Every practice has a Bertha. About once a fortnight she could be found approaching the front desk of a radiology practice, brandishing yet another inappropriate referral. One week it was her ankles she was demanding to have x-rayed. The next week it was her shoulders. Every appearance disrupted the practice, because the radiographers fought over whose turn it was to x-ray her. Bertha was an aggressive, angry woman who threatened to sue anybody who didn’t give her the treatment she thought she needed. Everyone caved in to her demands – including her GP.
Yet it would have been better for her if someone had stood up to her, because all Bertha won for herself was a scary amount of radiation. And it’s quite possible her GP is a burnt-out wreck by now, because that’s what dealing with difficult patients can do to you.
What Bertha’s GP could have done was use some well-established communication techniques, to head Bertha’s demands off at the pass.
Increasingly, doctors need sophisticated communication skills, not least because patients now expect to be involved in their own care and resent doctors who can’t communicate well. Not only that, but patients are more likely to doubt the competence of doctors with poor interpersonal skills. As unfair as it seems, technically brilliant doctors who are poor communicators are at greater risk of being sued than less competent, but more likeable doctors.
“Many doctors who struggle with their communication are actually very sympathetic,” says Dr Mark O’Brien, founder and medical director of the Cognitive Institute, a Sydney-based provider of education to medical professionals. “But many assume that as long as they do a technically good job, the patient will be grateful.”
He says that because patients have difficulty telling whether a doctor is expert or not, they often use interpersonal skills as a marker of technical competency. This is one of a range of issues dealt with in Cognitive Institute courses, designed to give doctors and allied health professionals practical communication skills. O’Brien offers a three-pronged approach to dealing with the Berthas of the world.
“First, show enormous empathy for the patient,” he says. If the patient is a lonely old lady, tell her you understand how difficult it must be to get around with a stiff hip. If the patient is a heroin addict who craves drugs, explain that you understand how tough their situation is. Say how much you wish you could help them.
Then draw clear boundaries. State simply and clearly that you are unable to give the patient what they want. Tell the old lady it’s not possible to write a radiology referral. Tell the addict you’re not able to prescribe narcotics. Under no circumstances negotiate with the patient, or enter into a discussion that might lead the patient to believe that you are going to give them what they want.
“Doctors are sometimes reluctant to state boundaries firmly,” says O’Brien. “They often delay stating boundaries, which makes the situation worse. In five or ten minutes you can make someone really angry.” Finally, ask the patient to solve the problem by posing a question such as “what do you think we should do now?”
Some difficult patients may use passive-aggressive techniques to get what they want. O’Brien says, “Difficult people often project their challenges onto the doctor.” He says if you find yourself becoming tense or angry, it’s a clue that a boundary violation is going on. The best thing to do in this situation is to go through the three steps outlined above. At all times speak quietly and calmly.
It’s also vital to communicate clearly when you are going to perform a procedure with known complications. Failure to warn properly is a major cause of patient anger and litigation. O’Brien says patients may become angry or upset if the results isn’t what they expected, even if “the patient may, in fact, have had a fantastic technical job done”.
The best way to head such problems off at the pass is to show that you care about the patient. Do this by not rushing the patient, by listening to them, and by being empathetic.
“If you get a recognised complication, but the patient likes and trusts the doctor, he is more likely to infer that it’s bad luck,” says O’Brien.
Sitting and listening in your rooms is fine for dealing with the patients you know, but what do you do in an emergency with dealing with people you’ve never seen before?
Professor Stewart Dunn, a medical psychologist and director of the Pam McLean Cancer Communications Centre at Royal North Shore Hospital, says this situation is common in specialties like anaesthetics. He uses the example of a woman in labour who needs an epidural. “You have got to get her to calm down and keep still,” he says, “as well as working closely with the patient and making sure she understands the risks.”
One of the first things to do – and yet one of the most overlooked – is to introduce yourself to the patient. “Some anaesthetists would go around to the back of the patient,” he says. “They would just be a faceless voice.”
