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The Art of Breaking Bad News (And Good News, Too)

Every physician occasionally must deliver bad news to patients. But how best to do this? Jalid Sehouli, MD, director of the Clinic for Gynecology and the Center for Surgical Oncology in Berlin, Germany, has been dealing with this issue for over 20 years. He has written a book on the subject (Von der Kunst, schlechte Nachrichten zu überbringen) and recently conducted a large study (“How to Break Bad News”) among physicians and medical students.

Medscape: You surveyed 1300 physicians and medical students on the topic of breaking bad news. What are the main findings of your study?

Sehouli: The majority of those surveyed indicated having difficulties with delivering bad news because they tend not to have learned any relevant techniques. They also have no structured advanced or further education on this topic. But they also indicated that they would generally be ready to engage with this subject. It was also clear that those surveyed were afraid to break bad news.

Medscape: In your study, only 31.2% of the surveyed physicians indicated having learned suitable communication skills. Did this surprise you?

Sehouli: First, I find it great that the physicians surveyed were so honest. I do think that the proportion is much smaller, though. Still, a lot of self-reflection is needed to determine this, which is not something that is covered during medical training, neither during study nor in the further education curricula.

This honesty encouraged me to say, “Okay, if someone articulates a problem, then that is a good basis to work from.” If everyone surveyed had said, “We don’t have any issues with it,” then I would see things differently, since it’s not possible to get through to these people. I see this confession as a cry for help, a very loud cry for help.

Medscape: You have said that the distinction between one who breaks bad news and a recipient of such news is too simple. To what extent?

Sehouli: People need to detach themselves from this stereotype. This is because as soon as someone delivers difficult or bad news, they themselves are also a recipient at the same time. And whoever receives the bad news is also a breaker of it, since he or she must also tell his or her partner or children.

This means that these role switches are dynamic, always bidirectional, and always simultaneous. This should be made clear to people first.

Medscape: How important is successful communication for physician and patient satisfaction?

Sehouli: From the healthcare perspective, on one hand, it is all about the patients as recipients. Therefore, satisfaction plays a major role. But it is also about patient safety. If someone communicates better with the patient, then this patient has fewer problems to contend with, should complications arise, since he or she is better prepared.

The second aspect is that a physician considers a good discussion to be meaningful and one that strengthens the relationship. We are social individuals who live through social interaction. This means, I assume — and I also have experienced this with my team — that physicians who have a lot of difficulties with their communication, in an area in which there are lots of problems, do not last very long. I believe that we would see far fewer burnouts if there was functioning communication and thereby stronger relationships.

Medscape: Should there be a standard for good communication skills?

Sehouli: That is a question we need to ask ourselves in society. I believe that there should be a communication standard. On one hand, we need it for reasons of self-preservation, to maintain professionalism without losing empathy. On the other hand, we need it because patients like to be seen and heard. That is a part of the relationship, and it is the backbone of every diagnostic and therapeutic intervention. I think that such changes are possible.

The question is how we achieve them. Nowadays, you can study medicine and become a physician without ever having done a course on communication. That is not just in Germany, but globally.

Medscape: Why is it, then, that more importance is not accorded to communication? A lack of time?

Sehouli: Yes, it is a problem of time. But also, not everyone is aware how extremely important it is. If I were to hold a seminar on a new surgical technique, then the room would overflow with attendees. In contrast, it would require a lot of energy to motivate people to attend a course on how to talk, because everyone thinks, “I can already do that. Why should I go? I don’t need to go.”

If I start to reflect, no matter how methodically, it can first lead to destabilization. It can emerge that you cannot communicate nearly as well as you think. And if you do not have the tools to improve, then it is easier to just avoid it and to muddle through difficult situations.

Communication is a topic like death or sexuality. We always hear that “nobody talks about it.” It is clear that nobody talks about it. The reason is relatively simple: because it cannot be delegated and there is no structure for it. If you were to have a sexual therapist in your clinic, it would be easy to bring up the topic. But if you had to talk about it yourself without knowing how you can respond to questions, then you would rather not bring it up. And it is the same, too, with the communication of bad news.

Medscape: You have been dealing with the topic of bad news for over 20 years. Now, that is a topic that one doesn’t necessarily go looking for. Was there a specific reason you wanted to confront it?

Sehouli: As a young physician, I assisted with the difficult cancer operations, doing what is known as second assistance, essentially holding the hooks, neither suturing nor stitching. When doing so, I saw that complications can occur. But I also saw that my colleagues often did not visit the patients and had major difficulties in communicating with them.

And then I thought that for me, part of being a good surgeon is that I can communicate. So, as a young physician at the time, I organized the first course here in the gynecology department on the topic of breaking bad news. I heard about the first approaches to this topic in England. I thought that we should set up that kind of thing here at the Charité.

