Last week was tough. I had to refer several patients to hospice, and a few more received bad news regarding their disease. This has always been the toughest part of my job, but it’s also the part patients need me to handle best. I have to remind myself that no matter how hard it is for me to give bad news, the patient and their families are the ones receiving it. That fact has never made it any easier for me, it just helps to ground my perspective.
Oncologists have always recognized this aspect of their jobs. We all acknowledge that this is the “hard part” of our specialty. It’s what we do. Most of us received very little, if any, formal instruction on how to properly deliver bad news. In fact, surveys conducted of oncology fellowship directors have clearly demonstrated that most oncologists are never formally “trained” to give bad news. So how can young cancer doctors acquire this vital skill ?
Speaking for myself, this is something I had to learn “on the job.” As a fellow, I would occasionally shadow my faculty in real patient encounters where bad news was delivered. This was not something I got to do often. When bad news was anticipated, often I was excluded from the encounter for the patient’s sake. Who wants another person in the room, a complete stranger for that matter, when you find out something tragic ? So, I would wait for my professor to return from the exam room and to summarize what he/she had said to the patient. Learning this way is like me telling you how to drive a car by describing it for you – clearly not the most effective way to teach anything. When the patient was actually mine, I personally gave the bad news myself in an unsupervised encounter. No feedback from faculty, no opportunity to ask how I performed. If I had done a lousy job, it remained between me and the patient. I suspect this is how most practicing oncologists were trained to give bad news as well. This also why, I suspect, many patients express such dissatisfaction with their doctor over this very matter. If their physician has never learned how to give bad news properly, he/she will likely continue to make the same mistakes time and again with the next patients.
Maybe we need to take a closer look at how young doctors are trained to perform this task. Many fellowship programs have adopted formal curricula for teaching their trainees how to communicate bad news. This is very encouraging, and certainly suggests that the message has made its way back to program directors. For those of us who have already left training, we can not be complacent with just being “okay” at this part of the job. Delivering bad news is never easy, but if done well it can make a lasting impact on patient perception and satisfaction (in spite of the bad news).
Since leaving my fellowship, I have really strived to get better at giving bad news. I have read On Death and Dying (again) and tried to glean some more insight on how to interact with dying patients. I have adopted the so-called “SPIKES” technique, and now unconsciously apply this protocol to my patient encounters. I talk with my colleagues, I de-brief with my nursing staff, and most of all, I try to learn from my mistakes. I don’t always get it right, and recognizing that fact has helped tremendously to make me more effective in how I communicate with patients.
John Salter is a hematologist-oncologist who blogs at SalterMD.com.
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