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Effect of breaking bad news on patients' perceptions of doctors

Article in Journal of the Royal Society of Medicine · August 2002

DOI: 10.1258/jrsm.95.7.343 · Source: PubMed

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 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 95 July 2002

Effect of breaking bad news on patients’ perceptions

ORIGINAL ARTICLE
of doctors
Mandy M Barnett MD MRCGP

J R Soc Med 2002;95:343–347

SUMMARY
The breaking of bad news is a routine but difficult task for many health professionals. There are numerous
anecdotes of insensitive practice but the subject has attracted little systematic research. We therefore interviewed
106 patients with advanced cancer (from an original sample of 195) to assess their perceptions of the doctors
involved in their care. Aspects of the ‘breaking bad news’ event were recorded during discussion of the illness
history and were subsequently rated. Participants were also asked to nominate doctors under the headings ‘most
helpful’ and ‘less helpful’, and completed standardized psychological screening questionnaires.
In 94 of the 106 cases the bad news had been given by a doctor, usually a surgeon. Of the 13 doctors categorized
as ‘most helpful’ when breaking bad news, 8 were general practitioners; of the 7 categorized as ‘less helpful’ all
were surgeons. 69% of patients were neutral or positive about the bad-news consultation, but 20% were negative
and 6% very negative. Doctors in surgical specialties were significantly more likely to be rated poorly than non-
surgical specialists or general practitioners.
Surgeons were the group of doctors most likely to break bad news, but non-surgical doctors were rated more
positively in performance of the task. This finding has implications for training.

INTRODUCTION to link the bad-news ‘event’ with later psychological

The breaking of bad news is an emotive subject for both distress in parents of terminally ill children yielded no
health professionals and patients. Anecdotes abound of correlation, though parents were noted to retain vivid
insensitive practice and patient distress, but there has been memories of the interview and were sometimes still
little systematic study1. The task is feared by junior doctors2 preoccupied with it many years later10. A recent study of
and struggled with by surgeons3,4. Even experienced breast cancer survivors did find a relationship between
oncologists acknowledge difficulty in detecting psychologi- positive perceptions of physician behaviour during the
cal distress5. In an American study of 55 patients, 74% had diagnostic consultation and psychological adjustment, but
been told their diagnosis by a surgeon, only 11% by their the effect was modest11. In this study, we aimed to examine
primary care doctor. Those informed over the telephone or the long-term psychological adjustment of patients in the
in the recovery room were most likely to describe the terminal phase of their illness and to compare this with
encounter in negative terms6. In the UK, Macmillan Cancer patient perceptions of their doctors’ attitudes and skills,
Relief surveyed 2000 patients7. Reports varied widely, but including their experiences of receiving bad news.
the mean time for the consultation was only 13 minutes,
reflecting a generally hurried approach. Most respondents
PATIENTS AND METHODS
desired more information and 20% described harrowing
experiences. In contrast, Seale8 found that bereaved 195 adult (418 years) patients with advanced cancer
relatives were largely positive about the manner in which (estimated prognosis 51 year) were identified consecu-
they and the deceased patient had been informed. tively from various sources—cancer registries, oncology
The overall view is that a positive or negative bad-news and respiratory clinics, palliative care nurses, general
experience can affect a patient’s subsequent adjustment9, practitioners—and asked to participate in a study
but few have measured the long-term effects. One attempt considering their experience of medical care. For the
present substudy the interview included the Hospital
Anxiety and Depression Scale12 and the Rotterdam
Centre for Primary Health Care Studies, University of Warwick, Symptom Checklist13. A semi-structured subsection on
Coventry CV4 7AL, UK the breaking of bad news was piloted in 6 patients but
E-mail: [email protected] proved difficult to complete. This was modified to open 343
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 95 July 2002

