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Communicating bad news

By: Stephen D. Brown, MD

Read the following scenarios on communicating bad news to patients and test yourself by choosing the best answer to the provided prompts.

Scenario one

A 45-year-old woman with a strong maternal family history of breast cancer presents for routine mammography. After the initial imaging, the radiologist determines that additional views are required because of findings on the initial images that may represent cancer in one or both breasts. The woman expresses deep anxiety to the technologist and asks to speak with the radiologist before continuing the examination. The patient’s referring physician has worked with the radiologist closely for many years, and the entire group practice has always supported the radiologist’s clinical involvement in care of these patients.

What should the radiologist do in this situation?
A) Instruct the technologist to obtain the additional images immediately, since it is not the job of the radiologist to inform the patient about the pertinent diagnostic test results.
This is incorrect. Try another answer.
B) Instruct the technologist to obtain the additional images immediately, since a radiologist should not talk to patients in the middle of a mammographic examination.
This is incorrect. Try another answer.
C) Talk to the patient about the need to get a complete mammographic study, and tell the patient to make an appointment with her physician to discuss the study results.
This is incorrect. Try another answer.
D) Talk to the patient about the need to get a complete mammographic study because there is concern about the possibility of an abnormality in one or both breasts.
Correct.


The current health care environment in radiology has increasingly emphasized patient-centered care, of which direct radiologist-to-patient communication is a key component (1,2). Breast imaging has traditionally been an area where such communication is common. Indeed, for some breast imagers, discussing adverse results with patients is a critical role (3). Therefore, answer A is incorrect.

All radiologic examinations have variable lengths and protocols, depending on the patient’s clinical status and the nature of initial imaging findings. Therefore, some studies are longer and more complex than others. Additional images can often be obtained without significant work-flow interruption and without patient discomfort. Sometimes, however, technical or patient-specific issues require intervention by a radiologist. In particular, if a patient refuses to continue a radiologic examination without seeing the radiologist first, then it behooves the covering radiologist to make himself available to the patient and to address the patient’s concerns directly. Therefore, answer B is incorrect.

The radiologist who has already reviewed the initial mammographic images and determined the need for further images should discuss this need directly with the patient. Specifically, the radiologist should indicate that the reason for further images is to evaluate possible abnormalities on the initial images. Therefore, answer D is correct.

After having discussed the initial images with the radiologist, the patient may reasonably expect the radiologist to give follow-up diagnostic information after the study is completed and not to defer this discussion to the referring physician for a future appointment, especially if no immediate appointment exists. Therefore, answer C is incorrect.

On the other hand, discussing a high likelihood of breast cancer with the patient before obtaining the additional mammographic views interrupts the diagnostic imaging process and risks the possibilities of study delay, undue stress related to a false-positive preliminary impression, or patient refusal of further imaging altogether, which may result in a suboptimal mammographic study in a patient with likely positive imaging findings. Therefore, answer E is incorrect.
E) Tell the patient that there is likely to be cancer in both breasts and that the patient should cooperate with the technologist in getting the additional views.
This is incorrect. Try another answer.

Scenario two

A 21-year-old woman, gravida 1, para 0, is referred for detailed obstetric ultrasonography (US) because of an elevated maternal serum alpha-fetoprotein level. Because she has had difficulty getting time off from work, the US examination is not performed until 20.5 weeks’ gestation. US shows a male fetus with an L2-L3 neural tube defect, morphologic features of a Chiari II malformation, and moderate bilateral ventriculomegaly. The sonographer who performed the examination and reviewed the images with you tells you that the woman is currently living with a friend, who is in the examination room with her. The woman is not in contact with her own family or with the baby’s father. According to the radiology practice’s protocol, the radiologist must examine the patient (ie, repeat the US examination) and talk to her about the findings.

In this setting, all of the following are barriers to effective communication except ______.
A) Physician anxiety.
This is incorrect. Try another answer.
B) Incorrect assumptions about what news will be considered “bad.”
This is incorrect. Try another answer.
C) Lack of adequate space in the examination room.
This is incorrect. Try another answer.
D) Bringing a nurse or social worker into the examination room.
Correct.