The factual book was a result of the courses. When researching and writing, it occurred to me that there were very few practical guidebooks and barely any science on the subject. It was therefore clear to me that the evidence surrounding the topic must be improved, and I started two projects. One of them was this survey of physicians and medical students, and the other was a study with patients, which will begin shortly.

Medscape: What will your survey of patients look like?

Sehouli: My aim is to interview 1000 female patients. The final preparations for the survey are ongoing. The bad news that the female patients receive will provide the parameters for it. We want to know how they dealt with the bad news, what they want, and how they, in their opinion, could have been better prepared for it.

And I have developed a kind of checklist for these patients. I would like the patients to comment on this checklist, whether they find it helpful to have such a checklist with them. Would patients be ready to educate themselves further on the topic of communication at a patient academy? The study will begin soon at the Charité and will run nationwide across Germany.

Medscape: As a physician, how can you prepare yourself for a bad news conversation?

Sehouli: You should ask yourself these questions: Am I prepared? Can I even do it? How much time do I have? What are the fundamentals of the conversation? It is important that I explicitly prepare myself for this.

Many physicians go into such a conversation without any preparation, without knowing who the patient is, where the patient is caught in the socio-cultural context, and how much the patient may know. There is a difference, whether the patient is prepared for the situation or whether, after an examination, the patient only wants to hear that everything is okay and I have to tell them that they have liver metastases.

I compare this “preparation,” this “realization,” with a pole vaulter who goes through the details of the jump in their head before the jump. This is the first step.

The second step is how I react to the person in the conversation. It is important that I observe and, of course, respect this person’s emotions unless they get violent.

The third step? It is also important to stay silent in the conversation and to listen more than talk. And then to try to translate what was heard and to ask the other person. What does that mean for you? What could the next step look like?

It is also important, after the conversation, to have a debriefing with myself, to prepare myself for the next conversation. It is a kind of algorithm.

Medscape: Since when have medical students also been trained in communication?

Sehouli: It has been getting better for the last 10 years. There are language courses. There are even simulation patients. They are used at lots of universities and simulate diseases to a very high quality. They are also then in the position to give feedback to the students. This concept is gaining more and more traction in universities. But it is still not enough.

I believe that you can only really learn by fine-tuning and taking responsibility. That means that if you are talking about communication but are not taking any responsibility for mistakes or for therapeutic decisions, then the learning process is not as strong and long-lasting as if you had to take this responsibility.

I think it’s important that the topic has been introduced to study, but it must be continuously pursued in further education.

Medscape: Do you think that the younger generation of medics finds it easier to communicate bad news?

Sehouli: The idea that the younger generation no longer has this problem is incorrect. On the contrary, I think that the younger generation has even more challenges to overcome because they were not prepared enough for analog and digital communication. I am afraid that communication will get even worse. Because we have not reconsidered analog or digital communication strategies.

The first important step would be discussions. There are a few examples of this. How do I lead a discussion with a patient via email? How do I lead a discussion with a patient via an app? How do I hold a good video consultation? How do I build my patient relationship concept, taking the use of digital media into consideration?

We are also planning a study about how to handle digital media and on the influence of digital media on the patient-physician relationship. That is a study that will be started here in a few weeks.

Medscape: When it comes to learning about how to break bad news, how do you feel about mentor systems?

Sehouli: Yes, in principle this would always be possible, since we learn best from role models. I would find a mentor concept very good, but it would have to be a mentor who transcends hierarchy and, at best, it would have to be a mentor from outside of their own ward. Otherwise, conflicts could develop. A team member from another department, another discipline, or a mentor from another institution would be worth considering.

The reason it has not happened is down to a question of time and money, since you have to pay for it. A mentor program is work. It must be structured. Therefore, there would have to be appropriate resources. The team members would have to have time set aside for it. The move must be made from “nice to have” to a quality criterion. A mentor concept should become a quality criterion.

Medscape: So far, we have only discussed bad news, but you have also developed a checklist on how to convey good news. What does that look like?

Sehouli: There are five golden rules.

Rule 1: Invest time in the preparation and increase your attentiveness for good news (eg, normal findings, lack of signs of relapse, and improvement in findings).

Rule 2: Announce the positive information or message.

Rule 3: After delivering the core message, give your counterpart time to accept it. Use the pause to recognize your own and your patient’s emotions.

Rule 4: Discuss the practical matters and the consequences of the good message.

Rule 5: Use the opportunity for yourself and the patient to retain the good news (eg, keep a diary or “celebrate”). Talk about it, including with your colleagues and your social circle if you want to.

Medscape: Thank you very much for the conversation.

This article was translated from the Medscape German edition.

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