discussion of the patient’s history, details of the breaking- scores were grouped together into three ‘psychological
bad-news experience being recorded as they emerged, with distress bands’ as follows: (1) ‘case’ on one or both HAD
specific comments noted verbatim. Where there was more scales and/or ‘case’ on the RSCL (cut-off 410); (2)
than one episode (e.g. original diagnosis and later ‘borderline’ on one or both HAD scales (score 8–10) (there
recurrence) participants were asked to describe the event is no borderline score described for the RSCL); (3) ‘non-
that was most important to them. case’ on all three. Psychological ratings, time from diagnosis
Contemporaneously recorded interview notes were and breaking-bad-news ratings could then be compared by
analysed and coded by the researcher (retrospectively for one-way anova and chi-square.
the first 66 participants, directly after the interview for the
remaining 40). Responses were graded positive, neutral,
negative, very negative, uncodable. The quality of the RESULTS
information given could not be assessed systematically; Of 195 patients who were approached, 126 responded
thus, grading reflected a global assessment of the patient’s positively and 109 were interviewed at home: 3 were
account, with emphasis on the personal qualities and overall subsequently excluded (not terminal prognosis), leaving
supportiveness of the bad-news breaker, unless explanation 106 for analysis.
issues were specifically raised. The ‘uncodable’ category In most instances (94/106), the bad news had been
applied where text was substantially lacking or uninforma- broken by a doctor: specialty was clearly identifiable in 85;
tive, while ‘neutral’ was employed where the account a further 5 could be identified as hospital doctors, though
either indicated no strong feelings or offered only factual 4 without specialty or grade and 1 was said to be a private
information that did not allow for interpretation of the consultant, specialty unknown. 77 doctors were fully
patient’s views. While this might tend to skew the results identified by name.
towards neutral, it was expected to offset single-researcher 73 patients (86%) had been given the news by a hospital
bias by ensuring that the analysis was confined to interviews specialist, usually (48/85) a surgeon; general practitioners
in which the patient had commented specifically on the way were involved far less (13/85) and oncologists least (4/85).
bad news had been given. The coding was then given a Grade was identifiable in 71/73 specialists and in 55 it was a
numerical rating. consultant; where the task was performed by junior doctors
Further on in the interview, patients were asked to (16/73) most were in surgical specialties (10/16). Nearly
consider all doctors with whom they had had contact in the all patients were told face to face rather than by telephone
context of their current illness, and to nominate a ‘most or letter.
helpful’ and a ‘less helpful’ doctor. In this paper we report 49% of patient accounts were neutral and 20% positive.
only on doctors who had given the bad news. However, in 20% memory of the event was negative and in
For statistical analysis, breaking-bad-news ratings in 6% very negative (Table 1). Box 1 gives extracts of
relation to doctors’ specialties was examined by Fisher’s verbatim comments. Patients especially recalled individuals
exact test. The Hospital Anxiety Depression scale (HAD) who were brusque, unsympathetic or impatient. In
has separate subscales for anxiety and depression; the addition, the need for simple clear information was a
Rotterdam Symptom Checklist (RSCL) has physical and persistent theme; one participant was particularly distressed
psychological distress subscales. Individual scores were by a junior doctor who was perceived to have given
defined in terms of ‘caseness’14 on each subscale, with conflicting information on different occasions but subse-
standard cut-offs of 410. For comparisons, psychological quently denied doing so.

Table 1 Breaking-bad-news coding (all patients, n=106)

No. of No. of identifiable No. of partly No. of unidentified Unknown or indirect

Bad news code patients (%) doctors identifiable doctors doctors (includes family) source Total

Not codable 6 (6%) 3 1 0 2 6

Positive 21 (20%) 18 2 1 0 21
Neutral 52 (49%) 37 0 6 9 52
Negative 21 (20%) 14 4 2 1 (family) 21
Very negative 6 (6%) 5 1 0 0 6

