How do you say it?

On July 4th at 5 a.m., I'm loading the family into the car and driving very far away, where cellphones, pagers, and most critically the internet, do not work. Blogging has been very hard for me lately. I love writing, but due to work and family mishegos it's been hard to keep up with the posting. I'm hoping a stint up in the woods providing medical supervision to 400 souls will be rejuvenating. While I'm gone, I'll leave you with some of my favorite posts about the human side of medicine. I hope you enjoy reading them again, or for the first time. --PalMD

I am often the bearer of bad news. I don't think I've ever been formally taught how to deliver bad news, but I've developed a style over the years, and I'm pretty good at it.

I work with medical residents every day in their outpatient clinics. Most of them have never had to deliver bad news. Some people are natural communicators, and some aren't. Often, one of my residents just "gets it"---they have a great deal of empathy, can "read" the patient from moment to moment, and without any help from me, they can successfully give the news.

What does it mean to give bad news "successfully"?

In medicine, it means giving complex information in a short period of time, with proper emotional content, and in such a way that the patient takes it seriously, but doesn't become so frightened that they forget the entire discussion. Once the word "cancer" comes out, little after that is retained. Over and over, I hear people say, "what was that thing you said I have?"

There is no substitute for young doctors giving bad news to their own patients, but it's good to model behaviors and to pass along tips.

For example, if I have to tell someone they have HIV, I usually make sure to shake their hand, put a hand on their shoulder, sit near them, and keep my arms uncrossed. These signals set the tone for how they will view their illness. If you, as a doctor, seem physically distant, the patient will sense that, and may end up feeling stigmatized, isolated, and more afraid. Also, they may disappear out of fear, delaying further treatment.

Giving bad news has to be a flexible skill. All patients are different, and need to hear news differently. For example, I had a patient with a breast lump. She is a bright and straight-forward person, so I asked her, "Do you prefer a good surgeon who is warm and fuzzy and will hold your hand, or who will just get the job done?" She chose the latter.

I can only hope that my skills keep improving and that my residents keep learning. Unfortunately, there will always be people to give the news to.