Delivering bad news is one of the core competencies of physicians. Yet for many physicians, this remains an unaddressed challenge. In a study by Charité professor Jalid Sehouli, half of all physicians surveyed said they had no adequate tools at all for breaking bad news to their patients. The topic urgently needs to be covered in detail in training and further education. But what immediate help is there?
esanum: Prof. Sehouli, what can you give young physicians who are insecure in patient communication as an immediate measure so that they can have better patient conversations tomorrow?
Sehouli: Firstly, one must always be aware that every communication of a pathological finding basically has the potential of bad news - defined by the fact that afterwards one's life, quality of life and perspective on life changes. There is often a discordance between what the physician assesses and what the patient feels. The physician may think with a hysterectomy that the bleeding is over anyway, but for the woman it can have great meaning. Secondly, more important than the words is the relationship. Communication must be direct, authentic and truthful, but the physician-patient relationship is more important than the content of the words. Thirdly, make sure that the patient has the space to digest the message so that he or she can find orientation again. In other words, don't overload the conversation with information and deliberately allow pauses in speech and pay attention to non-verbal communication.
esanum: What is the right preparation for such a conversation?
Sehouli: The most important consideration is: Do I want to deliver this bad news at all? Do I have the resources? The physician has to learn to say no. If I only have two minutes, I can't have such a conversation. He can delegate it, get help from colleagues or agree on a better time with the patient. It's like flying: If the pilot has a problem, the co-pilot takes over.
esanum: What is a good emotional attitude?
Sehouli: Empathy does not mean suffering or dying along with the patient. Professionalism means that I can also be empathetic to the next patient and the one after that. For that, we also need boundaries. The physician does not have to take on everything alone, he can use professional structures and should also know them. Police officers always go into a conversation in pairs when they have to deliver bad news. Physicians are usually alone. That is not good. We physicians can also learn from other professions.
esanum: Please give us two basic dos and don'ts for physician-patient communication.
Sehouli: An absolute don't is to have the conversation even though you don't want to or can't stand it. An absolute do is to know that a good conversation is just as important as a complicated operation. Communication with the patient remains the most beautiful gift and the highest responsibility. You don't need a good numerus clausus to study medicine, you need a love of communication, of words.
esanum: What is indispensable to get a grip on the difficult topic of breaking bad news?
Sehouli: Picking up patients - they are often not prepared for the situation. So you should announce the message and forewarn them: I have some bad news. Pause for a few seconds. But please also celebrate good news. Otherwise patients think that a detailed conversation always means: bad news.
esanum: Where are things going well in education and training in terms of communication?
Sehouli: The Charité is very far along. We have the obligatory KIT seminars - for communication, interaction, teamwork. And the so-called TÄV - a learning centre for training and instruction in interactional and professional reflection on one's own behaviour. The University of Freiburg and the University of Leipzig are also doing a lot. At many others, the topic of communication skills is making its way into the curricula. These include courses with simulation patients. These stories are developed by a commission under didactic aspects. The trained actresses can also give direct feedback. But this is not being done across the board. And there is a lack of continuation in further training. But we can only drive really well if we continue driving after the driving school - on our own responsibility.
esanum: Finally, the good news - there is good news!
Sehouli: Yes, how often do you actually convey bad and good news? I took notes on this for a while and found out: In 13 conversations per day, there were 10 good news and three bad news. This also has to be done mindfully. We tend to communicate the potassium level that is not good and forget that we have diagnosed all sorts of organs that are fine. We need a change of perspective because we have a great profession.
5 golden rules for breaking good news: