“Unfortunately, your ultrasound scan is normal.”
Watching a trainee’s video consultation I speculated about his next steps; my fears were realised.
“So, we still do not know what is wrong with you, this means I need to refer you to a specialist and get some more tests done in the meantime.”
This negative view, of a result that is actually good news, led to a confused and frustrated doctor and patient. This patient had mild, colicky abdominal pains, now reducing in intensity, without other symptoms; physical examination was normal. The purpose of the scan was unclear and the result, although predictable, did not seem to help the situation. Yet, the referral and investigations came up with no specific answers either; a diagnosis of “Irritable Bowel Syndrome” was given, which worried the patient, although her symptoms had resolved before she went to the clinic. Excessive investigation and referral drives a lot of overdiagnosis. Is this partly driven by a lack of “breaking good news” skills?
In primary care there are difficult issues to resolve. Many patients consult because they are worried about the meaning, rather than the intensity, of their symptoms and they hope for reassurance. The doctor walks a tightrope; all serious problems start with something, and that “something” can be minor or trivial. Serious disease must not be missed, yet non serious problems need to be handled in a way that encourages resolution and rehabilitation.
A further problem arises because medical schools teach about diagnosis as if there is pretty much always a disease or a diagnosis to be identified. Even in secondary care this is only partially true. In every clinic there are patients whose symptoms are not really explained by current disease models. Patients with such symptoms are common in primary care. Thus, clinicians have to explain normal tests in a way that is simultaneously reassuring, (“great stuff your scan is normal”), while leading to effective symptom control, (“this is what we can do to help your tummy ache”) and also allowing for the possibility of serious disease developing later if things change, develop, or do not go away (“Please come back if things get worse or do not go away of if these specific things happen”), also known as “safety netting.”
If we go back to one definition of bad news as “any information that….drastically alters the patient’s view of his or her future,” then it becomes clear that some “good news” may be experienced as “bad news” by the patient (who may be expecting a specific diagnosis rather than a reassuring absence of disease) and even by the doctor, who is more familiar with disease than normality. [1]
With this complexity, “breaking good news” might be even more difficult than “breaking bad news”, but there is far less attention paid to learning this important skill. [2] The stakes may feel higher for good news breaking. Everyone knows someone who went to the doctor only to be told all was well, and who turned out to have a serious problem in the end. Even survival, when death is expected, might be tricky to explain as Liam Farrell humorously comments and yet there is little written about how to “break good news.” Here is a start. [3]
Firstly, doctors can only break good news, if they have genuinely good news to impart. A thoughtfully explored history, a proper examination and good clinical reasoning (especially around the use of investigations) must precede any “breaking of good news.”
Moreover, the skills for “breaking good news” begin early in the consultation. The words used when exploring symptoms, and explaining examination findings, can be reassuring if stated in positive language. Saying “your chest sounds healthy” is better than negative or uncertain phrases like “there does not seem to be anything wrong.” The phrase “I can’t find anything the matter,” may lead the patient to believe that the problem is a hidden, more sinister one, whereas what the doctor really means is, “things are normal.”
Furthermore, before any tests are performed, their purpose and expected results must be thought through by the clinician and explained fully to the patient. This means being clear whether tests are really to rule out serious disease, or whether the aim is to rule in something specific. The potential for normal, reassuring results can be signalled at the start. This will begin to prevent the spiral of anxiety about normal tests that sometimes drives further investigations. Doctors use mental energy processing investigation results. Being able to break good news earlier, preventing a cascade of tests, saves time and effort; patients start their recovery more quickly when appropriately reassured.
Understanding precisely where the patient is coming from before arranging investigations transforms post-test discussions. This means understanding and addressing patients own concerns and fears directly; “You mentioned a concern about tiredness being caused by anaemia; everything is normal when I examine you. If a full blood count and urine dip are normal, as seems likely, then there will be no cause for concern at present.” A Dutch study showed that these are the only tests needed in the initial investigation of tiredness otherwise unexplained in the history and examination. [4] Anticipating the idea that a normal test means no further testing, changes the discussion towards helpful actions, (better sleep, more exercise, dealing with stressful issues properly), rather than a futile search for an “explanation.” The clinician can suggest that time may resolve symptoms, if the history and examination reveal only normal or non-sinister findings.
When normal results are available, the clinician should further signal that “good news” is coming (just as we signal “bad news”) and use positive language to explain things. Using words like “healthy”, “normal” or “great for your age” can seem odd to doctors, who prefer to talk about pathology, yet will help patients understand.
Clearly, planning of tests with the patient may take time and is the opposite of the “dysfunctional way out” of dismissing the patient by “arranging some tests and seeing what comes up.” [5] However, the prize is a good one; time and resources will be saved and anxiety reduced all round. Perhaps all clinicians should update their “breaking good news” skills.
Avril Danczak is a GP in Manchester and a Primary Care Medical Educator training General Practitioners on the Central and South Manchester Specialty Training Programme for General Practice. She is currently working on a patient safety project about diagnosis in General Practice.
Competing interests: I have co authored a book called Mapping Uncertainty in Medicine: what do you do when you don’t know what to do? by Avril Danczak, Alison Lea, and Geraldine Murphy. RCGP books.
References:
- Buckman R Breaking bad news: why is it still so difficult? BMJ 1984;288:1597
- H J Warraich Breaking Good News can be as hard as breaking bad. https://well.blogs.nytimes.com/2015/09/10/breaking-good-news-can-be-as-hard-as-breaking-bad/
- Farrell L Breaking good news: BMJ 2012;345:e7355
- Koch H, Bokhoven M, de Riet JM, Tineke van Alphen-Jager T, van der Weijden, P Bindels Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial Br J Gen Pract. 2009 Apr 1; 59(561): e93–e100.doi: 10.3399/bjgp09X420310
- Danczak A Lea A Murphy G Mapping Uncertainty in Medicine; what do you do when you don’t know what to do?