Bearing Bad Tidings
Guidelines for preparing and delivering
bad news to your patient.
LESLIE GOLDBERG, Associate
bad news to a patient is one of the most difficult and taxing parts of an optometrist's
job. The majority of eyecare providers, and healthcare providers in general, have
never been trained to deliver bad news and are woefully under-prepared for this
facet of their job. "Historically, schools have not devoted time or energy to 'soft
skills.' Most students do not realize the value of good communication skills until
they are in a practice," says Gale Stoner, professional practice management speaker
and author of Some Assembly Required: Seeing Your Practice Through Your Patients'
Eyes. Even when the news that you deliver to your patient is not a matter of
life and death, it still may signal a significant changes in lifestyle. Below are
some guiding principles to better help you deliver bad news to a patient.
Get a plan
The following is a course of action that should help to reduce
your anxiety and prepare you for addressing your patient:
First, it's imperative that you are prepared to deliver the news, says Joel Schwartz,
M.D., chair of the department of psychiatry at Abington Memorial Hospital in Pennsylvania.
Allot enough time in your schedule for delivering the news and responding to your
Dr. Schwartz recommends, "Whenever possible, make this the last
appointment of the day so that you will be able to give your patient your undivided
attention and have fewer chances of interruption."
Next, have the information you need readily available. Make sure that you are able
to present physical evidence to your patient and can verify your diagnosis.
Deliver the information as clearly and concisely as possible. Remove as much medical
jargon as possible. Mr. Stoner recommends that the O.D. create a script. "Type out
and rehearse what you are going to say. It is important that you feel prepared when
delivering your news."
Body language is extremely important. Using the proper body language is almost as
important as the delivery of your message. Dr. Steve Lancaster of the Atlantic Eye
Institute in Jacksonville, Fla., recommends that you "keep eye contact, sit at the
same level as the patient, keep your back to no one and keep focus mostly on the
patient while involving other support members." (Both Dr. Lancaster and Mr. Stoner
have lectured on the subject of presenting bad news at Vistakon's Vision Care Institute.)
Recognize the importance of observing a patient's reaction to the news you have
delivered. Provide your information in small chunks. If a patient appears to be
confused, ask them to repeat what you have said in their own words and then clarify
any misunderstanding, says Dr. Lancaster.
Once you have delivered the news, it is important that you encourage the patient
to ask questions. Find out what the patient already knows about the condition and
how much he wants to know.
Allow your patient to vent. Whether it's anger, sadness or relief, it is very important
that your patient be allowed to react to the news.
Be sure to validate the feelings of the patient. "Never say 'I know how you're feeling'
because you don't," Dr. Schwartz advises. "Instead say, 'I can only imagine how
difficult this is for you.' " This shows the patient that while you can't walk in
his shoes, you are sympathetic to his condition.
Lastly, have a plan on how to proceed once you have delivered the news.
Guiding them through
"In order to ensure the smooth flow of patient care, it's important
to orchestrate the entire process. Explain the current situation to your patient,
ask for questions and then direct your patient to a specialist, if necessary. Send
a letter to the primary care physician so that he has a full picture of the care
his patient is receiving, and explain the possible need for further diagnostic testing,"
Dr. Lancaster says.
His practice also provides its personal cell phone numbers to
patients in crisis so that the patients know they have access to a doctor 24/7.
Mr. Stoner reiterates, "Patients to do not come back to you year after year strictly
because of your clinical competence. What makes them come back is how you make them
feel; your likability."
An O.D. may frequently find it necessary to deliver information
that will cause a patient to make changes in his daily life. For example, when delivering
the news to an older adult that he may not be able to drive again, you are forever
altering his life. The loss of driving privileges can be traumatizing to your patient.
You may feel uncomfortable talking about revoking your patient's driving privileges
because you don't have any positive solutions to offer.
"Many times the children of elderly patients will accompany their
parents to an appointment and beg us to take away their parent's driving privileges.
They fear for both their parent's safety and for the other drivers on the road,"
says Dr. Lancaster. "Not only do we evaluate the patient's ocular status, we need
to do a better job of assessing their lifestyle needs and refer them to other services
so that they can receive appropriate care." By providing your patient with a physical
list of resources, such as alternative travel information or low vision companies,
you help them feel less dependent on others and therefore, more in control of their
Changing their lives
On the other side of the age spectrum, you may find it difficult
to convince a young child with amblyopia that she needs to wear an eye patch. While
this diagnosis may come as a great relief to a parent who's been worried about a
child's poor hand-eye coordination or progress in school, it may require a lot of
convincing to get a young child to actually wear a patch.
Because the major cause of failure in wearing an eye patch is
noncompliance, it's important to help both the patient and the parent get off on
the right foot. Help the family to understand why the patch is so important and
suggest to the parent that she pass this information on to teachers and friends
so that they can be part of a support system. You might also want to talk to the
parent about using a reward system or suggest activities that they can do together
that will help strengthen the weaker eye.
Be ready with a save
Whatever the diagnosis, it's much easier for your patient to digest
bad news if you're able to provide useful information and guidelines for them to
follow. Offering relevant support system information, Web site addresses or pamphlet
information will help to inform your patients and help them to ask educated questions.
Watch out for these pitfalls
When delivering bad news to your patient, avoid the following
Do not be too blunt when delivering your message. You must realize that what you
are about to say may very well change this person's life.
Choose an appropriate time and place to deliver your news. Inform your patient in
advance that your consultation may take some extra time and that he may want to
arrive with a family member or companion who can provide support.
Dr. Schwartz warns that under the new HIPAA laws, the only people
allowed to hear evidence of the patient's bad news are those that the patient allows.
Most importantly, do not allow the patient to leave the consultation with a sense
You're not the bad guy
Giving news that is not positive is difficult. When preparing
and delivering bad news to a patient, remember that you are not causing the patient
harm; the problem is. Being prepared and well-organized will help you through this
In some cases, Dr. Lancaster recommends getting a second opinion
from other doctors within the practice and developing a structured plan of action
for delivering the news. This will help to alleviate the feelings of guilt associated
with delivering bad news. Dr. Lancaster says that during this crucial time, "It
is most important to have compassion for the patient and respect their privacy as
well as their emotions during this stressful time. Focus on care and concern for
the patient's well being."
Don't let it follow you home
Mr. Stoner recommends giving yourself five to 10 minutes at the
end of the day to gather "good listeners" from your staff. Ask them, "What worked
and what didn't work?" and let them vent. Then it's your turn. Once you have the
opportunity to let off steam and receive feedback, you can leave your work at the
office and go home.
Optometric Management, Issue: August 2005