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Analysis

How to Deliver Cancer Diagnoses in Phone Calls

By Christopher Cheney  
   September 24, 2018

Best practices for giving bad news over the phone include communicating directly from physician to patient, being supportive, and arranging a follow-up visit.

Conveying breast cancer diagnoses over the phone has been on the rise over the past decade, new research shows.

The research, which was published in the journal Supportive Care in Cancer, says there are risks for patient experience and patient outcomes.

"Reports of communication problems by cancer patients have been associated with poor compliance with medical treatment and increased distress. Consequently, disparities between physician practices and patient expectations about the mode of bad news delivery may negatively impact breast cancer patient outcomes," the Supportive Care in Cancer researchers wrote.

The researchers examined data from nearly 2,900 patients who had received a breast cancer diagnosis from 1967 to 2017. There were several key findings:

  • From 1967 to 2006, breast cancer diagnoses were conveyed more often in person than via telephone calls
     
  • From 2006 to 2017, more than half of breast cancer diagnoses were conveyed through telephone calls
     
  • From 2015 to 2017, 60% of breast cancer diagnoses were conveyed via telephone calls

The researchers say there are two primary reasons why breast cancer patients are receiving more diagnoses via telephone calls.

First, modes of communication have changed over the past decade.

"The digital age has increased the use of telemedicine for cancer care, especially for patients living far from cancer centers. … Consequently, our study suggests that some physicians have decided to talk to their patients about test results sooner over the telephone and before the posting of the test results versus later at a clinic visit," the researchers wrote.

Second, more patients are requesting test results over the phone.

"Some patients are actively involved in their care and request delivery of bad news over the telephone. This mutual decision between the healthcare provider and patient about when, where, and how to communicate medical results is a natural sequel to the cultural shift toward patient autonomy and shared decision-making," the researchers wrote.

Best practices
 

There are several best practices for delivering bad news such as a breast cancer diagnosis, according to Natalie Long, MD, a family physician at University of Missouri Health Care in Columbia, Missouri. Four out of seven of the co-authors for the Supportive Care in Cancer research are affiliated with the University of Missouri. Long was not a co-author.

  • First, try to anticipate how the patient would like to be informed—a telephone call, in-person visit, or portal message. Try to determine whether the patient's preference will change based on the results.
     
  • Bad news should be conveyed in a caring and informative manner.
     
  • Any time bad news is delivered it should be given directly by the physician to the patient. Bad news should not be conveyed by staff, via voice mail, or through a family member.
     
  • In-person discussions should be held in a private and quiet location.
     
  • For telephone conversations, the physician should ask whether now is a good time to talk before delivering the news. If the time is not good, an alternative time should be arranged.
     
  • Set the context and prepare the patient by leading with an introductory statement to allow the patient to prepare for the possibility of bad news such as, "Unfortunately, the biopsy results are not what we were hoping for."
     
  • Bad news should be delivered clearly and unequivocally, followed by a pause to allow the patient to process the news.
     
  • The physician should be supportive because the patient is likely to have an emotional response. Empathy can include supportive phrases and physical contact, if appropriate.
     
  • Securing close follow up is crucial, especially if bad news is given over the phone. This allows the patient to prepare questions and bring supportive friends or family members.

Medical education
 

Medical schools should develop curriculum for delivering bad news over the phone, Long says.

"University of Missouri School of Medicine's curriculum now includes additional training for first-year medical students to talk about situations and techniques for breaking bad news over the phone. We teach students to use the same principals we use for in-person notification and apply those techniques over the phone," Long says.

Timing and empathy are crucial factors.

"The first goal is to make sure the patient is in a good place to talk, not in a car, at the store, or in the middle of a work setting. The students are taught skills related to listening, empathy, offering a good follow-up plan, and ensuring the patient has a support system to process the news," Long says.

Arranging follow-up visits in-person are also essential.

"We also talk to our students about the importance of offering a follow-up visit to go over the results in more detail. It gives the patient time to process the news before we talk about next steps in the treatment. Often, the patient is only able to process a small amount of information when delivering bad news, so an in-person follow up will allow time to provide a more detailed explanation," she says.

Medical students should be prepared to hold these conversations, Long says. "By teaching our medical students a patient-centered approach to notification, we are leading the next generation of physicians to inject humanity into healthcare."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

From 2015 to 2017, researchers found that 60% of breast cancer diagnoses were conveyed via telephone calls.

Reflecting the shift to shared decision-making, some patients request delivery of bad news over the telephone.

For medical students, bad news phone call curriculum includes listening skills and ensuring patients have a support system to help cope with diagnoses.


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