I never dress up for Halloween in my office. As a pediatrician, you’d think it would be the holiday I most looked forward to, with its potential for goofy fun. But other than an easily-removed item like a funny hat or silly pin, I don’t wear a costume. The reason I don’t is summed up in a little pearl of wisdom someone told me during medical school, after I had settled on pediatrics as a specialty: “You never want to tell someone their child has cancer when you’re wearing clown make-up.”
Seeing it written down, it looks dangerously close to glibness. But in reality, the sentiment it expresses is deeply serious. In medicine, you never know when you might have to give terrible news. With the possible exception of law enforcement, medical providers are uniquely burdened with delivering difficult or devastating information to people.
It is a burden I have tried to shoulder well. I have told two patients that they were HIV positive, for example. As compassionate, supportive, and encouraging as I strove to be on those occasions, I still look back and wonder if I shared that life-altering news as well as I should have. Was there some way I could have made it easier than I did? Could I have been somehow a little kinder? I hope I did right by them, but I still turn those moments over in my head and worry sometimes. (Perhaps if I were in a field like oncology, I would have grown more used to this tragic duty by now.)
In both of those cases, I had the benefit of knowing ahead of time that those appointments would be hard and could prepare for them. Sometimes medical providers have no such warning. A flash of white appears at the back of a patient’s eye or there is no twitch where a reflex should be, and you’re explaining to a suddenly-worried parent why their child’s routine physical has just stopped being routine. You didn’t expect to be discussing the possibility of cancer or neurological disorders when you looked at your schedule that morning.
The incredible importance of this aspect of our jobs was brought home to me by seeing it botched. A few years ago, my closest friend gave birth to a son with a rare (and wholly unexpected) genetic syndrome. In the first weeks of his life, she and her husband had meeting after meeting with all manner of subspecialists, almost none of them evincing the kind of compassion that is the hallmark of truly good medical care. By turns evasive, cocksure, or dismissive, I winced over and over as I heard about each new doctor they met and how badly they had come off. How could members of my profession be so inept at talking to suffering people?
To be sure, it’s very difficult to know the “right” way to deliver news of an earth-shattering diagnosis. There are so many different things that play into how we handle it. On one hand, people go into medicine because they want to help others, and to fix them when we can. We always want to focus on what we can do to help, to find that glimmer of optimism. On the other hand, we have to be straightforward and honest, avoiding the creation of false hope. Further, there is a great deal more uncertainty about medical care than many physicians know how to express to patients, and threading that gap between hopefulness and realism can be treacherous. I can see how it would make people come across as cagey or aloof.
Yet as important as getting this aspect of our jobs is, I don’t think I’ve ever had any kind of formal training about delivering bad news. There was no class in medical school, no rounds during my residency or fellowship. The closest I came was watching as instructors brought me along when they assumed that unwanted task, trying to impart guidance to me by example. Perhaps I just ended up lucky in this regard, but those times when I was witness to these conversations (a young family being given their daughter’s leukemia diagnosis, for example) I saw the physician offering clear, understandable information about next steps in treatment. It was simultaneously reassuring and truthful.
Curious if my experience in medical school was typical, I asked several colleagues about whether or not they had received any kind of education about how to deliver bad news to patients. I also asked people I’d known during residency, as well as several current or recent medical students at various schools and in various states of training.
The responses I got back were quite varied. Many reported that what little formal education they had received on the subject had seemed perfunctory, and perceived it as having little practical value. What did seem of more value to them was similar to what I had benefitted from, which was being brought along when an instructor met with patients to deliver this kind of news in person. Not all of these witnessed conversations were good ones, but even the bad ones offered lessons in how not to do it. Others reported that their schools seemed to take this aspect of medical education much more seriously. Many schools seem to include both didactic sessions and practice sessions with simulated patients. The more seriously the school appeared to take the issue, the more helpful the students appeared to find the training.
What I found particularly striking was the experience of a nurse practitioner in my office. Instruction in how to deliver bad news to patients and support them afterward was very much part of her education. It had been incorporated from the beginning and emphasized repeatedly along the way, which was in keeping with the kind of work more thought to be nurses’ than doctors’ at the time she was training. Though I believe there has been something of a cultural shift in medicine since the time of her training (about a decade before mine), there does seem to be some evidence that patient satisfaction is better with nurse practitioners when they feel they need more time and support.
One colleague who completed her training around the same time as me expressed skepticism that being good at difficult conversations is the kind of thing that can be taught. Indeed, there is at least some evidence that efforts to teach communication skills to doctors don’t produce measurable success.
However, the concentration on that aspect of patient care during the nurse practioner’s training makes me wonder otherwise. I suspect taking it more seriously as an important piece of medical education would be more effective than trying to remediate providers who are found to lack this skill after the fact. Presenting it early as an equally important part of medical care to being a competent diagnostician strikes me as a change worth trying. At very least, it is essential that medical training include consistent exposure to this immensely challenging but essential aspect of patient care.
No medical provider is going to be adept at everything (I’m not a surgeon for a reason). There are specialties where interpersonal skills can take a backseat without harm to patient well-being. But for those of us who, routinely or sporadically, must deliver difficult, often life-altering news to patients and their families, it is vital we recognize how important doing so compassionately and carefully truly is.