doctors

How Doctors Deliver Bad News

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The doctor in the grainy video is standing up, shifting uncomfortably as he spouts medical jargon that members of his patient’s family don’t understand.

 

When the reality sets in—that their father and husband is dead—the family’s intense emotions fluster the doctor. He awkwardly suggests an autopsy before rushing away to respond to his chirping beeper.

It is a low-budget training video that Andrew Epstein, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York, uses often as he teaches medical students the art of breaking bad news.

“If you don’t balance out the physiological basis of disease and treatment of disease with the psychosocial side of medicine, you’re at risk” of alienating patients and their families, Dr. Epstein tells a group of students at a training session last week.
Doctors are trying new ways of solving an old problem—how to break bad news, which is as much a staple of doctors’ lives as ordering blood work and reviewing scans. One issue: Patients and their families, of course, aren’t all going to respond in the same way. Research into the effectiveness of training doctors in how to deliver bad news has turned up mixed results, with patients often not noticing any benefit.

“How much do people want to know? What techniques should be used? It’s a moving target,” says Dr. Epstein, who is also trained in palliative medicine.

Among pointers his students are taught: Always deliver bad news in a private, quiet area. Ask patients what they already know about their medical situation and if it is OK to share the news you have. Use silence to acknowledge sadness or other emotions. Avoid medical jargon. Speak clearly but sensitively.

And empathize. “This is clearly terrible news that I have given you. I can’t imagine what you’re going through,” says Dr. Epstein, giving the students an example of empathetic statements.

The skills can also be useful in daily life outside medicine as most people find themselves at times having to deliver unwelcome news.

“Breaking bad news is actually a golden opportunity to deepen the patient-doctor relationship,” says Nila Webster, a stage-IV lung-cancer patient in Revere Beach, Mass. “For a doctor to be willing to be emotionally available is a tremendous gift for any patient.”

Ms. Webster, 51 years old, left the cancer center at Massachusetts General Hospital this year because she was saddened at how a doctor told her about a setback. A drug trial was under way at the hospital that might have helped her, but she was told there was no room for her.

The oncologist “suggested I go try a couple of other hospitals,” Ms. Webster says. “It was like this long relationship was over and the doctor was ready to pawn me over to another hospital.”

Dr. Andrew Epstein, left, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York, leads a monthly seminar for medical students on how to discuss bad medical news with patients and their families. ‘If you don’t balance out the physiological basis of disease and treatment of disease with the psychosocial side of medicine, you’re at risk’ of alienating patients and their families, Dr. Epstein tells the students at a recent session. ENLARGE
Dr. Andrew Epstein, left, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York, leads a monthly seminar for medical students on how to discuss bad medical news with patients and their families. ‘If you don’t balance out the physiological basis of disease and treatment of disease with the psychosocial side of medicine, you’re at risk’ of alienating patients and their families, Dr. Epstein tells the students at a recent session.
Perhaps no specialty deals with having to break bad news to patients more than oncology. One study estimated an oncologist breaks bad news as many as 20,000 times over a career. Patient and family reactions can run the gamut from extreme sadness and weeping to shock and disbelief to anger. Some doctors tell of patients—or more frequently their family members—punching walls, yelling at them or even threatening to shoot them, in extreme cases.

“Often what happens is clinicians just keep talking and it’s just white noise for the patient,” says James Tulsky, chief of Duke Palliative Care at Duke University. “You need to attend to the fact that this is really serious news and attend to the emotion.”

Dr. Tulsky is one of the developers of VitalTalk, a nonprofit that trains medical professionals in communication skills and empathy, with the aim of developing healthier connections between patients and clinicians. He says doctors delivering bad news should be brief, clear and to the point. “Pause after delivering the bad news. Allow the patient to process that. Generally the patient should be the first one to speak after you deliver the news.”

At Sloan Kettering, Dr. Epstein’s session includes teaching two mnemonics, acronyms often taught in medical school to help students remember information like treatment protocols. One mnemonic he uses is SPIKES, aimed at helping doctors break bad news to patients, and NURSE, for exploring emotions. Dr. Epstein said he includes the memory prompts “because I think we need all the help we can get.”

(SPIKES stands for setting, patient perspective, information, knowledge, empathize/explore emotions and strategize/summarize. NURSE stands for name emotion, understand, respect, support and explore emotions.)

