Heide Aungst

 sheds greater light on something primary care physicians have long suspected: Give a patient bad news, and he or she won't remember much of what you say after that. 

The research, led by Jesse Jansen, a PhD candidate at the Netherlands Institute for Health Services Research, examined 260 patients with cancer who were seeing a medical or radiation oncologist for the first time. Regardless of age, patients with a poorer prognosis recalled less than other patients. In addition, the more information the physician gave the patients, the less they recalled. 

Although family physicians usually aren't the ones to deliver news of a terminal disease, the lessons hold for milder diagnoses as well. 

Terry Stein, MD, director of clinician-patient communication for the Permanente Medical Group in Oakland, California, says a biologic process occurs when a patient is given bad news. She likes the word "frazzle," used by best-selling author and psychologist Daniel Goleman in his 2006 book "Social Intelligence: The New Science of Human Relationships." 

The book, Stein says, explains what happens in the brain during human interaction, as shown on functional MRIs. 

"There's now this way to look at brain-blood flow and what happens to our ability to receive information and express ourselves when we're in a state of frazzle," Stein explains. "I've brought that into teaching doctors about communication to help them appreciate that whatever we can do to reduce our own frazzle - and our patients' frazzle or anxiety - is very important." 

According to Stein, the biggest mistake doctors make when communicating bad news is reverting to "just-the-facts" mode as a defense against their own unease at giving unwelcome news. That defensiveness often leads to a lack of empathy for the patient or a "data dump" - giving too much information, which can be difficult to retain under even the best circumstances.  

Another common mistake is using complex language, which can confuse and frighten the patient. 

"There's a whole multi-syllabic lingo that's the way doctors talk to each other," Stein says. "They are often words that people don't understand." 

Jensen, of the American Academy of Communication in Healthcare, adds that it can be as simple as using the word "cancer" instead of "malignancy." Malignancy is so common to physicians' vocabulary that they often don't realize how many people don't understand what it means. 

Dean Schillinger, MD, a primary care physician and general internist at San Francisco General Hospital, studies physician-patient communication in vulnerable populations. Many of the patients he works with are illiterate, poor, and from foreign cultures. 

The most effective means of assessing whether a patient has understood the diagnosis and treatment plan is by using the "teach-back" method, Schillinger says. 

"It's important that this be done correctly. It's not, 'So, do you understand?' It's really an explicit request that the patient articulate in his or her own words their understanding or reaction to the new information." 

The key is to ensure that patients do not feel additional stress, as if they are undergoing a test or being interrogated. To avoid this situation, Schillinger puts the onus on himself as the teacher. 

His typical conversation sounds like this: "I want to make sure that I've explained myself well, so just bear with me here. When you go home and talk to your wife or talk to your kids about what my thoughts on what your disease is, how are you going to explain it to them? . . .Because I want to make sure I did a good job explaining it to you." 

Jensen refers to this as "chunking and checking" - providing a chunk of information and then checking with the patient to ensure he or she has clearly understood what's been said. 

Articles

The biggest mistake doctors make when communicating bad news is reverting to "just-the-facts" mode as a defense, one expert says.

How to deliver bad news to patients

To handle the numerous complications of interrelated cardiometabolic disorders, the clinic has implemented a program model that incorporates clinical pharmacists who see patients with physicians.  

"One of the things that the pharmacist can do is work in conjunction with the MD to not only medically maximize these patients, but to do it while minimizing risk of drug interactions and adverse effects," says Daniel Riche, PharmD, pharmacy director of the clinic and a certified diabetes educator. "It acts as a nice checks-and-balances on all ends of the care system, which, ultimately, really improves patient outcomes." 

In addition to providing a new model of care, the clinic is conducting ongoing clinical trials, many of which focus on the role of dietary supplements in treating obesity, peripheral artery disease, and Framingham risk factors. Supplements used in recent trials include hoodia, mulberry extract, and vitamin D. 

The Cardiometabolic Clinic provides "one-stop shopping" for patients and eases the burden on primary care physicians, particularly those in rural areas where obesity and cardiovascular disease are chronic problems, says Honey East, MD, associate professor of medicine and a clinic physician. "That's where it really helps to have multiple providers within the clinic." 

Mississippi Medical Center is the only facility in the state to treat patients with very high low-density lipoprotein cholesterol who do not respond to diet or medication, by removing the harmful cholesterol particles from their blood using plasmapheresis equipment.  

Leading-edge care is why Kara Brantley, MD, an obstetrician-gynecologist with Southern Women's Health in Jackson, Mississippi, sends her patients to the clinic. Before it opened, Brantley struggled to find internists who were up on the latest medications; patients, as a result, often experienced six-month waits. 

"It's been 11 years since my residency, and I haven't had any training on the newest [anti]hyperlipidemic drugs or the [anti]hypertensives, so it has taken a burden off of me from using older medications and out-of-date care for these patients," Brantley says.  

Mississippi leads the nation in heart disease deaths. To combat the problem, the University of Mississippi Medical Center opened a Cardiometabolic Clinic in 2007 that provides comprehensive care backed by leading-edge research.

CCE Cardiometabolic disorders: University of Mississippi

The following data were evaluated to determine the University of Mississippi's standing as a Clinical Center of Excellence for cardiometabolic disorders: 

Patients reaching all target lipid levels 

Achievement of quality assurance treatment markers such as annual monofilament  foot examinations, aspirin therapy, and vaccinations 

The numbers behind the University of Mississippi's cardiometabolic disorders program

CCE Cardiometabolic disorders: University of Mississippi by the numbers

The following data were evaluated to determine Massachusetts General Hospitals's standing as a Clinical Center of Excellence for seizure disorders: 

3,000: Annual visits, including 2,500 adults and 500 children

The numbers behind Massachusetts Generals's seizure disorders program.

Author | Heide Aungst

Articles

How to deliver bad news to patients

CCE Cardiometabolic disorders: University of Mississippi

CCE Cardiometabolic disorders: University of Mississippi by the numbers

CCE Seizure Disorders: Massachusetts General Hospital by the numbers