Learning how to give bad news

November 27, 2000

Heather Heilman

"When you have to give bad news you turn your beeper off," said Lesley Saketkoo, a third-year medical student at Tulane. "You have to remember that this event is a mind-blowing experience in the patient's life." That seems obvious, and most of us would expect this basic courtesy from any doctor who told us we had six months to live.

But doctors who are rushed, stressed, and maybe scared can develop hugely bad habits, according to Saketkoo. Hans Andersson, associate professor of pediatrics in the human genetics program, is working to break those habits before they start. As part of the genetics curriculum in the second year of medical school, he teaches students how to give bad news.

Andersson originally became interested in genetics because it's an intellectually challenging branch of medicine, where every patient is a puzzle. But he soon found that being a good geneticist demanded as much emotionally as it did intellectually.

One of the hardest parts of his job is telling parents that their child suffers from a rare genetic disorder, perhaps one that could impede the child's growth and development or eventually prove fatal. Andersson realized it wasn't enough to teach students about the clinical and technological side of his field. He had to talk to them about the human side.

"I find it ironic that someone in such a technology-based field as genetics is concerned with the humanistic aspects of healing," Andersson said. "But the more I learn about the expectations of patients, the more I realize that what they want most is for the physician to care about them. What forges the bond between a patient and their doctor is the expression of concern by the doctor for the patient. But that's often completely missed in the effort to wade through the data and options for care."

His advice is simple and practical. He tells students to turn off their beepers and plan to spend some time with the patient. They should take it slow, avoid medical jargon and not predict the future for any patient, but instead just talk about what the effects of the disease could be. "You have to be honest, but you also have to give an individual reason to be hopeful," he said. "When you take away hope from someone you've done them a terrible injury."

"It's also important for doctors to let patients know they will always be there for them and won't abandon them with unsolvable problems. The only thing worse than having a terrible disease is having a terrible disease and being alone," Andersson said. "If your physician is invested in going through it with you, that's a whole different place to be than if the doctor just says, 'here's the information, thank you very much, see you later.'"

Saketkoo, who was Andersson's student last year, remembers one of the most shocking things he learned was that sometimes it might be okay for the patient to see the doctor cry. "Some people thought that if you're the doctor people don't want to see you crying," she said. "But crying is an expression of sympathy for what they're going through. It shouldn't be self-indulgent, but if you're genuinely concerned and moved by the decisions someone has to make, it shows that you're invested and you're going to do the best you can for them. What matters is that students see that it's okay to care about patients."

"The tendency in medical school is to create defense mechanisms to prevent you from feeling the suffering that your patients are feeling," Andersson said. "To some degree that's probably necessary if doctors are to avoid burnout, but a little goes a long way. I'm trying to break down their barriers just a little bit," Andersson said.

Of course, Andersson is not the only professor in the medical school who addresses the issue of giving bad news. This is a complex issue that needs to be addressed more than once, as students perspectives on it change as their roles and clinical experience expand, said Cathy Lazarus, director of the Foundations in Medicine program.

The topic of giving bad news is broached as part of learning about death and dying in the Foundations in Medicine program in the first and second years. And Marc Kahn, associate professor of medicine, last year received a grant to develop a program using standardized patients to teach end-of-life skills. As part of the program, third-year students have to tell standardized patients that they have a recurrence of colon cancer.

"The program gives them practical experience in giving bad news," Kahn said. "It's different from watching other people do it. Students were allotted up to 40 minutes to spend with each patient and were evaluated on making good eye contact, being factual, showing compassion and giving the patient time to absorb the information and ask questions."

"Those kinds of things can't be stressed enough," said Saketkoo. "It's very easy, once you're in the wards, for things to become minimized," she said. "It's amazing how huge events that blow other peoples' lives apart become incidents between cups of coffee for you. It's really important for professors to catch us before we get to that point."

Tulane University, New Orleans, LA 70118 504-865-5000