Dunn says the key issue is establishing trust with the patients in the first minute, and that this must be a clear objective for the doctor. The very first ting to do, he says, is make eye contact. Then introduce yourself. Dunn adds that very basic physical things, such as speaking calmly and gently, can build trust between doctor and patient.
Establishing trust with people in the throes of a medical complication is bad enough, but what do you do when you have to break bad news to a patient?
According to Dunn, 60 per cent of doctors find themselves in this position during their intern year. The experience is so traumatic that whatever coping skills they used to get them through the situation at the time are the skills they use forever more, as though they’ve been imprinted. Unfortunately, if the first time a doctor breaks bad news she does it brusquely, that’s the way she’ll do it for the rest of her career.
The Pam McLean Centre uses professional actors to role-play people with serious illnesses, giving doctors a safe environment in which to test different ways to break bad news. “We have a workshop based on the best available literature, so it is clinically and psychologically real,” says Dunn.
Dunn suggests one of the problems doctors can have with breaking bad news is a very human desire to lessen the blow. A doctor might inform a patient that she has breast cancer, for example, and then say “at least it’s not lung cancer”. This gives the patient conflicting information and leaves her wondering whether she’s seriously ill or not. Dunn calls this “taking bad the bad news” and says it’s a trap.
“The fact that the doctor is ambivalent or ambiguous is difficult for the patient,” he says. His advice is to deliver the news and then allow the patient to talk, rather than try to comfort or reassure them. “If you allow people to talk about their fears and anxieties and don’t stop them or offer reassurance, they will generate their own positive messages.”
The second problem that Dunn sees is with doctors who use euphemisms; a doctor might talk about a “tumour”, for example, rather than “cancer”. This is guaranteed to leave the patient confused and anxious. Dunns recommends the SIT approach to breaking bad news (see the side bar Help in Breaking Bad News, below) and adds that doctors need to learn that they don’t have to fill the silences. “Many people think communication is about talking,” he says. “Often it’s about listening.”
Mark O’Brien says it’s important that doctors recognise the stages of grief, such as extreme anger or bargaining. He says it’s vital that doctors stick with patients, even when they’re at their most difficult. “Don’t get defensive,” he says. “Don’t let them feel that you’ve lost interest or are cutting them off.”
It’s a lot to remember, especially when faced with intensely emotional situations. The goods news it that Dunn believes that Australian doctors in general communicate very effectively with patients.
“Some of the stuff we do in Australia is world leading,” Dunn says. “It’s a blend of Australian rationalism and the qualitative approach of the English.”
He has another tip about using boundary settings to deal with stress: “Establish a clear boundary between work and home.” Dunn says he knows one doctor who imagines that the boom gate at the hospital entrance is the market between home and work. Once he’s passed the boom gate, he no longer thinks about his patients. Which means that, no matter how many Berthas he has to deal with, he’s unlikely to burn out.
Steps for breaking bad news
There are a number of protocols available to guide the way you break bad news to patients, some of which are quite complex. Dunn suggests the simple SIT approach:
Take the patient or relative somewhere quiet where you can sit together uninterrupted. Let them know you have their undivided time and attention and give them ample time to absorb the news and ask questions.
Introduce yourself. Establish context and credibility for your news.
Quietly and calmly tell the patient your news. Do not use euphemisms and do not “take the news back”. Remember that most people go number after they hear words like “cancer” and will not take in much that you say. You may need to repeat the information over and over, or repeat it again at different times. Don’t try and fill in the silences – let your patients do the talking.
Behaviours to avoid at all costs
O’Brien suggests there are some behaviours that are particularly inflammatory:
- Blaming the patient for a poor result (“if only you’d lost weight”).
- Deserting a patient after an adverse outcome.
- Doing anything that conveys you don’t care about them.
- Failing to maintain boundaries. Be very clear about which boundaries you are not prepared to cross, whether it’s as simple as refusing to write a doctor’s certificate, to refusing to write a prescription for narcotics.
This article originally appeared in Professional Life magazine, a publication that no longer exists. When was it published? A long, looooong time ago!