The Art of Hard Conversation

BRENDA LEARNED she had breast cancer six months ago. After multiple rounds of chemotherapy and other treatments, she has only grown sicker. She’s tired and miserable, and she’s been downplaying the illness to her family so they won’t worry. Now, her situation has arrived at the point her primary care physician must break terrible news to her: this cancer will kill her within six months.

At the news, Brenda gasps sharply. Then she slumps. There are tears in her eyes.

“Six months?” she says. “I…I don’t even know what to do with that.”

“Time out,” says another voice.

Brenda, who is an actor, relaxes into her seat. Her physician, an internal medicine resident named Julia, turns to a group of people who witnessed the scene—and looks for feedback. This is, after all, a classroom, and the voice who called for the pause belongs to Rafael Rosario, MD, an Indiana University School of Medicine faculty member. He is the facilitator of this training session called IU Talk, one that’s expanding across multiple departments and aimed at honing an essential skill in the practice of medicine: delivering bad news.

Multiple studies have shown that how a doctor communicates bad news can have a sharp impact on patient anxiety, depression, and even post-traumatic stress. Patients commonly complain that doctors can be robotic and detached, speak in too much jargon, or simply don’t clarify what is happening and what next steps should follow.

On the flip side, surveys of residents and physicians reveal that doctors often struggle the most when they must deliver bad news suddenly, as in emergency medicine settings, or when the prognosis simply isn’t clear. The emotional toll for physicians can be great: higher stress, feelings of guilt and helplessness, and an increase in burnout.

Conventional wisdom long held that good ‘bedside manner’ can’t be taught. Generations of physicians had to learn what they could on the job. But a movement that began in the late 1990s—originating mostly in cancer care—takes the approach that there are teachable skills to help physicians address this unavoidable aspect of the job.

IU Talk, based on a national teaching model developed by VitalTalk, is aimed at residents, fellows and established physicians. It began in earnest in 2012, said Lyle Fettig, MD, a palliative care physician at Sidney & Lois Eskenazi Hospital, who helped create the training at IU. This spring, more than a dozen IU School of Medicine faculty across multiple departments will be able to conduct IU Talk sessions.

The training offers lessons in ways to listen, communicate and guide patients and families during what can be heartbreaking moments, and pivotal ones in the patient-doctor relationship. “The goal of this is to really help them learn how to listen to patients’ and families’ perspectives in a meaningful way that’s going to be as personalized as possible for the patient and family,” Fettig said.

The workshops can last from half a day to two full days. The learners practice their techniques on actors from the Simulation Center at Fairbanks Hall on the Indianapolis campus.

The scenarios are ones physicians might encounter hundreds of times throughout their careers: patients in denial; combative and terrified family members; and adult children grappling with taking a dying parent off life support. Rather than following any predetermined script, the actors are instructed to react to each learner’s delivery.

If a learner doesn’t provide emotional support in their response to the ‘patient,’ the actor may respond with tears or confused anger. Some ‘patients’ are in denial, confused about their prognosis, or want a treatment that will harm rather than help. These are all normal responses physicians see in real life. The actors don’t break character, and their backstories are drawn from all walks of life.

Because there is no one-size-fits-all technique for such complicated situations, the learners glean a variety of communicative skills and strategies. Sometimes it is as simple as making sure that a patient isn’t confused about a medical term or giving them time to process new information. At other times, it is a frank explanation of what end-of-life decisions are necessary.

Throughout the conversations, the learners or the facilitator can call a ‘time out,’ as Rosario did, and talk about what is going well, what is going badly, and what the ideal outcome looks like. The topics are weighty and serious, with learners discussing how to help patients navigate the fear of death or the burden of guilt that can come with making end-of-life decisions for a loved one.

The point of IU Talk is to give learners a safe place to practice the most unpredictable and human side of medicine. There is no perfect way to deliver bad news, but there are many ways to make it easier for the doctor and the patient. Good communication skills can help physicians be a source of comfort and stability in the middle of the chaos of a serious illness.

Those same skills can allow physicians to walk away from the conversation knowing that they did the best job they possibly could for their patient.