On communicating ‘bad news’

February 2019

EDITORIAL: On communicating ‘bad news’

Feb
2019
Vol. 31. No. 1
Richard Balon, MD

Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University School of Medicine
Detroit, Michigan, USA

I recently encountered a couple of cases that made me wonder about delivering “bad news” to patients in medicine in general and in psychiatry in particular—who, when, and how should this be delivered?

The first case involved a 24-year-old male, a first-year medical student, who was referred for evaluation and treatment by the counseling office due to a concern about his school performance. He failed multiple examinations, and it appeared that he suffered from attention problems. A psychologist thought that he may have attention-deficit/hyperactivity disorder (ADHD). However, the student denied experiencing any problems, except for his inability to pass medical school exams. He had to take some exams twice and ended up repeating his first year of medical school. He denied having any concentration, attention, or hyperactivity problems during his childhood. He admitted that he struggled “a bit” during his college years, but “nothing compared to what I am facing now.” Toward the end of the interview, he pulled from his bag a file containing a year-old psychological evaluation. It included IQ testing that showed he was in the upper level of the average range (90 to 109). When asked whether he was apprised of these results, he said that neither the psychologist nor his counselor commented on his testing. “They just said I must have ADHD.”

The second case was a dental school student in his late 20s. He presented asking for medication for his “ADHD.” He had no history of hyperactivity, concentration, or attention difficulties during his childhood. He attended a small college on a sport scholarship. He initially failed to get acceptance at a dental school, but after taking a 2-year basic medical science course, was finally accepted. He spent much of his time studying, yet he reported, “I am not getting it.” He failed multiple exams. A psychological evaluation he had in his possession showed an IQ of 95. No one had discussed this with him.

I ended up delivering the bad news to both students, discussing the implications of their IQ on school performance. It was not a pleasant situation for any of us. I was not sure how exactly to communicate this news, but it was clear that neither man had the intellectual ability to succeed in his chosen career. In both cases, I asked myself why had no one told them earlier. Was it because it was unpleasant and stressful? Or because psychologists and counselors are not trained to do this?

Communication about undesirable findings of tests and examinations (aka “bad news”) is stressful not only for patients, but also for health care personnel, including physicians.1 All of us have probably had to deliver bad news to patients, and many of us have been on the receiving end. As pointed out by Ramirez et al,2 dealing with patient suffering, which includes reporting bad news, contributes to job stress and potentially to burnout.2 Some specialties, such as oncology, seem to be better prepared to deliver bad news than others. That specialty has developed a set of guidelines for sharing bad news.3

What about psychiatry? We also must deliver bad news from time to time to our patients and their families, including the news I had to deliver to the young men mentioned earlier. How should we do this? Are we taught to deliver bad news? What are the “rules of engagement” and who should deliver bad news? Should psychologists explain the implications of their testing? There are no easy answers.

Interestingly, even practitioners in specialties that one may believe to be better equipped to deliver bad news, such as psychiatry, may struggle to do so. Ramirez et al2 reported that the overwhelming majority of a group of specialists that included oncologists and surgeons felt that they received adequate training in the treatment of disease and in symptom control. However, only 45% reported that they received adequate training in communication skills (which I believe includes training in the delivery of upsetting or bad news) and only 22% in management skills. Those who felt insufficiently trained in communication skills were more likely to experience high depersonalization and low personal accomplishment than those who felt adequately trained in these skills.2

Psychiatrists are trained in communication. However, I do not believe we are trained to deliver bad news. There may be more bad news to deliver with the advent of various genetic tests. We clearly need better training in this area, including the establishment of the rules of who delivers what (eg, results of psychological testing) and when. Furthermore, demonstrating the delivery of bad news to residents may be more appropriate than foisting it on them.

CORRESPONDENCE

Richard Balon, MD
Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University
Tolan Park Building, 3rd floor
3901 Chrysler Service Drive
Detroit, MI 48201 USA
E-MAIL
[email protected]

REFERENCES

1. Studer RK, Danuser B, Gomez P. Physicians’ psychophysiological stress reaction in medical communication of bad news: a critical literature review. Int J Psychophysiol. 2017;120:14-22.

2. Ramirez AJ, Graham J, Richards MA, et al. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet. 1996;347:724-728.

3. Girgis A, Sanson-Fisher RW. Breaking bad news: consensus guidelines for medical practitioners. J Clin Oncol. 1995;13:2449-2456.