Starting the Conversation
Dr. Kim
At the onset of the meeting, the physician should sit and speak at eye level with the patient, making eye contact. Remove any barriers, such as a desk or computer, between the physician and patient. Set the emotional atmosphere by conveying a caring attitude with your posture and tone of voice. “Introduce yourself, and greet everyone in the room, asking about their relationship to the patient,” Dr. Kim says.
An empathic and honest approach is always best. “Telling patients, ‘I know this may be difficult to hear, but it is important for you to know exactly what is going on so we can make good decisions together,’ is a good way to start the dialogue,” Dr. Minardo says.
“Touching a patient’s arm can be reassuring, but only if you are comfortable doing so,” says Anne A. McVey, PhD, clinical psychologist and assistant clinical professor, The Ohio State University Wexner Medical Center, Columbus, Ohio. “Do not rush the conversation, and do not look at your watch or the clock. Be sure to use direct, straightforward language. Match the language you use to the patient’s education level; do not use medical jargon. Choose your words carefully, avoiding doom-and-gloom messages.”
David Borenstein, MD, MACR, MACP, partner, Arthritis and Rheumatism Associates, and clinical professor, Medicine Division of Rheumatology, Department of Medicine, The George Washington University Medical Center, Washington, D.C., begins by saying that he has formed his opinion by reviewing the patient’s medical history, laboratory studies and radiographs, and by completing a physical examination. “Patients realize that I have spent the time to arrive at a conclusion that is based on what pertains to his or her situation at the present time,” he says. “I may agree with what may have been given as a diagnosis previously or tell the patient why I have formed a different conclusion. If this is a new diagnosis, I assure the patient that I will provide the reasons for my diagnosis.”
Nuts & Bolts
When relaying negative news, it’s helpful to share information in small quantities and to pause frequently. “This allows you to assess the patient’s understanding of what you said and gauge his or her emotional response to the information,” Dr. Kim says.
“Part of communicating bad news is also giving the patient the space and time to respond to it. Initially after hearing the bad news, the patient may be angry, confused or distressed. You should allow the patient to go through this phase by waiting quietly. When the patient is ready to talk, you can respond with empathetic statements, such as, ‘I can only imagine what you’re going through right now,’ or ‘this must be overwhelming for you.’”
Sometimes, visuals can be helpful. If you think drawing a diagram is the best way for the patient to understand what you are saying, say, “I think it would be helpful to explain it this way,” and then offer the diagram. “Looking at something, rather than just listening, is a different way to take in information, which some patients really welcome,” Dr. Minardo says. Handouts and pamphlets can be helpful as well.
When sharing information about the diagnosis, it can also be important to discuss the prognosis. Regarding RA, Dr. Kim might say, “I do have some good news. In the past couple of decades, many new medicines for RA have come onto the market. RA is actually a very treatable condition. I want you to feel hopeful about this disease, because we can control it with medications and prevent future damage and deformities in your hands.”
Likewise, Dr. Borenstein tries to reassure patients that the medical community’s abilities to care for individuals with osteoarthritis, RA and other rheumatic diseases have advanced significantly in recent years. “I tell patients that therapy will correspond to the intensity of disease and the patient’s response,” he says. “I will begin by prescribing therapies with fewer toxicities, and only advance to medications with more side effects if necessary. I also point out that non-drug therapies, such as physical therapy, certain forms of exercise and good nutritional choices, can have beneficial effects.”
Dr. Borenstein emphasizes his years of experience in caring for people who have rheumatic conditions—many of whom have been able to live full and happy lives. “Many young women are concerned about becoming pregnant while having RA,” he says. “I tell them that I’ve had many young women go through pregnancy with healthy babies. They figure out ways to take care of their children even when they have pain in their hands or wrists.”
Dr. Elyse Rubenstein, rheumatologist, Providence Saint John’s Health Center in Santa Monica, Calif., also sheds positive light on all news. “Although I will mention higher risks of cancer, such as in the case of dermatomyositis, I let the patient know that we will watch for it appropriately. When a patient is stuck on being ill, I will make him or her realize that this is not cancer and that they can get better with treatment,” she says.
