COMMENTARY

Physicians Are Talking About: How to Deliver Bad News

Nancy R. Terry

Disclosures

October 23, 2009

Abnormal laboratory results can be a cause of stress for patients, yet physicians routinely have staff members call to inform patients of what could be a potentially life-changing condition.

The disadvantages of this practice were brought home to an internist when his nurse telephoned him, crying hysterically, to say that her gynecologist's secretary had called to say that her Pap smear was irregular. Her gynecologist was unavailable to explain the findings, and the secretary could offer no information. The nurse was left to imagine the worst: cervical cancer.

The internist, in a posting on Medscape Physician Connect (MPC), a physician-only discussion board, questioned whether telephone notification of abnormal lab results -- particularly by staff members -- is ideal medical practice. In response, MPC contributors, speaking both as physicians and patients, voiced their preferences for how to deliver bad news.

Telephoning Troubles

"In an ideal world where time was not an issue, I would love to call every patient," says an obstetrician/gynecologist. "I let my nurse call, and she has been doing it long enough that she knows how to soothe folks. No one calls back in tears."

"We don't have the time to call personally about every abnormality and to answer numerous questions," comments an internist. "Really bad news requires a call from the physician and a prompt office follow-up." To minimize the patient's level of anxiety before the office visit, the internist suggests that "bad news can be given the least ominous interpretation while additional tests or consultations are being arranged."

However, a cheerful phone delivery from a staff member can backfire. "I and my wife have been frightened too many times by cheerful messages from aides," says a family medicine physician. And too casual a message can lull a patient into indifference. An ob/gyn reports that a patient whose recent biopsy indicated squamous cell carcinoma could have been diagnosed at a precancerous stage had she taken appropriate action a few years earlier. "The patient was told by her family physician's secretary that she had an abnormal Pap that was probably nothing, but that she needed to come in. Since it was probably nothing, she did nothing. You can either risk fear or complacency."

The telephone is frequently the preferred method of notification when the patient requires urgent follow-up. "I was taught never to give bad news over the phone," says an endocrinologist, "but I don't follow that when a patient's potassium is 6." In such a case, a telephone call to a patient prompted a life-saving trip to the emergency room. A rheumatologist agrees. "Sometimes to expedite things, phone use is the best way to go."

Yet, as a general practice, some physicians consider telephone notification to be impractical. An ob/gyn says that the frequent incidence of phone tag or calls made to patients at work or while driving, when it was inappropriate to talk to the patient, prompted her nurse to adopt a policy of written notification. "Now, all patients get notification of results -- if normal, a standard letter; if abnormal, a notice to call my nurse," says the ob/gyn. Other physicians point out that time spent in telephone consultation is not billable. "Patients with multiple questions are offered an appointment," says an internist. "I am not going to provide unreimbursed care that includes lengthy phone calls." An ob/gyn agrees. "If I am going to spend more than 2 minutes talking to a patient, the reality of reimbursement is that it must be a billable visit. The patient needs to come in."

Paying for the News

"My practice," says a neurologist, "is to schedule all patients for a follow-up visit in the office. If results are normal or unremarkable, the visit time gives us a chance to discuss other options of management. If test results are abnormal, I break the news to the patient and use the visit time to answer questions." An internist follows a similar procedure. "My standard practice is to have all patients come in 2 weeks later to discuss results."

Several physicians take issue with the practice of having patients schedule office visits to review normal results. "If I had every Pap smear patient come back in 2 weeks," says an ob/gyn, "I would have a lot of no-shows, a lot of pissed-off women, and a rapidly shrinking practice because the community would consider me gouging." A dermatologist remarks, "I personally would not be happy to drive an hour or pay a copay or take time off work to get a normal result; or be told that no news is good news; or have to wait 2 weeks to hear if I had a melanoma; or meet a dead-end with the medical assistant if I had a question."

The dermatologist's preferred notification method resembles that of other physicians. "My staff calls on the majority of things, but I write down exactly what they need to say. I call with some of the results, especially when I anticipate anxiety or if the case is complicated or serious. It is true that I am not paid for this, but patients appreciate it, and it is how I would want to be treated." He concedes that the best method of notification may vary, depending on the specialty and the particular practice.

Whatever notification method is used, physicians emphasize (1) the importance of reporting all test results to ensure that none go astray and (2) the coordination between primary care physician and specialist to guarantee that appropriate information is delivered to the patient with efficiency and compassion.

A Change of Mind Rather Than Method

"There is a right way and a wrong way to convey information regarding an abnormal Pap," says an internist. "I would never call anyone, even if they have cancer or a mass, and indicate that by phone, because it is too emotional for the patient. I don't want to cause anxiety." An ob/gyn agrees that it's important to convey "a sense of seriousness without panic." Consideration is crucial. "It is easy for those of us to forget the fear experienced by patients."

To read the full discussion of the preferred ways to notify patients of test results, see http://boards.medscape.com/forums/.29f54ea0

View this and other discussions in Physician Connect (physicians only; click here to learn more).

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