do not go as expected, it is our responsibility to inform the patients’ caregivers. That responsibility is a daunting challenge and, in many times, is somewhat harder than the medical condition itself. Having to tell a worrying wife that his previously-recovering husband suddenly deteriorates into critical condition is nerve-wrecking. If the process itself is not hard enough, do remember that a person’s response to bad news is quite unpredictable.
Reading many blogs written by doctors and medical students before me, I see that breaking the bad news is a hard thing because it is never properly taught in medical school beyond a lecture or two, forgotten right after the complex biochemistry lecture or physiology lab that follows it. When these young doctors are then plunged into real life clinical setting, they do not have the slightest idea how to even begin breaking the bad news. Do they need to confront the matter or beat around the bush? How do they properly and professionally show empathy?
Fast-forward to current trends in medical education, humanistic qualities and real-life empathy skills have gotten more time on the stage. From the very beginning of medical school, students are reminded that humanistic qualities are part and parcel of being a doctor, not just a bonus point that one can dispose as long as he/she is capable of making superb medical decisions. Subjects dedicated to communication skills permeate our curriculum and students enter clinical life having rehearsed many different scenarios, including breaking bad news to patients and their caregivers.
Now, students know what to do…in a perfect world. Apparently, the change in curricula does not completely solve the problem. In role plays, both student and (simulated) patient follow a checklist; in real life, patients make their own script. They’re too cool to follow your rule.
“Pause a moment to let the caregiver digest the bad news” — or barrage you with questions that frequently slips into irrelevance.
“Keep in mind that patients or caregivers will go through the 5 stages of grief” — and let you experience 7 levels of communication hell where no message can be conveyed at all.
“Stay professional” — instead of treating patients like reality show participants.
These turns of events (which is too ordinary on other settings) may baffle some students, especially those with above average tendency for ‘feelings’. Expectations of information transfer, emotional support, and patient empowerment can feel so distant at times, leaving them unsatisfied and maybe disappointed.
At the end of the day, a little flexibility will go a long way to help our patients accept their condition without compromising our own emotional well-being. The script we are taught in role plays can only take us halfway; it is but a tool we are ready to utilize if the moment calls for it. However, when a different reality emerges, we still have different tricks up our sleeves.
We do not have to answer all of the questions regarding the bad news in one session. In fact, we have to help patients prioritize their curiosity so we are not feeding his/her anxiety. We do not have to feel what the patient feels; we need to understand what they are feeling and the related causes so that we can provide well-targeted emotional support. We do not have to bear the brunt of anyone’s anger; help patients or caregivers cool down by backing off when necessary.
