Doctors finally learning how to deliver bad news

Downloadable videos help doctors deal with the difficult situations.
By DAWN FALLIK
KNIGHT RIDDER NEWSPAPERS
When Karl Jackson learned that his mother had cancer almost 15 years ago, it was a cold, hard discussion, with little room for emotion and lots of plans for surgery.
Ten years later, it was Jackson's turn. His doctor sat down next to him, said the blood work was in and asked if he was ready to hear the results. It turned out to be multiple myeloma, an incurable but treatable cancer of the plasma cell.
"Every time he explained something, he asked if I had a question for him -- I really felt like he cared," Jackson said.
That kind of bad news is repeated thousands of times a day at bedsides, across desktops and over the phone, turning lives upside down. But as recently as a decade ago, those giving the news received no training in how to handle the "talk," often leaving both doctor and patient feeling even worse.
Now a majority of the medical schools at least address the issue, says a spokeswoman from the Association of American Medical Schools.
Revisiting technique
Even seasoned doctors -- many of whom explicitly remember their first "talk" -- are being asked to revisit their technique.
"I learned how to give bad news by making mistakes, and I said a lot of things that I regretted later," says Dennis Novack, associate dean of medical education at Drexel University College of Medicine. "There was one patient who asked me, 'Am I dying?,' and I just said, 'Yes.' I would never say that now."
Part of the problem, professors say, is that mentors are often not open to talking about emotional connections to patients.
One 2005 study looked at third-year medical students whose patients died while on their internal medicine rotation. In a majority of the cases, there was no discussion of the death at all by the student's medical team, and when it was mentioned, the attending physician focused solely on the medical technicalities. Doctors brought up emotional issues in only six out of 27 deaths.
"On these rare occasions when the attending physician discussed the emotional aspects of the death with the team, the medical students thought it was helpful and expressed appreciation," said the study, based partly out of the University of Pittsburgh.
So when students sit down for the talk, they make mistakes. Mostly, they talk too much, spewing out medical facts and babbling about how sorry they are and not focusing the conversation on the patient, says Ellen Tedaldi, a professor at Temple and director of the school's HIV Program.
Novack, along with Drexel professor Christof Daetwyler, received a $200,000 grant to create a series of 40 downloadable videos for both students and experienced medical professionals. It's called "Doc.com" in which experts re-create scenarios with patient-actors, stopping along the way to explain why they did what they did.
Difficult patient
Used by several medical schools, including Yale and Stanford, the most downloaded scene is "Dealing With the Difficult Patient," Novack says.
In March they taped Timothy Quill and Muriel Gillick, palliative-care specialists from the University of Rochester and Harvard Medical School. Using a make-believe patient with breast cancer, the doctors demonstrated different discussions throughout her illness.
Each doctor showed different styles. One touched, the other didn't. One repeatedly encouraged the patient to talk about her emotions. Both doctors let the patient cry, ask questions -- or not -- if she wasn't ready, and finished with a plan for future contact.
"When you're getting bad news, even if it's done very well, it's bad," says Quill, who says he received the "call from hell" when his brother was seriously injured in a bicycling accident years ago.
Doctors have mixed feelings about giving bad news over the phone, he says, because "if things go sour, you're not there to pick up the pieces and help the patient."
Students say that they may not remember everything given in the sessions, but they make an impression. Scott Campbell is a fourth-year medical student at the University of Pennsylvania Medical School. At the school, students are required to take a "doctoring" class, which includes a session specifically on giving bad news and how to handle it as a physician.
At age 26, Campbell had never been on the other side of the bad news scenario, so when he told a 20-year-old she had hepatitis C, he paused.
"I said, 'I need to let you know that the test came back positive,'" Campbell said. "She started crying and wailing.
"We just let her get it all out and helped her refocus and reassured her that it wasn't a death sentence and about the options she had."
Unanticipated reactions
But doctors say that no matter how seasoned, some reactions can't be anticipated.
"My colleague told a family that their mother was very sick, and the son had a heart attack in her office," says David Muller, dean of Mount Sinai Medical School in New York.
To watch Drexel's "Doc.com" training video for giving bad news, go to http://go.philly.com/badnews