Kate Hogan Green, on right, holding Lorelei, decided to continue with the pregnancy despite learning the baby had Down syndrome. But she says she left her perinatologist after being abruptly told the fetus had a separate, fatal condition. The condition eventually cleared up, and Lorelei is now 14 months old. On the left are Ms. Green’s husband, Bryan, and 3-year-old Adelaide.
Kate Hogan Green, on right, holding Lorelei, decided to continue with the pregnancy despite learning the baby had Down syndrome. But she says she left her perinatologist after being abruptly told the fetus had a separate, fatal condition. The condition eventually cleared up, and Lorelei is now 14 months old. On the left are Ms. Green’s husband, Bryan, and 3-year-old Adelaide.
Kate Hogan Green, of Westerville, Ohio, was 12 weeks pregnant when she learned she was going to have a baby girl who had tested positive for Down syndrome. The 40-year-old decided to continue with the pregnancy. At 18 weeks she saw a perinatologist who told her at an ultrasound appointment that her baby also had nonimmune fetal hydrops, a separate condition in which fluid accumulates and that often results in death.

“I’m sitting there with jelly on my stomach and he’s telling me the baby has this condition. I didn’t have a clue what that was,” she recalls. “He said the baby will likely not survive. He said that we could terminate.” Ms. Green recalls being handed scratchy paper towels as she sobbed.

She switched specialists and about a month later the fluid cleared up. She now has a 14-month-old daughter, Lorelei Clair Green, who has Down syndrome.

A 2011 study in the Annals of Internal Medicine found that giving oncologists feedback on recorded conversations they had with patients made them twice as likely to use more empathic statements in future talks than were doctors who didn’t receive feedback. Patients also reported greater trust in the doctors who had gotten feedback. The study, led by Dr. Tulsky, involved 48 oncologists and 300 recorded conversations with patients.

However, a 2013 study found that doctors and nurse practitioners who received communication-skill training focused on end-of-life care were rated no higher by patients than medical professionals who didn’t receive the training. The study, published in JAMA, included 391 doctors and 91 nurse practitioners.

Another study, published online in February in JAMA Oncology, found the majority of about 100 cancer patients who watched videos with actors playing doctors preferred the on-screen physicians who relayed a more optimistic message. The finding appears to run counter to most doctors’ advice that bad news should be given sensitively but not sugar coated. The researchers said the study underscores the importance of doctors building a relationship with patients so delivering bad news doesn’t have too much of a negative impact.

Helen Riess, a psychiatrist at Massachusetts General Hospital, says she has seen the importance of empathy training for doctors. “I noticed that my patients were spending way too much time feeling upset after their medical visits,” she says.

Dr. Riess, who is the director of the hospital’s empathy and relational science program, founded Empathetics, which offers online empathy courses. The training includes interpreting and managing patients’ emotions through facial expressions and body language. It also teaches doctors how to manage their own emotions during serious patient discussions. “Delivering bad news unsettles everybody, not just the patient,” she says.

Are Doctors Being Exploited?

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Introduction

Physicians have seen their incomes fall, their clout with insurers shrink, and their practices weighed down by a plethora of new requirements. As some doctors see it, this is the direct result of exploitation by payers, hospitals, policymakers, and other groups that have become more powerful than their own profession.

Some say the lower payments and new requirements are the natural result of a society trying to reduce national healthcare costs. But others, including many doctors, say that too much of the burden is being foisted onto physicians. Some reasons cited: Doctors have no way to fight back; they’re not going to refuse to treat patients; some people resent doctors making “too much” money and feel that they should earn less.

What are some of the forces making it so tough on doctors? Here, these physicians explain how they feel that medicine has been taken to the cleaners and what might be done about it.

Problems Trying to Increase Reimbursement

Payers have forced physicians into a flawed business model that is starting to really hurt, said Jerry D. Kennett, MD, a cardiologist at Missouri Heart Center in Columbia, Missouri. For practices, unlike in almost any other line of work, “there is no ability to modify what you charge, based on what your costs are,” he said. Medicare and Medicaid won’t allow physicians to negotiate reimbursement rates, and private payers have forced physicians to sign contracts that limit what they can charge.

Physicians have made do with this business model for many years, but in the past decade or so, costs have generally exceeded reimbursements for many practices, according to Dr. Kennett, the immediate past Chair of the American College of Cardiology Advocacy Committee. In the 2013 Medscape Physician Compensation Report,[1] slightly less than half of physicians felt that they were fairly compensated.

Jeff Goldsmith, PhD, President of Health Futures, a health policy analysis firm in Charlottesville, Virginia, has studied the divergence between physicians’ practice costs and income. “Each new federal initiative seems to require more paperwork,” he said, adding that reporting and billing requirements were a key factor in practices adding 165,000 new positions from 2007 to 2011, according to the Bureau of Labor Statistics.[2] On the income side, he noted that lagging reimbursements were coupled with a 0.9% decline in office visits from 2011 to 2012, according to IMS Health.[3]

One way to escape this downward spiral is “to move into the risk-taking space,” said Lawrence Kosinski, MD, Chair of the Practice Management and Economics Committee at the American Gastroenterological Association. He recommended that doctors explore alternative forms of payment, such as bundled payments and shared savings in Accountable Care Organizations.

