How Doctors Get Better at Breaking Bad News
Has a doctor ever said something so insensitive that you remember it even years later? Unfortunately, I think many of us have had that experience. The fact is, most doctors haven't been trained to communicate with patients and families effectively, and even fewer have been taught how to break bad news. But last week I was a fly on the wall at an event aimed to change that.
I observed part of a three-day training session of a program called Breaking Bad News (BBN), which took place at Morristown Medical Center in New Jersey. The portion I witnessed involved young doctors who are in various stages of their three-year pediatric residency; no resident of Goryeb Children's Hospital at Morristown can graduate without having completed BBN. It works like this: Actors who have been specially prepared through BBN play the role of parents. The resident has to convey information to the parents that ranges from difficult to tragic. The conversation is videotaped and watched live in a nearby room by the doctors and staff involved with BBN as well as parent instructors. They all take notes and share their observations: "He's comfortable with silence—or he doesn't know what to say," "She's frozen. She hasn't changed her position once yet," "He spoke to them for 43 seconds before dropping the bombshell" (P.S.: That's not long enough). Immediately afterward, the resident watches the tape of the conversation, receives feedback from the BBN team, and discusses what felt comfortable and what was challenging.
It was absolutely fascinating. First of all, the actors were convincing, even as their characters in each scenario spanned different ages and socioeconomic backgrounds. Second, the residents were visibly nervous during the interactions, adding to the tension. And third, it was very easy to spot what they were doing wrong—and compelling to later hear from the experienced doctors precisely how they could improve.
In one scenario, the parents learn that their 5-year-old son, who had been trapped underwater at the beach, is gravely injured. In sharing the news, the resident made a few key errors. - He used the term "stable." But as pediatrician and BBN co-director Mary Ann LoFrumento, M.D., pointed out, "That's a falsely reassuring term. It puts the parents in a place of hope." - He said the child had brain damage. "I'm not crazy about 'damage.' I prefer 'injury,'" noted Dr. LoFrumento, who also is the associate director of the pediatric residency program. - He used the phrase "I think." BBN founder and neonatologist Anthony Orsini, M.D., explained why that wasn't wise. "'I think' means you don't know. You can say 'In my experience,' or 'I'm concerned' or 'I'm worried,' which is also more compassionate." - Most troubling was when the parents asked if they could see their son and the resident warned, "He won't recognize you or hear your voice." During the feedback, one of the parent instructors looked at the doctor in disbelief and said, "As a parent, I'm thinking, really? You really needed to say that?" Dr. Orsini got specific: "You never tell parents that their child can't hear them, because we don't know that for sure, do we? If they ask if their child can hear them, you can say, 'He may not respond, but I have no reason to believe he can't hear you.' You need to prep them for what they'll see in the hospital room—describe the tubes, the machines. And go with them, and tell them you'll go with them: 'I'm going to be there with you,' versus 'Yeah, I'll let you see him.'"
In another scenario, the resident frequently addressed the parents as "you guys." Dr. LoFrumento explained, "You need to avoid 'you guys,' especially when you're delivering news this serious. It's very common with your generation, but you're not their peer."
But the doctors-in-training did some things right, of course. One resident continued the conversation with the mother when the father took a phone call (his third!). "A lot of residents never acknowledge Mom. They completely ignore her," said Dr. LoFrumento. That same resident also had good body language, keeping her hands on the table (under is meek, said Dr. Orsini). And another doctor maintained eye contact with the parents even when the conversation became extremely heated.
One parent instructor, Stacey Rubinstein, has 6-year-old twins who were born prematurely and went on to develop seizure disorders. She's passionate about her role with BBN: "We bring a different point of view and allow doctors to understand how their words have an impact." She points out that parents often can't choose their doctor: "When you're in an emergency situation, you get who you get. So the more doctors we can train to deliver bad news in a way that helps empower patients and families, and gives them a feeling of direction and of hope, the better."
Later, Dr. Orsini told me why he feels the BBN model is so effective. While medical schools are increasingly teaching ways to foster good communication, Dr. Orsini believes that the best time to train doctors is later, during the residency program. "That's when they're actually getting the experience with patients, and they're used to being reviewed. We know that empathy among doctors decreases over their three- to five-year residency period, which makes it even more important to reach them during that time."
The challenge for BBN is funding. Though it's not particularly expensive—it costs roughly $400 to train one resident, and eight can be trained in one day—it's not something many hospitals are readily willing to invest in. This doesn't make much sense to Dr. Orsini, who cites that 40 percent of malpractice lawsuits stem from communication errors. He's hopeful that BBN will soon come to hospitals in Delaware, Florida, and Virginia, who've all shown interest in the program.
In the meantime, the 100+ doctors who've been trained in BBN are making an impact. "This program is one of the most effective, exciting things I've been a part of in my 30 years at Morristown," Dr. LoFrumento said. "I've seen so many dramatic effects on my residents." Dr. Orsini recently heard from an experienced doctor who needed to break difficult news to parents. Instead, he deferred to his resident, who'd been trained by Dr. Orsini's team. "You should be so proud," the doctor reported to Dr. Orsini. "This resident did such a wonderful job."
BBN is actually part of a 501 c3 nonprofit—the BBN Foundation—which will hold its first gala on October 25. Proceeds will support and provide educational programs that promote effective and compassionate communication in healthcare. That feels like the kind of movement all of us can get behind—and benefit from.
To learn more, go to bbnfoundation.org.