Editorials - December 15, 2001 - American Family Physician

Editorials

The New U.S. Preventive Services Task Force

ALFRED O. BERG, M.D., M.P.H.
Chair, U.S. Preventive Services Task Force
University of Washington
Seattle, Washington

JANET ALLAN, PH.D., R.N., C.S.
Vice-Chair, U.S. Preventive Services Task Force
University of Texas Health Science Center
San Antonio, Texas

See report on
page 1995.

The U.S. Preventive Services Task Force (USPSTF) is back. Following in the steps of its predecessors, which produced similar evidence reports in 1989 and 1995, the third USPSTF (convened by the Agency for Healthcare Research and Quality [AHRQ] in 1998) systematically reviews the evidence on the effectiveness of clinical preventive services in primary care, including screening, counseling, and chemoprevention.

However, in other respects this Task Force differs from its predecessors. The systematic evidence reviews that support Task Force recommendations are now conducted by two AHRQ-supported Evidence-based Practice Centers (EPCs), one at Oregon Health Sciences University, Portland, and the other at Research Triangle Institute, Research Triangle Park, N.C. In preparing the reviews, the EPCs conduct a comprehensive analysis of the research literature using state-of-the-art standards of evidence, and solicit input from a number of federal and private reviewers.

The USPSTF uses the reviews and comments, but guards its independence by separating the evidence review from the crafting of recommendations. Final recommendations are based on the quality of the evidence and the relative balance of benefits and harms. The expertise of the Task Force is broader than it has been in the past, with members representing family medicine, pediatrics, internal medicine, obstetrics and gynecology, geriatrics, preventive medicine, public health, behavioral medicine, and nursing. The Task Force has chosen to release its recommendations in print and on the Web (http://www.ahrq.gov/clinic/uspstfix.htm) as they are completed, rather than waiting until the conclusion of all its work to release a single volume.

AHRQ and American Family Physician are working together to publish the recommendations of the new USPSTF. Although Task Force recommendations will appear first in other journals or on the AHRQ Web site, AFP will publish most, if not all, Task Force reports and recommendations in its print version and will feature all on its Web site in full-text format.

The Task Force recommendation that appears in this issue is based on a review of the evidence on the effectiveness of routine screening of newborns for hearing loss. Soon, AFP will publish previously released Task Force recommendations on screening for lipid disorders, chlamydial infection, bacterial vaginosis in pregnancy, and skin cancer. Other new recommendations, on such topics as the role of aspirin in the primary prevention of cardiovascular events, screening for depression in primary care, breast cancer chemoprevention, colorectal cancer screening, and hormone replacement therapy, will appear in AFP in the coming year.

The Task Force has helped to establish the importance of prevention in primary health care, ensuring medical insurance coverage for preventive services and holding clinicians and health care systems accountable for delivering effective care. Its recommendations highlight opportunities for improved delivery of effective health care services and have helped to narrow gaps in the provision of preventive care in different populations.

We are pleased to launch AFP's publication of the new USPSTF recommendations and look forward to bringing you the complete set in the months and years to come.

Alfred O. Berg, M.D., M.P.H., is chair of the USPSTF and professor and chair in the Department of Family Medicine at the University of Washington School of Medicine in Seattle, Wash.

Janet Allan, Ph.D., R.N., C.S., is vice-chair of the USPSTF and dean and professor in the School of Nursing at the University of Texas Health Science Center in San Antonio, Tex.

Address correspondence to Alfred O. Berg, M.D., M.P.H., Department of Family Medicine, University of Washington, Box 356390, Seattle, WA 98195-0001. Reprints are not available from the authors.

Breaking Bad News: The Many Roles of the Family Physician

MICHAEL L. SPARACINO, D.O.
Mercy Medical Center-North Iowa
Mason City, Iowa

See article on
page 1975.

In this issue of American Family Physician, VandeKieft discusses breaking bad news to patients.¹ The increased importance noted by current literature in family medicine on end-of-life issues reflects the desire on the part of society to collaborate with their family physicians in dealing with such issues.

Breaking bad news is a sentinel skill of the family physician. Family physicians who provide continuity care to patients are in an ideal position to compassionately, yet clearly, convey devastating news. The importance of the physician-patient relationship in such engagements is critical.² Having already developed a sense of mutual trust, the family physician is often in the position to break such news.

