This may sound obvious, but for goals and treatments to be aligned, patients must have an honest understanding of both their medical condition and the potential benefits/burdens of proposed treatment options.
I’m pointing this out, because in our desire to maintain ‘hope’, providers often couch bad news in niceties and ambiguities, which is not helpful for informed decision-making.
an eye-opening study in the New England Journal of Medicine
The NEJM published an article (Oct 2012) that presented some sobering information on this front. The authors were looking at patient expectations concerning the effectiveness of chemotherapy, specifically whether patients with metastatic lung or colorectal cancer (i.e., incurable cancers) understood that their chemo regimen was palliative in nature, not curative– a critical distinction. And the researchers wanted to try to identify factors associated with any misunderstanding.
The results:
- a majority of patients (61% lung cancer, 81% colorectal cancer) did not understand that their chemo regimen was palliative, i.e., they thought their disease could be cured by chemotherapy.
- the patients who had the more realistic expectations regarding their treatment (i.e., they understood that chemo was palliative) rated communication with their provider as less favorable than those patients who did not have a realistic picture.
- and the converse, patients with a mistaken impression of the effectiveness of their treatments (i.e., they thought their disease was curable and therefore chemotherapy was curative) rated their doctors more favorably.
For emphasis, I’ll repeat the results again
The reality for these study patients was that chemotherapy would at best, slow down disease progression, but not cure their disease. Patients who understood this and thus could more realistically weigh the benefits/burdens of continued treatment, rated their providers less favorably. The patients who rated their providers more highly, had the greatest misunderstanding about the potential utility of the treatment.
This is concerning (understatement).
From the patient’s perspective: this is a large % of patients with misunderstanding about their treatments, and calls into question the process of obtaining informed consent.
From the provider’s perspective: in today’s health care work environment, where Press Ganey type of patient satisfaction surveys impact on provider job stability, this can translate into potentially ‘bad’ practice getting rewarded, while truth-telling, deemed a ‘marker of high quality of care’ is penalized.
This has a number of implications including:
- Patient satisfaction metrics don’t necessarily translate into outcomes.
- Patients have incomplete information when rating their providers.
- Be careful how you deliver bad news.
While I could ‘muse’ at length about (1) and (2) as it relates to the US healthcare industry, for the purposes of this blog, the take home message is:
(3) providers have to be careful about their delivery of bad news.
While this article does not explore the actual ‘breaking bad news’ conversations, it’s safe to conclude that communication skills training is needed. Providers need to convey the true situation to their patients, and they need the skills to help them deliver this news humanely, in a manner that allows patients to feel supported. Because only with accurate information and understanding can patients make truly informed decisions.
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