Total 106 (101%) 77 8 9 12 106

344
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 95 July 2002

Box 1 Extracts from interview notes

Positive—Mrs A: The tumour was found at the hospital, but it was Dr X her own doctor (GP) who told her about it. He did it beautifully, kept
her calm
Neutral—Mrs B: Referred to consultant surgeon with breast lump for needle aspiration; he told her the diagnosis—he was quite
sympathetic, and she wasn’t surprised
Negative—Mr C: Had a colostomy done for a ‘blockage’. Later surgical team came and told him about operation; they had done all
they could; nothing else to be done in hospital; it was now up to his GP. Patient’s daughter rang consultant to ask for more information.
He then came ‘storming’ onto the ward to see the patient, saying ‘I thought I’d told you’
Very negative—Mrs D: Developed a lump in her breast at 35. When seen after its removal, consultant surgeon told her she had cancer
across her chest. She cried when she heard. He told her to ‘stop that, you’ve a lot more to go through’—and this was seeing him as a
private patient (recalled 11 years after event).

Table 2 Specialty, grade and ratings for all partially or fully identified doctors (n=85) (numbers in parentheses indicate juniors (jun) included in total)

Spec BBN + BBN neutl BBN7 BBN v7 Not codable Total

Oncology 1 2 0 0 1 4
Surg (jun) 9 (3) 18 (1) 14 (4) 5 (1) 2 (1) 48 (10)
Chest phys 5 (1) 4 1 0 0 10 (1)
Phys (jun) 1 (1) 3 0 0 0 4 (1)
Gynae (jun) 1 (1) 3 (2) 1 (1) 0 0 5 (4)
Cons unkn 1 0 0 0 0 1
GP 2 8 1 1 1 13
Total 20 (6) 38 (3) 17 (5) 6 (1) 4 (1) 85 (16)

BBN += positive experience of receiving bad news; BBN neutl = neutral experience; BBN7 = negative experience; BBN v7 = very negative experience; jun = junior;
phys = physician; cons unkn = consultant of unknown specialty

A spread of ratings was obtained across all hospital bad-news breakers in 4 cases, had 2 nominations, both
specialists (Table 2). When doctors in surgical specialties ‘most helpful’.
were compared with those in non-surgical specialties, A total of 23/106 (22%) patients reached ‘caseness’
the distribution of negative/very negative and neutral/ (i.e. significant psychological distress) on the HAD and/or
positive ratings differed, with surgeons performing worse the RSCL. However, many patients had very low scores
(P exact=0.018). For the purpose of this analysis, (i.e. good psychological adjustment): the median scores for
oncologists were excluded. When gynaecologists (with each subscale were HAD anxiety 4, HAD depression 5,
their hybrid role) were excluded from the surgical RSCL psychological subscale 6.5.
group the result remained significant (P=0.04). Surgeons There was no significant association between patients’
scored worse than general practitioners, though not current psychological morbidity and their perceptions of the
significantly so (P exact=0.08). The grade of doctor had bad-news event, in either direction; that is, patients with a
no significant effect, but the number of juniors was positive memory were not protected from depression, and
small. patients with highly negative memories were not more
In the categorization of ‘most helpful’ and ‘less helpful’ likely to be depressed (P=0.68).
doctors in the whole course of the illness, 20 of the There was a trend (by one-way anova) for shorter
nominations were the doctors who had given the bad news. adaptation time from diagnosis to be associated with greater
These categories were consistent with observer ratings of psychological distress, particularly in the case of recurrence
the bad-news experience (P exact=0.027) (Table 3). For (Table 4). However, there was no relation between time
acute hospital bad-news breakers there were 10 nominations from diagnosis and breaking-bad-news rating; in other
—3 favourable, 7 (all surgeons) unfavourable. General words, patients’ recall and description of highly positive or
practitioners, who were the bad-news breakers in 13 cases, negative events was not attenuated or enhanced by the
received 8 nominations, all ‘most helpful’. Oncologists, passage of time (P=0.38). 345
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 95 July 2002

