People who are physicians have been trained to believe that it is a scientific objectivity that makes them most effective in their efforts to understand and resolve the pain others bring them, and a mental distance that protects them from becoming wounded by this difficult work. It is an extremely demanding training. Yet objectivity makes us far more vulnerable emotionally than compassion or a simple humanity. Objectivity separates us from the life around us and within us. We are wounded by that life just the same; it is only the healing which cannot reach us. Physicians pay a terrible personal price for their hard-won objectivity. Objectivity is not whole. In the objective stance no one can draw on their own human strengths, no one can cry, or accept comfort, or find meaning, or pray. No one who is untouched by it can really understand the life around them either.

from Kitchen Table Wisdom: Stories That Heal. Riverhead Books

In many medical settings outside the US, withholding bad news from cancer patients is common. Instead, the bad news is often delivered to a spouse or close family members, with loved ones telling the doctor that the patient mustn’t know about his or her prognosis. Within many Mediterranean cultures—as well as Japan—the decision to withhold information is often based on such values as keeping the patient free from anxiety about her or his condition, building hope through suppression of information, and abdicating control to the family whose responsibility it is to protect the patient from the psychological distress of cancer.

Costantini and colleagues offer that the lack of communication skills and familial pressures might be fueling these cultural practices. To address what the researchers call cultural barriers, they examined the effectiveness of training programs to assist Italian doctors to confront the aforementioned cultural pressures in order to be able to disclose more information to the patient. Furthermore, they wanted to find out whether communication training done in countries where full disclosure is practiced could be adapted to other cultures. Their findings suggest that the optimal communication intervention involves overcoming surface-level barriers to change (low self-efficacy, one’s own attitudes about disclosure to patients), role-play situations that allow doctors to practice their skills, and patients’ active involvement in the simulations.

I often advocate for full disclosure to the patient when I talk to providers about their medical interactions. Despite what Costantini and colleagues add to the body of literature, there is a larger issue that goes unaddressed, which is the assumption that the patient must be given the information, or that the provider always knows what’s best for the patient. Given that patients in the US generally want to be told the truth about their illness, it’s hard for some of us to imagine that there is an alternative point of view. But then again, the notion of “overcoming” cultural barriers might seem culturally myopic ethnocentric to others. Perhaps the real issue is whether patients themselves want to know the bad news, or instead be shielded from the potential trauma and distress of a bleak outcome. If we truly believe that full disclosure is crucial, then we must rethink what we mean when we say we’re culturally sensitive or relative. In other words, sometimes well-meaning providers must act in ways that might look ethnocentric after all.

Costantini, A., Baile, W., Lenzi, R., Costantini, M., Ziparo, V., Marchetti, P., Grassi, L. (2009). Overcoming cultural barriers to giving bad news: Feasibility of training to promote truth-telling to cancer patients, Journal of Cancer Education, 24, 180-185. doi: 10.1080/08858190902876262.

Early disclosure of the bad news is almost always advisable. The provider should also keep patients and families up-to-date and discuss the situation as much as the patient needs. Kaplan (2010) and others propose a framework—SPIKES—that can help facilitate this difficult discussion. It’s an acronym for a series of steps designed to reduce uncertainty and ease the inevitable pain of bad news.

The first step is setting; find a quiet and private setting in which to have the conversation. If feasible and appropriate, choose a setting that can accommodate a few close family members. Second is perception. Establish that the patient understands the situation before breaking the news. This is also a good time to clear up misconceptions. This step might require a few discussions before you deliver the actual news. You then should plan the invitation. What kinds of information would be helpful to the patient? If possible, determine the patient’s preferred learning style. For example, is a verbal description the best approach, or will the patient want some things written down? When reaching the knowledge step, it’s best to warn the patient before you hit him or her with the news. Ease up on the medical jargon; breaking it down in lay language is best. Also, give the patient some time to absorb news. Once the news is delivered, it’s important to show empathy. Acknowledge the patient’s emotions and respond to emotional expressions appropriately. Finally, summarize or strategize. Make sure the patient understands the information and allow for questions. You might have to explain something more than once.

Breaking bad news is never an easy task, and it’s important to do what one can to reduce stress for all parties involved. Whether you use SPIKES or any other framework, have a structured plan before you commence the discussion. Hopefully we can draw attention to the need for more focused efforts to train medical students—not just teaching the skill sets but placing them in simulated practice contexts.

Harrison, M. E., & Walling, A. (2010). What do we know about giving bad news? A review. Clinical Pediatrics, 49(7), 619-626.

Kaplan, M. (2010). SPIKES: A framework for breaking bad news to patients with cancer. Clinical Journal of Oncology Nursing, 14(4), 514-516.

