How to pass on bad news to patient, kin

"“Last year you offered an advisory in your column on how medical personnel should pass some sensitive news such as diagnosis of terminal illnesses. I, however, still take issue with doctors who take too long to tell you the truth about a patient’s condition and leaving loved ones with false hope. Isn’t there special training for medical personnel on such matters?”

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Most medical schools have modules that teach medical students how to communicate effectively with their patients. That said, we still see many instances where doctors and their patients fail to communicate and this is perhaps the most common reason for doctors and their patients to end up in court on charges of malpractice. In this regard, there is no doubt that doctors who communicate effectively with their patients are less likely to be sued than those whose communication skills are less effective.

A few examples will clarify this point which seems to be getting more complex with the passage of time. The factors that come into play in the clinical encounter are many and varied and obviously each case has to be viewed on its merit.

A few months ago, a 21-year-old student came to us for review and bluntly stated that what he wanted was help to plan his care, because he had already done his research and already knew that he had Bipolar Mood Disorder. Asked how he knew that this was indeed the correct diagnosis, he carefully and systematically presented his case, much as a good lawyer might do in court.

The young man traced his illness to the age of 13 when he was sent to boarding school.

There, he had what was clearly the first episode of depression. His school performance was poor; he lost weight and slept poorly. He wished he was dead and cursed the day he was born. When he went to a different school in the following term, things were no different and he remained miserable. On hindsight the first school was not the problem. Two other episodes of depression followed during his teenage years. Prior to coming to us, he had just gone through a manic episode. For about three weeks, he had become progressively active and excessively ‘happy’ in which state he developed grandiose ideas of how he would become a billionaire before the age of 20.

He had dropped out of school and spent much time moving from office to office in the city selling an App that could resolve all banking problems in a way that only he seemed to understand. He had many other ideas. He hardly slept, was loud, irritable and frequently disagreed with friends and family. Just as it had started, the episode slowly resolved on treatment, and he decided to research on what could have happened to him. He had decided that this problem was best described as a mood disorder and he needed help.

In time, and after another more serious episode of mania requiring hospitalisation, he was put on lithium carbonate, which is one of the commonly used drugs for treatment of bipolar mood disorder. He had earlier researched all the available options in treatment and decided that other mood stabilisers were not good for him.

As you can see from this rather long story, the landscape of care in Kenya is changing rapidly and more and more people come to doctors fully equipped with knowledge and the doctor is no longer the custodian of knowledge. Sadly, many ‘old fashioned’ doctors feel threatened by patients who sometimes know more than such doctors!

In a sense this is the essence of your question. How should the doctors relate to an increasingly sophisticated patient base that is more knowledgeable and, therefore, more demanding?

It is clear that doctors must be able to listen and hear what their patients are saying. A study once showed that patients are interrupted on average after 23 seconds of explaining their symptoms by their doctors, hardly enough time to state what is ailing them.

The other problem is what we call the ‘next patient’ syndrome. Doctors believe that their jobs are to clear queues in hospitals and rather than to get the patients better. This deeply rooted method of work is seen in both public and private practice and often leads to very poor communication between doctor and patient.

Related to this is lack of empathy. A doctor in a rush to see the next ‘case’ through theatre, after a shift that has already lasted 24 hours, will possibly tell relatives of a dying patient the ‘bad news’ in a noisy corridors rather than do what he was taught which is to pass such news in a quiet room and with enough time for the family to ask questions, cry, be angry and in a sense be normal human recipients of bad news.

The doctor might know what to do but pressure of time might make him seem to be a bad one.