Berks County Medical Society Medical Record Summer 2018 - 20

m E d i C a l r E C o r d F E at u r E

MANAGING

Difficult Conversations
by Marc A. Rovito, MD
Medical Director, Penn State St. Joseph Cancer Center

D

ifficult conversations, depending on the specialty of
medicine practiced, can in many instances be a daily
occurrence. Physicians who have the responsibility of
delivering bad news usually have a strategy for conveying the
information.
Being in the position of delivering bad news also brings the
responsibility of dealing with the response to the information.
This is the "conversation" part of the encounter. You hear stories
of "the doctor walked in, told me I had (X) (TIME) to live, and
walked out." I have. Though I doubt the intent was to be as cold
or unsympathetic as the account would have you think, it does
illustrate the need to be prepared to focus on the conversation, on
how you will deliver the message and to understand how to manage
it with that particular patient.
The first issue I try to resolve is to quickly take inventory of
how I myself would prefer to hear the message that is going to
be delivered. I also consider how people I know would prefer to
hear such information; my wife, children, brothers, sisters. It is
not uncommon for patients to come into the office with family
members, who also experience any information that is relayed
to the patient and act as a second set of ears and eyes. How they
may receive the information needs to be considered. Plus, I also
take into account how they would prefer a loved one of theirs to
receive the information. This process may sound like it would
take significant time, but it doesn't take more than a few minutes
and it gets me in the proper mind set to focus, to be involved, to
have an investment in the conversation. It helps me refocus my
energies from the mental gymnastics of reviewing the CT scan and
considering the next line of chemotherapy (the medical future), to
being with the patient...being in the now.
Before entering the room, I typically spend time reviewing the
factors mentioned above. I also review the source of the negative
information: blood work results or a CAT scan or other test. I try

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to have specifics in my mind so I am prepared to produce the CAT
scan or other tests, to be reviewed by everyone in the room.
In giving the information you need to be direct - not blunt,
but honest and without modifying what is said to soften the blow.
It's important to remember that the message must be factual and
empathetic.
Finally, I think the most important thing to consider is time.
Some patients, upon hearing bad news, ask a few questions then
leave. However, I believe most patients want to ask questions
and try to get a deeper understanding of the implications of the
information they just received. It's important to give the patient
the necessary time to process some of that information in your
presence. I typically allot one half hour to 45 minutes for this
process, but there are times when it takes longer. If extra time is
needed, it is given to the patient without reservation. I will review
my schedule in advance and alter patient schedules to account for
the necessary allotted time.
Occasionally patients can't say anything, and you sit in silence
with them. In that silence, your presence with them demonstrates
support of them. And even if the silence is a brief silence, having
you in the room, giving your time to them without conveying
a sense of urgency about getting on to the next task, is very
valuable for patients. Gently helping them to the next phase of
understanding and decision-making will come, but for that brief
period time stands still in that room.
Lastly, I don't stand or sit at my computer during this
process. It's face-to-face all the way. It is tempting to use props,
monitors, scans, etc., to manage our discomfort in having difficult
conversations. The patients ask us for our honesty and our skill.
Just as medicine is an ongoing educational process that improves
our skill, we also must work to provide honesty, which frequently
means honestly assessing ourselves.


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Berks County Medical Society Medical Record Summer 2018

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