Stripped of Negotiating Clout

Scattered in separate practices, most physicians have no clout when negotiating with insurers, said Jeffrey M. Kagan, MD, an internist in Newington, Connecticut. “Doctors never got organized enough to stand up to managed care,” he said, adding that other professions didn’t let insurers limit what they could charge patients. Dentists, for example, are still free to balance-bill the patient whatever amount insurance doesn’t pay, Dr. Kagan said.

A major payer commands so many patients that physicians can’t afford to walk away from them, he said. Insurers have been consolidating, reaching overwhelming market dominance. In 2012, the American Medical Association (AMA) found a significant absence of competition among health insurers in 70% of the metropolitan areas it studied.[4]

Lack of negotiating clout is forcing physicians to abandon small practices, said Steven T. Kmucha, MD, an otolaryngologist in a 4-member group in Daly City, California. This year he expects to leave his small group and find work in a larger organization. “Physicians are becoming more and more frustrated with trying to stay solo or in small groups,” he said.

The AMA has tracked a 22-point decline in the percentage of physicians in solo practices over the past 30 years, from 40.5% in 1983 to 18.4% in 2012.[5] “In the past, reports of the death of small practices were ‘greatly exaggerated,’ to quote Mark Twain, but it may be time now,” Dr. Kmucha said. Many agree. In a 2012 poll[6]cosponsored by Sermo, an online physician discussion board, 81% of physicians said they did not see a viable future for independent practice, a 19-point increase over 2011.

Dr. Goldsmith said physicians can find refuge in larger groups that have real negotiating clout, such as Atrius Health in Massachusettsand Hill Physicians in California”Doctors can keep some degree of independence within the larger group,” he said.

Another approach is to drop insurance contracts and open a concierge practice, charging patients a monthly fee. According to a 2012 survey for the Physicians Foundation,[7] 9.6% of practice owners were planning to convert to concierge practices in the next 3 years. Concierge practices, which often are solo or partnerships, could rejuvenate the small practice.

Turned Into Captives of the Insurance Industry

Rob Lamberts, MD, an internist in Martinez, Georgia, cut his insurers loose and opened a solo concierge practice in 2012; looking back, he wishes he had done it sooner. “Doctors have been turned into tools of the insurance industry,” Dr. Lamberts said. “You always work for whoever pays you. When you work for an insurer, you are constantly under pressure to do a lot of things that don’t improve the care of the patient.”

According to Dr. Kagan, one key way insurers exert their control over physicians is by requiring prior authorizations for certain therapies. These requirements often wear physicians down, and they’ll stop asking, the Connecticut internist said. He says he has to continually request prior authorizations for every MRI and CT scan, even though 99% are approved.

Sometimes the insurer requires him to have a peer-to-peer discussion with one of its physicians. “It ties me up and costs me money,” Dr. Kagan said, adding that he thinks insurers should have to pay physicians for the extra time they have to spend. In a recent study[8] in the Journal of the American Board of Family Medicine,researchers estimated that the mean annual cost of prior authorizations ranges from $2161 to $3430 per physician.

Pressured to Sell Healthcare as a Commodity

Mark Shelley, MD, a family physician from Port Allegany, Pennsylvania, decried what he calls the “commoditization” of healthcare. “The art of medicine has been turned into the business of medicine,” he said. “Rather than trying to make patients functional and happy, the physician gets caught up in financial issues, such as whether Medicare will pay for a wheelchair.”

Feeling unable to make an income charging for necessary services, some physicians begin charging for procedures patients don’t need, he said. “Yes, you need to make money in order to see patients, but you shouldn’t see patients in order to make money,” Dr. Shelley said. “I know doctors who earn a lot of money and are absolutely miserable.”

Howard P. Forman, MD, a radiologist and a professor at the Yale School of Management in New Haven, Connecticut, has a different definition of “commoditization.” To him, it is about standardizing healthcare services as part of the trend toward healthcare consumerism — and he sees it as generally a good thing. “Someday we’ll treat physician services as a commodity,” he said, adding, “a commodity is basically interchangeable, like milk or gasoline, but it can also have great value, like gold or platinum.”

