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Seeking good ways to give bad news All too often, doctors are insensitive to patients' emotional needs when the diagnosis is grim, and there's a recognition that their communication skills need to improve

One of the hardest jobs in medicine doesn't require high-tech devices or sure hands. It's that painfully awkward moment when a doctor has to deliver bad news.

Generally, patients want the facts cushioned by compassion and encouragement. Yet as simple as that sounds, the right words often go unspoken.

Bill McLaughlin of Clarence, for instance, recalls how his urologist called on the telephone with the results of a biopsy that confirmed prostate cancer.

"It was his way of not having to face me," he said.

McLaughlin likes to say he "fired" the doctor after the encounter.

Rose Hauser of West Seneca still talks angrily about the neurologist who sat her down, pointed out a brain tumor on an MRI scan and told her little more than that she had seven to 10 years to live.

"I'm thinking it's the end of the world, and he's just as dry as a bone," she said.

That was 15 years ago, and she's still alive.

Of course, some doctors do communicate well with patients or work at the skill. But others don't, as reflected in the large number of studies and personal stories about improving the doctor-patient relationship.

A recent example: Dr. Diane S. Morse at the University of Rochester hit a nerve last month with intense reaction nationally to her research in the Archives of Internal Medicine suggesting that physicians usually miss or ignore chances to express understanding and support.

She and her colleagues examined transcripts from recordings of consultations between doctors at a Veterans Affairs hospital and patients with lung cancer. They identified 384 opportunities for empathy when patients expressed concerns about death, symptoms or treatment options but found that physicians responded in only 10 percent of the moments.

In some cases, doctors failed to pick up on clues in their conversations with patients.

"I was doing a man's labor, and I was always told I had a good strong heart and lungs. But the lungs couldn't withstand all that cigarettes," one patient told a physician in an attempt to discuss his smoking.

"Yeah," the doctor said.

"Asbestos and pollution and secondhand smoke and all these other things, I guess," the patient said.

"Do you have glaucoma?" asked the physician, simply changing the subject.

Empathy, which means understanding a person's plight yet remaining detached, is another way of describing bedside manner.

Doctors overestimate the amount of time and effort it takes to voice empathy, Morse said, suggesting that physicians start building a relationship in early encounters with patients to learn how best to handle bad news later.

"Patients hunger for physicians to hear their concerns in some way. It doesn't necessarily have to take a lot of time, but doctors need to acknowledge them," said Morse, an assistant professor of psychiatry and medicine.

Her findings are consistent with other studies and cannot be easily dismissed as a warm-and-fuzzy extra to the main task of providing medical care. Research also confirms what seems to make sense: that doctors who express empathy get the highest patient ratings and fewer complaints, as well as better compliance with treatment and better outcomes.

"Doctors need to know that when they break bad news, it's a huge moment in a patient's life. As soon as they say the word 'cancer,' a patient is probably not going to hear anything else," said Hillary Ruchlin, executive director of the Cancer Wellness Center, a patient support group in Buffalo.

Even if everyone agrees that good bedside manner is desirable, it doesn't make it easier to accomplish.

Relaying bad news is difficult. Few people are comfortable talking about death and dying. And empathy can take time that busy doctors often believe they don't have.

Doctors also come with different skills and personalities. Some can naturally communicate like Olympic champion Michael Phelps swims. Others can barely dog paddle.

Patients are different, too. Some want their information direct. Others require a go-slow approach. Some will handle a diagnosis of cancer with poise. Others will wilt over a negative test result for a condition that isn't fatal.

"It's a situation no one wants, yet there needs to be some interaction. Physicians are people. They are not all stamped out of the same mold. Patients are different and bring with them emotional, family, religious and cultural issues," said Dr. Michael A. Zevon, chairman of the department of psychosocial oncology at Roswell Park Cancer Institute.

To Zevon, the mistake is for physicians to treat breaking bad news as a single, pressure-filled moment when they should pay more attention to building trust with a patient over time.

"If I have one message, it's that this is a process and not an event," he said.

One other problem is the tendency to rely too much on statistics, experts say.

Cancer patients want to know how long they have to live, and doctors will show them the published statistics. But survival statistics are based on averages of large populations, may be dated and may not take into account changes in treatments, said William R. Potter.

Potter, a Roswell Park researcher, gives lectures to medical students about what he describes as "detoxifying statistics."

"We've been brainwashed about statistics and their ability to predict that a bad outcome will come true. But statistics are not individually predictive at the start of a diagnosis," he said. "If a patient wants to know their chances, the only answer is that they have a life-threatening condition and will have to see how things come out.

"Statistical uncertainty is the place where hope resides."

Empathy may be a quality that a person is or isn't born with. But good communication skills can be taught. Many medical schools, including the University at Buffalo School of Medicine and Biomedical Sciences, have incorporated training programs.

UB's is unusual for using cancer survivors as volunteers for role-playing exercises in which second-year students practice breaking bad news and receive feedback from the volunteers.

Such programs also teach the students guidelines they can use to help them navigate uncomfortable moments -- everything from remembering to introduce themselves to periodically checking with the patients to make sure they understand what is being said.

Still, there is an unnerving quality even to the role-playing conversations. Patients cry. There are long silences. People ask questions for which the doctor-in-training doesn't have good answers.

"You can't BS a patient. You can't make yourself sound as if you have all the answers," Dr. Christopher P. Schaeffer, assistant professor of clinical medicine, told a group of students recently after their role-playing exercise.

If his lesson can be boiled down, it's to search for the right words when relaying bad news and to give patients time to react, even if it means putting up with silence or leaving them alone to take in what they've heard.

"The doctor's instinct is to move on, but that cuts people off while they're having an emotional reaction," Schaeffer said.

Despite the academic efforts, cultivating doctors with more empathy may be an uphill battle that conflicts with the organization of medical training.

A study published earlier this year in the journal Academic Medicine began with a question: Is there hardening of the heart during medical school? The conclusion was yes.

The researchers said students often lose empathy during medical school. The reasons, they said, could involve the stress and competition of medical school. The study also suggested that an unrealistic image of doctors as heroes in popular culture leaves the students with a view of their profession that's cynical.


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