Many physicians experience substantial stress when communicating with patients about unexpected or difficult information (4–6). For some, the stress is compounded by lack of opportunities for communication skills training. Physician stress has been associated with poor communication performance, which may be compounded by burnout and fatigue. Taking a moment to stop and check one’s own “pulse” before entering a room in which the communication may be difficult may help both the physician and the patient relax once the conversation begins. Therefore, answer A is incorrect.

It may be challenging to know prospectively how a patient may react in any given situation. It can be hazardous to make assumptions about what a patient will consider bad news. It may be quite helpful to know as much clinical and social information as possible about the patient before entering the room, but making any assumptions about how she will react to the information about the myelomeningocele and the pregnancy itself could seriously undermine the conversation. Therefore, answer B is incorrect.

Creating a comfortable space in a dark, small US suite is challenging. The patient may be partially disrobed and covered by a thin paper sheet, with US gel still on her abdomen. Taking a small amount of time to help the patient clean off, sit up, and compose herself may make a major difference in the overall effectiveness of the communication and in the patient’s lasting memory of the experience. Therefore, answer C is incorrect.

In settings such as this, it may be helpful to both the physician and the patient to bring someone into the examination room who can serve as a supportive ally for both—such as a nurse or social worker. Therefore, answer D is correct.

While it is true that more physicians are being introduced to communication skills training exercises in medical school, and that communication skills curricula are proliferating broadly within residency training programs in medicine (7), few such programs exist for radiologists (8–11). Such programs may help radiologists become more comfortable not only with their communication skills, but also with their roles and responsibilities in direct communication with patients. Therefore, answer E is incorrect.
E) Limited or poor communication skills training.
This is incorrect. Try another answer.

Scenario three

A 37-year-old healthy woman, 13 weeks pregnant by her first-trimester US examination, is sent directly from her obstetrician’s office for a same-day US examination because no fetal heart activity could be detected by using “doptones” (hand-held fetal heart monitor). She has had two previous miscarriages and has declined maternal serum cell-free fetal DNA testing for this pregnancy. The US examination shows a fetus of 13-week size with normal cardiac activity. The fetus has a widened nuchal translucency and no nasal bone, both of which are associated with an increased likelihood that the fetus has trisomy 21 (Down syndrome). The radiologist must now discuss the imaging findings with the patient.

Important aspects to approaching this conversation with the patient include all of the following except ______.
A) Detailed, advanced preparation of the topic.
This is incorrect. Try another answer.
B) Paying attention to the patient’s perceptions and emotions.
This is incorrect. Try another answer.
C) Establishing rapport with the patient.
This is incorrect. Try another answer.
D) Relying heavily on mnemonic devices.
Correct.

The basic common elements of effective communication with patients about unexpected or adverse information are preparation, setting a tone that enables the patient to converse as comfortably as possible and without distraction, establishing what the patient knows and wants to know, communicating with sensitivity, acknowledging and supporting the patient’s reactions, assessing and prioritizing the patient’s needs and concerns, helping the patient understand what the next steps are, and obtaining necessary support (5,12–15). For this scenario, as with so many difficult conversations with patients, advance preparation is key to the success of all of the other steps in the process. It means not only having as much information as possible about the likelihood of trisomy 21 in the fetus, but also information about the woman’s social and medical history, the couple’s reproductive history, what additional tests may be necessary, what the potential next steps are in the process, who the patient may be meeting next, what trisomy 21 is, how an infant with trisomy 21 is cared for postnatally, and potential decisions to be made.

Advance preparation also means anticipating and preparing for the range of questions and emotions that may arise when the information is conveyed. It may not be the radiologist’s responsibility to dispense information or recommendations about all of the issues and questions that the patient may have. Indeed, it may be irresponsible for radiologists to step out of the bounds of their expertise. Nonetheless, it is the radiologist’s responsibility to anticipate the questions and reactions so that the radiologist can react supportively and empathetically and provide confidence that the next steps are in place to get the couple the information, support, and services that they need. Therefore, answers A, B, and C are incorrect (that is, they represent appropriate approaches to the communication).

