Giving Bad News

From the blog KevinMD, a brief piece from on oncologist on the difficulty of delivering bad news. The doctor/writer is realistic, I think, about the issue: "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."

He also laments his own lack of formal training in the area, and is pleased that more medical schools are paying closer attention to providing this kind of training. I actually asked Dr. R if he was given any training, and he did say that he was given a seminar on the subject. Certainly more than I can say for my general practitioner, who delivered the news to me (and who, thankfully, is no longer with the practice, so I don't need to avoid her when I go there).

I've told the story before, but I'll tell it again, because it's one of those experiences that cancer patients all remember and share.

It was horrible. The doctor called me and asked me to come in to talk about the biopsy, making the appointment for three hours later, and refusing to give me any news over the phone (which, of course, made me suspect something bad, which negated the whole "face-to-face" strategy that she seemed to have in mind). Then she made us (me and my wife) wait for thirty minutes before she came in to tell me. And when she did come in, the first thing she said was, "Stressed?" (One word -- not even a complete sentence. Uh, yeah, I'm stressed.) She then refused to answer any of our questions about what follicular lymphoma was, saying the oncologist would answer all of them, and then offered to write us a prescription for anti-anxiety meds (which we refused, thinking a couple of clear heads would be better at that point). I have nothing against anti-anxiety meds, which have done wonders for some of my support group friends, but giving me drugs seemed to be at the heart of her whole strategy, which is why she wanted me there, and why she asked first, before anything else, if I was stressed. Not the best way to approach a bad news situation. And neither was, simultaneously, pushing me off onto the oncologist.

The doctor who wrote the KevinMD blog post refers to something called the SPIKES technique, described in an issue of The Oncologist from 2000. The technique refers to a six-step process for delivering bad news. It involves:

1. SETTING up the interview, in a private area, where the doctor can sit down, to show she's not in a rush.
2. Assessing the patient's PERCEPTION, using open-ended questions to determine the patient's knowledge of her situation.
3. Obtaining the patient's INVITATION, finding out how she would like to get the news.
4. Giving KNOWLEDGE and information to the patient. Strategies like giving some warning ("I have bad news to tell you") might lessen the blow.
5. Addressing the patient's EMOTIONS with empathic responses.
6. STRATEGY and summary, because patients like to have a plan.

The funny thing is, looking at this list, I think my general practitioner might have actually been trying to implement this technique in some way.

1. She did SET UP THE INTERVIEW, calling me and then making me wait all that time in a room by myself (with my wife, of course), to ensure privacy. And I distinctly remember she sat down.
2. She did assess my PERCEPTION, asking me an open ended question ("Stressed?")
3. She did not do the INVITATION thing, from what I can remember. I think she went right into the biopsy results.
4. About the only KNOWLEDGE she gave me was that I had follicular NHL.
5. She did address my EMOTIONS, assessing that I was in shock and pulling out her prescription pad.
6. And she did have a STRATEGY for me: don't ask me anything. Ask the oncologist that I'm setting up an appointment with.

Or maybe not. She might have been half-listening at the Bad News seminar she want to.

Anyway, I'm clearly on board with the whole idea of better training for doctors in giving bad news. It's a hard enough road to travel; we don't need the journey to start out bad.