Lienard, A., Merckeart, I., Libert, Y., Bragard, I., Delvaux, N., Etienne, A-M., Marchal, S., Meunier, J., Reyneart, C., Slachmuylder, J-L., Razavi, D. (2010). Is it possible to improve residents breaking bad news? A randomized study assessing the efficacy of a communication skills training program. British Journal of Cancer, 103, 171-177. doi: 10.1038/sj.bjc.6605749.

Surgeons, as a group, adhere to a curious egalitarianism. They believe in practice, not talent. People often assume that you have to have great hands to become a surgeon, but it’s not true. When I interviewed to get into surgery programs, no one made me sew or take a dexterity test or checked if my hands were steady. You do not even need all ten fingers to be accepted. To be sure talent helps . . . Nonetheless, attending surgeons say that what’s most important to them is finding people who are conscientious, industrious, and boneheaded enough to stick at practicing this one difficult thing day and night for years on end . . . Skill, surgeons believe, can be taught; tenacity cannot.

Dr. Gawande argues that practice and tenacity—more so than raw talent—are what’s crucial to make it as a surgeon. His words instantly reminded me of what I say most often about communication: Everyone does it, but few of us do it well. When I teach health professionals how to interact with their patients and with each other, I point out that virtually anyone can learn to be an outstanding communicator, even if it feels like one lacks the raw ability. Positive health interactions aren’t just limited to a few gifted individuals who know how to “connect.” Borrowing Gawande’s point, it takes practice, and that’s how we need to approach teaching communication in the healing professions.

Gawande, A. (2002). Complications: A surgeon’s notes on an imperfect science. New York: Picador.

“My fascination with health communication began with individuals who were generous enough to share their stories:

• the woman who allowed me to be present when the bandages were removed from her eyes and she saw her children for the first time in 20 years
• the 34-year-old police officer I met in his parents’ front room, occupying the left side of a hospital bed, the right side reserved for his faithful canine companion. Shep, who, along with hospice, provided warmth and comfort during the final joyful and sad months of the man’s life
• the doctor who ushered everyone from the room when the patient (myself) seemed scared and nervous. “She’s shaking,” exclaimed Dr. Williamson. Then she sent everyone away and sat on the edge of the bed, holding my hands in hers to warm them, telling me that, in Japan, long fingers like mind are revered as a sign of beauty.

Stories such as these occur every day in health settings. I’ve been privileged to witness them as a news reporter, a public relations director, a researcher, and sometimes a participant. Such stories are the reason we do what we do—whether that be designing health campaigns, caring directly for patients, helping manage and guide health care organizations, researchers and teaching health communication, or studying the issues so that we and our loved ones will be better prepared when we are the patients.” (taken from preface)

It’s true that we all communicate, but most of us don’t do it very well. In our efforts to keep up with the complex and ever-changing world of medicine, it’s easy for us to overlook the emotional, cultural, and psychological needs of patients and the people who care for them. What Dr. du Pre’ does—and what I try to do as I follow her example—is illuminate the fact that health communication is part of everyday life. Just as our health shapes our talk, so can we use our talk to influence our healthcare interactions and bring about the best possible outcomes.

du Pre’, A. (2010). Communicating about health: Current issues and perspectives (3^rd ed.). New York: Oxford University Press.

In their study, Almut Winterstein and colleagues recruited “professional shoppers” to fill prescriptions for lisinopril and metformin at various pharmacies throughout the country. The researchers found that efforts to disseminate the information were effective. However, about half of the literature accompanying the prescriptions was missing directions for use; a significant amount of the information failed standards of comprehensibility, legibility, and reading level. The authors also found that large chain pharmacies complied more with consumer medical information (CMI) criteria than did independent stores. Such criteria include drug name and indications, directions for use, symptoms of adverse reactions, and precautions.

The authors argue that both content and formatting should be subject to more FDA guidance. They also suggest that future studies be done to determine how information can be presented to optimize comprehension, retention, and patient actions in response to instructions. In the meantime, providers can circumvent these shortcomings by briefing patients on the drugs prescribed them, and solicit brief questions from patients before they leave the office with their prescriptions in hand.

Almut G. Winterstein; Stephan Linden; Abigail E. Lee; Erica M. Fernandez; Carole L. Kimberlin, Arch Intern Med. 2010;170(15):1317-1324. doi:10.1001/archinternmed.2010.263

Dr. Rajiv Chandawarkar’s research team reported a study in the August issue of Archives of Surgery. Their study examined the effectiveness of a short-term lecture and role-play curriculum for surgical residents. The residents participating in the study were assessed with a checklist of communication behaviors specific to a clinical condition. They were also assessed on general communication skills, such as showing empathy and conducting interviews. The results showed that overall communication skills were not enhanced, but there was significant improvement in case-specific skills, such as delivering a diagnosis.