Pushed to Abandon Clinical Judgment

Dr. Shelley said insurers and other corporate interests have too much control of healthcare, and the result is that “the physician becomes accountable for what other people have decided.” A key example of this, he said, is forcing doctors to give up their medical intuition in favor of clinical practice guidelines, which are often used to determine prior authorizations, are embedded in electronic medical records, and are the basis of many pay-for-performance standards.

Rather than resort to guidelines, Dr. Shelley said he primarily relies on his intuition when diagnosing patients. If he is not satisfied with that, he said he reverts to analytic methods, such as ordering tests and consulting guidelines. But he sees this as an awkward and time-consuming way to approach clinical problems, “like having your car in 4-wheel drive all the time,” he said.

Moreover, he said practice guidelines have to be interpreted because they are often off the mark. Several studies[9,10] have questioned the validity of guidelines, and close to half of doctors in a 2012 Medscape survey[11] said quality measures and guidelines would have a negative impact on care.

Dr. Forman, on the other hand, supports guidelines and is skeptical of intuition. “There was a time when we allowed physicians to act like artists,” he said, but in the future, “practice styles will be more equal. Everybody will be expected to have basically the same diagnosis and treatment.”

Dr. Kennett, the Missouri cardiologist, said he supports voluntary use of clinical guidelines. “I’m a fan of appropriate use of clinical criteria — not for every single thing you do, but mainly for high-cost, advanced treatments,” he said.

Under Hospitals’ Thumb

In a 2011 survey[12] of final-year medical residents, conducted by the recruitment firm Merritt Hawkins, 60% wanted to be employed and only 1% wanted to go into solo practice. Hospitals, in particular, have been a magnet for these young physicians. In 2012, almost 30% of physicians worked in practices partly or wholly owned by a hospital, according to the AMA.[13]

Dr. Shelly thinks employed physicians are at risk of being co-opted by the hospital’s interests. “Their actions have to reflect the will of the organization,” he said, adding that an employed primary care doctor is expected to refer to the hospital’s own specialists.

Dr. Kennett said he is concerned that young employed physicians “expect predictable hours and outpatient practice only” and gravitate to “shift work.” Rather than following patients through treatment, they are happy to hand them off to the next physician, and that’s “a bit disappointing,” he said. Many physicians share these views.

Shunted Aside by Policymakers

Many physicians feel strongly that policymakers haven’t been listening to the physician perspective.

The Affordable Care Act (ACA) is often cited as an example of when policymakers turned a deaf ear to physicians’ interests. As many physicians see it, the law lacks substantive tort reform, failed to repeal the sustainable growth rate, and doesn’t seem to improve healthcare. In a 2013 survey[14] by the publishing company Wolters Kluwer, 62% of physicians thought the law would either have no impact or negatively impact patient care and outcomes.

Feeling powerless in the lawmaking process, “physicians fear what the ACA could lead to,” said Wayne Lipton, managing partner of Concierge Choice Physicians in Rockville Centre, New York. “They are concerned about more government involvement, such as a mandate for participation in Medicaid or Medicare.”

Who’s Advocating for Physicians?

If it’s true that physicians are getting a raw deal, who can protect them from further abuse? Many doctors have soured on the AMA for supporting the health reform law, though the national doctors’ organization did have some reservations.[15] A 2011 poll[16] of physicians by the recruitment firm of Jackson & Coker found that 77% disagreed with the AMA’s position on health reform, and 74% disagreed with the statement that the AMA is “a successful advocate of physicians issues.”

The 166-year-old organization has been patching up relations with its critics, and in the past 2 years it has turned around an enrollment decline that followed passage of the ACA. But Dr. Kagan believes that the organization has enormous challenges ahead. Although he recently became a member, he feels that the AMA would have a hard time improving reimbursements, even though “one role of the AMA is to lobby for higher Medicare fees.”

Dr. Kennett fears that many employed physicians might drop membership in organized medicine. He warned that groups like the American Hospital Association (AHA) won’t serve them well. “With all due respect to the AHA, they are going to be lobbying first and foremost for hospitals,” he said.

By contrast, Alexander Ding, MD, a young radiologist who recently started employment at a large group practice in the Bay Area, believes that employed physicians will stay with organized medicine. In a hospital, “there will be times when employed physicians will butt heads with leadership and will need to go to the AMA or their medical society,” said Dr. Ding, who served as a resident trustee on the AMA board and now is on the board of his county medical society.

As physicians look toward the future, Dr. Ding said the AMA’s nationwide perspective would serve them well. “Most doctors across the spectrum feel a sense of disempowerment,” he said. “They feel like they’re running on a treadmill. They don’t have the time to step back and view issues at a higher level.”