Several mnemonic devices have been developed to help practitioners approach conversations about difficult or unexpected adverse information. Perhaps the best known of these are ABCDE (Advance preparation, Build a therapeutic environment/relationship, Communicate well, Deal with patient and family reactions, and Encourage and validate emotions) (15) and SPIKES (Setting and listening skills, Patient’s perception, Invite patient to share information, Knowledge transmission, Explore emotions and empathize, and Summarize and strategize) (12). One mnemonic device that has been proposed specifically for radiology is RADPED (establish Rapport, Ask questions, Discuss the examination, Perform the procedure, use Examination distractions, and Discuss) (14).

While these mnemonic devices provide useful summaries of the steps for communicating bad news, important limitations exist to using mnemonic devices to help approach difficult conversations with patients. Mechanical recitation of a mnemonic device as if it were for identifying the cranial nerves will be ineffective in real-time communication, which requires numerous internalized actions to be performed fluidly, simultaneously, spontaneously, and reflexively (13). The correct answer, therefore, is D. Nonetheless, radiologists who are inexperienced or uncomfortable with difficult patient conversations may find it useful to review one of these mnemonic devices before entering the room with the patient.

Scenario four

 An 8-year-old boy is undergoing an outpatient magnetic resonance (MR) imaging examination of the brain because of worsening headaches over the past couple of months. The examination is done on a Saturday afternoon and shows a posterior mass abutting the fourth ventricle and causing moderate hydrocephalus. As the covering radiologist, you call the pediatrician’s office and speak with the covering pediatrician, who requests that the child be sent immediately to the emergency department (ED). You and the pediatrician both contact the ED, and the appropriate arrangements are made. The patient, his parents, and one of his grandmothers have been asked by the MR imaging technologist to wait in the radiology waiting room/reception area, but they are not sure why. You must now talk to them about the situation.

Effective communication about the information may be impaired by which of the following actions?
A) Introducing yourself to the patient, both parents, and the grandmother.
This is incorrect. Try another answer.
B) Explaining to them that “there is a posterior fossa mass causing obstructive hydrocephalus.”

Correct.

When communicating with parents about a child in the presence of the child, physicians should always introduce themselves to the child as well as both parents. In addition, physicians should introduce themselves to any other parties in the room. The physician cannot know the role that these individuals play in the patient’s life and the decision-making process. Making introductions to all parties not only demonstrates respect, but also helps to establish alliances and support that may be helpful when the information becomes overwhelming for the patient or the parents (13). Therefore, answer A is incorrect.

Technical jargon may impede the effective transmission of vital information. As importantly, technical jargon may act as a barrier to a genuine connection between the physician and the patient and may allow the physician to avoid difficult emotions by “hiding” behind the jargon (13). Therefore, answer B is correct.

Expressing sadness or genuine regret for the patient’s circumstances is always appropriate so long as one maintains one’s composure (16). Such an expression conveys empathy and respect, and it helps establish rapport and connection. Therefore, answer C is incorrect.

Conceding the limits of one’s knowledge can be problematic if the question clearly falls within the realm of what a patient would realistically expect from any given physician. More often than not, however, answering “I don’t know” to a patient’s question is likely to represent a reasonable and legitimate expression of the limits of one’s expertise. It is not a stumbling block if one is able to comfortably and contritely acknowledge it and, more importantly, offer the patient confidence and guidance about how the question will be answered (13). Therefore, answer D is incorrect.

Periods of silence may be awkward at times, but they can also be powerful aids in the communication process. Silence may allow patients to absorb and consolidate the information being provided and process their emotions, without being “talked over.” Allowing silence may thus convey both respect and empathy. Therefore, answer E is incorrect.

C) Expressing sadness about the situation.
This is incorrect. Try another answer.
D) Saying “I don’t know” when you are unsure about the answer to a question.
This is incorrect. Try another answer.
E) Allowing silence to pass during the conversation.
This is incorrect. Try another answer.