One of the conclusions of Chandawarkar et al’s. study was that communication training that teaches case-based skills—as opposed to general skills—yields more measurable improvements in medical students. This is especially the case when training is short-term or not even integrated in the medical education curriculum. It might not be enough to expect surgeons to attain communication skills in practice; therefore, the authors suggest that schools need to include more formal communication training in the curriculum.

“Pretraining and Posttraining Assessment of Residents’ Performance in the Fourth Accreditation Council for Graduate Medical Education Competency” by Rajiv Y. Chandawarkar, MD; Kimberly A. Ruscher, MD, MPH; Aleksandra Krajewski, MD; Manish Garg, PhD; Carol Pfeiffer, PhD; Rekha Singh, MD; Walter E. Longo, MD; Robert A. Kozol, MD; Beth Lesnikoski, MD; Prakash Nadkarni, MD, published in Arch Surg. 2011;146(8):916-921. doi:10.1001/archsurg.2011.167

As a pediatric intern, I was a secret baby kisser. This was so flagrantly “unprofessional” I was careful not to be discovered. Late at night under the guise of checking a surgical dressing or an IV, I would make solo rounds on the ward and kiss the children good night. If there was a favorite toy or blanket, I would be sure it was close, and if someone was crying I would even sing a little. I felt the other residents, mostly men, might think less of me for it.

One evening as I was talking to a patient’s father in the corridor, I glanced over his shoulder and saw Stan, my chief resident, bend over the crib of a little girl with leukemia and kiss her on the forehead. In that moment, I realized that others too might be struggling to extend themselves beyond an accepted professionalism to express a natural caring. Perhaps there was a way to talk about these things, even to support one another.

One night when we were waiting to be called to the operating room for a C section, I told Stan what I had seen and that it had meant something important to me. Although we were alone in the doctors’ lounge, Stan denied the whole thing.

We dropped the subject in embarrassment. For the rest of the year we worked together, thirty-six hours on call and twelve hours off. We became trusted colleagues, good friends, and even occasional drinking buddies, but we never mentioned the incident again.

Stan’s integrity was almost legendary. He would never have fudged a piece of lab data or said he had read an article when he hadn’t. But he would have had to step past our entire professional image and training to admit his heartfelt reaction to that little girl. It was impossible then. It is barely possible now. Expressing caring directly rather than through a willingness to work a thirty-six hour day or spend long evenings keeping up with the medical literature and the newest treatments transgresses a strong professional code. It was just not professional behavior. I stopped kissing the babies then. It did not seem worth the risk.

In some ways, a medical training is like a disease. It would be years before I would fully recover from mine.

To build on her theory of dignity violation, Jacobson interviewed 55 people as part of a research study. Interviewees included people who were marginalized because of their health status or individuals who provided health care to those marginalized. She asked them, “What does dignity mean to you?” and “How can people treat one another with dignity?” Jacobson asserts that dignity violation can be influenced by the relationships between the actors and their relative positions to each other, as well as characteristics of the social setting. Her findings reveal several ways patients perceived dignity violation:

• Rudeness: being called by one’s first name only, provider failing to introduce oneself
• Indifference: being kept waiting for more information or follow-up to bad news
• Condescension: being “talked down to”, being spoken to like a child
• Dismissal: having questions go ignored or unanswered
• Disregard: being ignored or talked about as though they were absent from the setting
• Dependence: being shown insensitivity when asking for assistance
• Intrusion: having one’s body or personal boundary transgressed
• Objectification: being treated like a thing, being poked “like a sack of potatoes”
• Restriction: having freedom, clothes, or other things taken away
• Labeling: being labeled as “difficult” “non-compliant,” “bed blocker”, etc.
• Contempt: being treated like one has no value, “like a criminal”
• Discrimination: being denied services because of addictions or a psychiatric diagnosis
• Revulsion: treated as though one is tainted or disgusting
• Deprivation: being denied services because of lack of insurance or other circumstances
• Assault: suffering physical force that demeans one’s body or spirit
• Abjection: being compelled to compromise on beliefs or practices

 Jacobson provides implications for bringing dignity to the forefront and for combating mistreatment of patients. On a personal or relational level, both patients and providers should reflect on situations in which they feel vulnerable, and how their gestures, words, and interpretations can lead to dignity violations in their own settings. At the organizational level, administrators can encourage employing professionals who serve as “health care navigators” to monitor patients’ experiences with the system and their reports of satisfaction. By recognizing dignity violation at all levels, we can realize that this is a “structural problem with structural solutions” (p. 1545).

 Jacobson, N. (2009). Dignity violation in health care. Qualitative Health Research, 19(11), 1536-1547. doi: 10.1177/1049732309349809.