{"id":42158,"date":"2018-05-22T10:58:52","date_gmt":"2018-05-22T09:58:52","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=42158"},"modified":"2018-05-30T11:41:51","modified_gmt":"2018-05-30T10:41:51","slug":"breaking-good-news-an-essential-skill-for-avoiding-too-much-medicine","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2018\/05\/22\/breaking-good-news-an-essential-skill-for-avoiding-too-much-medicine\/","title":{"rendered":"Breaking good news: an essential skill for avoiding too much medicine?"},"content":{"rendered":"

\"avril_danczak\"\u201cUnfortunately, your ultrasound scan is normal.\u201d<\/i><\/p>\n

Watching a trainee\u2019s video consultation I speculated about his next steps; my fears were realised.<\/span><\/p>\n

\u201cSo, 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.\u201d<\/span><\/i><\/p>\n

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 \u201cIrritable Bowel Syndrome\u201d 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 \u201cbreaking good news\u201d skills?<\/span><\/p>\n

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 \u201csomething\u201d 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. <\/span><\/p>\n

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, (\u201cgreat stuff your scan is normal\u201d), while leading to effective symptom control, (\u201cthis is what we can do to help your tummy ache\u201d) and also allowing for the possibility of serious disease developing later if things change, develop, or do not go away (\u201cPlease come back if things get worse or do not go away of if these specific things happen\u201d), also known as \u201csafety netting.\u201d<\/span><\/p>\n

If we go back to one definition of bad news as <\/span>\u201cany information that\u2026.drastically alters the patient\u2019s view of his or her future<\/span><\/i>,”<\/span> then it becomes clear that some \u201cgood news\u201d may be experienced as \u201cbad news\u201d 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]<\/span><\/p>\n

With this complexity, \u201cbreaking good news\u201d might be even more difficult than \u201cbreaking bad news\u201d, 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 \u201cbreak good news.\u201d Here is a start. [3]<\/span><\/p>\n

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 \u201cbreaking of good news.\u201d<\/span><\/p>\n

Moreover, the skills for \u201cbreaking good news\u201d begin early in the consultation. The words used when exploring symptoms, and explaining examination findings, can be reassuring if stated in positive language.\u00a0<\/span>Saying \u201cyour chest sounds healthy\u201d is better than negative or uncertain phrases like \u201cthere does not seem to be anything wrong.\u201d The phrase \u201cI can\u2019t find anything the matter,\u201d may lead the patient to believe that the problem is a hidden, more sinister one, whereas what the doctor really means is, \u201cthings are normal.\u201d \u00a0<\/span><\/p>\n

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 <\/span>normal<\/span><\/i> 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.<\/span><\/p>\n

Understanding precisely where the patient is coming from <\/span>before<\/span><\/i> arranging investigations transforms post-test discussions. This means understanding and addressing patients own concerns and fears directly; \u201cYou 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.\u201d 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 \u201cexplanation.\u201d The clinician can suggest that time may resolve symptoms, if the history and examination reveal only normal or non-sinister findings.<\/span><\/p>\n

When normal results are available, the clinician should further signal that \u201cgood news\u201d is coming (just as we signal \u201cbad news\u201d) and use positive language to explain things. Using words like \u201chealthy\u201d, \u201cnormal\u201d or \u201cgreat for your age\u201d can seem odd to doctors, who prefer to talk about pathology, yet will help patients understand. <\/span><\/p>\n

Clearly, planning of tests with the patient may take time and is the opposite of the \u201cdysfunctional way out\u201d of dismissing the patient by \u201carranging some tests and seeing what comes up.\u201d [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 \u201cbreaking good news\u201d skills.<\/span><\/p>\n

Avril Danczak<\/strong> 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.<\/em><\/p>\n

Competing interests:<\/strong> 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.<\/em><\/p>\n

References:<\/strong><\/p>\n

    \n
  1. Buckman R Breaking bad news: why is it still so difficult?<\/span>\u00a0BMJ\u00a01984;288:1597<\/span><\/li>\n
  2. H J Warraich Breaking Good News can be as hard as breaking bad.\u00a0<\/span>https:\/\/well.blogs.nytimes.com\/2015\/09\/10\/breaking-good-news-can-be-as-hard-as-breaking-bad\/<\/a>\u00a0<\/span><\/li>\n
  3. Farrell L Breaking good news:\u00a0BMJ\u00a02012;345:e7355<\/span><\/li>\n
  4. Koch H, Bokhoven M, de Riet JM, Tineke van Alphen-Jager T, van der Weijden, P Bindels \u00a0Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial \u00a0\u00a0<\/span>Br J Gen Pract<\/span><\/a>. 2009 Apr 1; 59(561): e93\u2013e100.doi:\u00a0\u00a0<\/span>10.3399\/bjgp09X420310<\/a><\/span><\/li>\n
  5. Danczak A Lea A Murphy G Mapping Uncertainty in Medicine; what do you do when you don\u2019t know what to do?<\/span><\/li>\n<\/ol>\n

     <\/p>\n

     <\/p>\n","protected":false},"excerpt":{"rendered":"

    \u201cUnfortunately, your ultrasound scan is normal.\u201d Watching a trainee\u2019s video consultation I speculated about his next steps; my fears were realised. \u201cSo, we still do not know what is wrong […]<\/p>\n

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