DISCUSSION of doctors between surgical and other specialties in the

To learn that one has a life-threatening disease is a major breaking of bad news.
event, and many patients recalled it with clarity even years The reasons could include, first, heightened patient
later. This has been noted before6,10,15. The event itself did anxiety; many hospital specialists were involved at an earlier
not seem to cause long-term psychological morbidity, and more uncertain stage in the patient’s illness. This could
although the findings must be interpreted with caution in lead to a greater recall bias, though it applies equally to
view of the range of time from diagnosis to interview surgical and non-surgical diagnosticians. Secondly, patients
(unavoidable in a diagnostically heterogeneous sample of had less contact with this group (2–6 encounters), so had
terminally ill patients). Another reassuring negative finding less opportunity to develop rapport. In addition, treatment
was that patients did not ‘shoot the messenger’16. Although may have been limited or unsuccessful, so these doctors
doctors broke the bad news on 94 occasions, only 7 of these might have been perceived as ‘less helpful’ for these reasons
were categorized as ‘less helpful’. It was the patients at the over and above the breaking of bad news. Thirdly, the
two extremes—those who recalled the interview as very circumstances of consultation—e.g. busy ward or out-
well or very badly done—who were most likely to recall patient clinic versus familiar surgery—may be relevant and
the exact circumstances and the words used. were not specifically recorded here. However, while these
Bad news is broken most commonly by hospital factors may differentiate between specialists and general
specialists, and this is what most patients expect and practitioners, these too apply equally to surgical and non-
desire17. In this study the specialist was usually a surgeon, surgical specialties. Time pressure is another factor cited by
and our diagnostically heterogeneous patient sample was doctors as a particular problem. However, results from the
probably representative. Doctors in surgical specialties were Doctor–Patient Relationship Questionnaire in the full study
significantly more likely to be rated negatively, and to showed that patients did not distinguish between ‘most
receive ‘less helpful’ nominations. Although these nomina- helpful’ and ‘least helpful’ doctors on this item (i.e. they
tions were applicable to any doctor involved in the patient’s perceived all doctors as busy, but felt that they had enough
care, the correlation between the bad-news rating and the time with both groups)18. Fourthly, the diagnosis could
nomination status did support the interpretation of have influenced the nature of the discussions.
causality, especially in the ‘less helpful’ category. There is a fifth possible explanation—that doctors in
The numbers are small, and the study has several surgical specialties were less effective communicators.
methodological flaws, both in its retrospective design and in While the General Medical Council recommended the
the global rating system. These criticisms notwithstanding, inclusion of communication skills training in the under-
there does appear to be a difference in patients’ perceptions graduate curriculum in 199319, this only recently became a
formal requirement, and a survey in the early 1990s
revealed a lack of training emphasis, both in time allocated
Table 3 Breaking-bad-news coding where doctor breaking bad news
was nominated (20 patients) and in formal assessment20. Among postgraduates, voca-
tional training schemes have incorporated communication
Bad-news code No. of ‘most helpful’ No. of ‘less helpful’ skills training for many years, and the Royal College of
General Practitioners introduced formal assessment into its
Not codable 1 (8%) 0 (0%) Membership examination in 1995. However, other Royal
Positive 4 (31%) 2 (29%) Colleges lagged behind and trainees in hospital specialties
Neutral 6 (46%) 0 (0%) still rely largely on the example of seniors and their own
Negative 2 (15%) 4 (57%) experience. In a personal survey of 201 doctors18, only
Very negative 0 (0%) 1 (14%) 14% had received any formal training as undergraduates in
how to break bad news. 40% reported communication skills

Table 4 Average time since diagnosis, according to depression band

Psychological distress band

Case (n = 23) Borderline (n = 19) Normal (n = 64)

Average time in wk since diagnosis (SD) 36.09 (45.43) 33.42 (31.62) 37.52 (53.26)
Average time in wk since recurrence, or diagnosis if no recurrence (SD) 15.87 (15.84) 17.63 (21.07) 20.52 (29.29)

346 SD = Standard deviation

 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 95 July 2002

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