Calming an Emotional Patient
If the patient becomes emotional and begins to cry, take a break and offer an empathic remark such as, “I know this must be difficult to hear” or “It must be overwhelming,” and just pause for him or her to have a natural reaction. Often, what is best, and what a patient needs, is for someone who cares to bear witness to his or her pain and to not feel alone. After a little while, or when the patient appears to be reconstituting, say, “There is more we need to talk about, but I want to make sure you’re OK first,” Dr. Minardo says.
“Try to understand what the patient is most concerned about,” Dr. Minardo continues. “Again, making empathic statements, such as, ‘You seem very upset. Tell me what you are most concerned about,’ will help you to gauge which direction to go. Saying, ‘Let’s talk about treatment options so you understand your choices’ and offering comforting remarks along with explaining that there are medications that can ease pain or providing some statistics (if they are compelling) will also reassure patients.”
Dr. Borenstein
Dr. Borenstein always has tissues in exam rooms for patients who are upset. “I offer them to the patient and say that he or she is having a natural response and we will work together to fight their illness,” he says. “Many times I refer to ‘we,’ in terms of taking on the challenge of the patient’s illness. Most patients respond to that pronoun in a positive way.”
Some patients get angry. “In rare instances, they may even blame me for the bad news,” Dr. Borenstein says. “I tell them I wish they did not have the diagnosis, but I deal with realities.”
Dr. Kim has also found that silence can be more therapeutic than anything eloquent that could be said. “Sitting there in silence with him or her while being there for the patient emotionally can be very healing,” he says.
Dr. Minardo
In cases in which patients clearly have a poor prognosis and there is not much more to offer in terms of therapeutic treatments, reassure the patient that he or she will not be abandoned. Involving a palliative care consultant can be extremely helpful in these situations.
“If the patient is in denial, I always state that I am ready to start treatment when he or she is ready,” Dr. Rubenstein says. “I say that he is welcome to call after the appointment if new questions arise.”
Closing Remarks
Dr. McVey
At the end of the appointment, summarize the information you presented and collaborate with the patient to make a plan for the next step, which includes any treatment plan or follow-up appointment. Also make sure the patient has understood the information and does not have any more questions or concerns, Dr. McVey says.
Say, “Tell me in your own words what you understood from our conversation today” so you can clarify any misunderstanding or confusion, Dr. Minardo adds.
“Gently let them know that they may continue to have some negative reactions over the next few days or weeks,” Dr. Minardo continues. Depending on your policies, offer the patient your contact information and state that it’s OK to contact you before meeting again. Suggest that he or she write down any additional questions before the meeting to make sure he or she gets all of the answers at your next meeting.
Dr. Rubenstein tries to end on a positive note. “I give realistic expectations of time lines [because] some medications can take weeks to months to make people feel better,” she says. “I let patients know that the goal is to make him or her feel better and that we will continue to work hard together to reduce their symptoms.”
Support Mechanisms
Patients can have many different responses to bad news. For some, the initial reaction is most intense, but then they are able to cope sufficiently thereafter. Other patients may be vulnerable to depression or anxiety, and it is important for doctors to be aware of this and to normalize it. “Making appropriate referrals to mental health professionals is often a good idea. Whether the patient is depressed or just having some difficulty coping or sticking to a treatment plan, psychologists have a wide range of expertise in behavioral medicine and can serve as invaluable resources,” Dr. Minardo says.
Many resources are available for patients looking for additional information. Dr. McVey suggests referring patients to governmental websites, such as Medline Plus and National Institute of Arthritis and Musculoskeletal and Skin Diseases, or national and local chapters of disease-specific organizations, such as the American College of Rheumatology or the Arthritis Foundation. “I always caution patients not to read online stories from other patients, which may cause them anxiety and provide misinformation,” she says.
“It is best to mention that you have resources to offer, but try not to overwhelm the patient while conveying the initial diagnosis,” Dr. Minardo concludes. “If the patient seems interested, then feel free to share them. If the patient had a particularly bad reaction or remained very emotional throughout the visit, it is a good idea to refer him or her to a psychologist or social worker on site. Otherwise, it is best to focus on this at a follow-up visit.”
Karen Appold is a medical writer in Pennsylvania.
