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A Physician's Tips for Delivering Bad News

Analysis  |  By Debra Shute  
   August 04, 2016

The 'work before the work' builds trust between clinicians and patients, allows more leeway to get difficult conversations right.

As part of their quest to deliver a better patient experience, healthcare providers have been placing greater emphasis on clinicians' communication skills.

The result has been better awareness and training, but there's still work to be done.

"We still have large gaps to close," says William Maples, MD, executive director and chief experience officer of the Institute for Healthcare Excellence and the chief medical officer at Professional Research Consultants.

Prior to launching the IHE, Maples was senior vice president and chief quality officer at Mission Health in Asheville, NC, and spent 25 years as a practicing oncologist and quality leader at the Mayo Clinic in Jacksonville, FL.

Related: Cleveland Clinic's Experience Chief Shares Lessons in Communication

"From the perspective of a profession that faces delivering difficult news frequently, I would say that even in situations where there's an opportunity to practice, time and again there are barriers that make it difficult actually executing conversations, especially those involving end of life or palliative care, for a variety of reasons," he says.

The following transcript has been lightly edited.

HealthLeaders Media: What are the fundamental communication skills most important to talking about difficult subjects?

Maples: There are several competencies involved, including finding the right setting to have the talk and recognizing and responding to the emotion in the room.

One of the most critical steps is the "work before the work."

Often there is some lead time to prepare a family and patient in terms of what news may be evolving. And the way you do that prework can make the actual conversation much more productive, helpful, thoughtful, compassionate, and empathetic.

HLM: Which training methods are most effective in helping clinicians improve their communication skills?

Maples: While some online programs can be helpful, they're really not sufficient.

Even if they incorporate some skills-based practice, the online experience is far short of an in-person, skills-based curriculum in which physicians work with physicians and learn from one another.

By far and away, the most effective is an experiential learning model where there's some time for reflection on the importance of getting this conversation right.

HLM: Surely in real life, clinicians don't always get it right. How can they recover from important conversations that don't proceed as hoped?

Maples: There's not a moment in a caregiver's day that something couldn't go wrong.

The risk doesn't just surround having a difficult conversation or delivering bad news, but around everything a clinician does every moment of every day.

One needs to incorporate all of the practices that help clinicians recover when things go wrong or are misinterpreted, and they have lots of chances to practice building resilience to come back and have a correcting conversation or take a correcting action.

Ultimately, it comes back to the work before the work. [That means] having an emotional, psychological bank account filled up so that there's room for forgiveness, there's room for self-awareness on the clinician's part, and there's an opportunity to revisit that conversation with the patient and family.

To be honest, if you've done your work before you actually have the conversation, patients will give you not only a second opportunity, but a third and fourth, as they know that you really care.

HLM: What can healthcare leaders do to support clinicians' development in handling difficult conversations?

Maples: Administration and leadership need to understand what the ramifications are if we don't get this right.

That includes consequences from the errors we create to lack of partnership with patients to deficiencies in safety, efficiency, outcomes, and ultimately the culture of the organization.

The second thing is to recognize that there is a return on investment that comes from creating trust within the medical team, reducing turnover rates, reducing malpractice claims, increasing patient satisfaction, you name it.

Debra Shute is the Senior Physicians Editor for HealthLeaders Media.

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