Breaking bad news as it relates to terminal illness also marks the beginning of a long and tumultuous journey that the physician and patient take together.³ The patient relies on the physician to provide appropriate medical care and advice, as well as provide appropriate psychosocial support. Physicians must balance a duty to provide this care for the patient while continually reevaluating their own response to the patient and family's crisis.

The ABCDE (Advance preparation, Building a therapeutic relationship, Communicating well, Dealing with the patient and family reactions and Encouraging/validating emotions) mnemonic works well in organizing a physician's approach to breaking bad news. The advanced preparation portion is critically important because it will lay the factual basis and foundation for the conversation to continue. Review of pertinent medical facts in collaboration with appropriate consultants should prepare the physician for providing information to the patient. Knowing the patient as an individual and human being is a critical factor in assessing how the bad news will be conveyed.

Assessing what the patient wants to know and what the patient knows already can serve as a step-off point to begin the discussion. Ideally, discussing this issue during the informed consent portion of a diagnostic procedure can include the phrase: "if we find something, how would you like me to tell you?" This can also serve as a way to initiate the conversation.² For example, "as we talked about when we went over this procedure, you had asked me to tell you straight." In preparing for the discussion, the selection of a quiet room with minimal interruptions is essential. After communicating the bad news in a clear, understandable, culturally sensitive way, the physician must be prepared for the patient's and family's reactions. Occasionally, the family insists that the physician not tell the patient, fearing the news would be too much to handle.

The family physician has a legal obligation to obtain informed consent from the patient and a duty to inform the patient of the news, unless the patient refuses. Ideally, the physician can take advantage of the knowledge of the family to promote a congenial family alliance. Asking the family why they don't want to tell the patient can uncover relational issues and dysfunctional family dynamics.⁴ The family physician must be prepared for the wide range of emotions available for the patient and the family. These may vary from loving acceptance to anger and rage. When emotions are communicated to the patient, it is important to listen quietly and intently, with specific attention to the emotional description of feelings. In addition to verbal communication, nonverbal communication, including open body language, is important. It is essential for family physicians to be culturally sensitive to the patient and the family when discussing such important news. Having appropriate family members or other support personnel present is important.

If language is a barrier, wait for a translator to be a part of the discussion. It is also important to assess the patient for inappropriate coping skills, such as suicidal or homicidal ideation.⁵ Finally, the physician must be able to assess personal emotional reactions to the conversation. Appropriate support from family, colleagues, and other appropriate people is critical for the continued effectiveness of the family physician. In our profession, we cannot afford a long learning curve when it comes to basic skills in end-of-life care.⁶ Courses and seminars concerning end-of-life care and spirituality are becoming more prevalent. One is a joint venture between the American Medical Association (AMA) Institute of Ethics and the Robert Wood Johnson Foundation entitled Educating Physicians on End-of-Life Care (EPEC).⁷ More information about the curriculum for the 16-hour basic course on end-of-life issues is available through the AMA. In addition, courses are available throughout the country providing EPEC training to interested family physicians, other primary care professionals, and allied health care workers.

Breaking bad news is an essential skill of any family physician. Our training and values support open and honest communication between the physician and patient. As a result, family physicians are in an ideal position to help patients with a terminal disease face their illness with compassion and dignity.

REFERENCES

VandeKieft, GK. Breaking bad news. Am Fam Physician 2001;64:1975-8.

Buckman R, Kason Y. How to break bad news: a guide for health care professionals. Baltimore, MD: Johns Hopkins University Press; 1992:65-97.

Faulkner A, Maguire P. Talking to cancer patients and their relatives. Oxford, New York: Oxford University Press; 1994:58-70.

Quill TE, Townsend P. Bad news: delivery, dialogue, and dilemmas. Arch Intern Med. 1991;151:463-8.

Pabst Battin, M. The least worst death: essays in bioethics on the end of life. New York: Oxford University Press, 1994:174-5.

Field MJ, Cassel CK. Approaching death: improving care at the end of life. Washington, DC: National Academy Press, 1997:59-64.

EPEC project: education for physicians on end-of-life care, 1998, American Medical Association, Institute for Ethics.

Michael L. Sparacino, D.O., is professor of clinical family medicine and program director for the family medicine residency program at Mercy Medical Center-North Iowa, Mason City, Iowa.

Address correspondence to Michael L. Sparacino, D.O., Mercy Family Medicine Residency, 1000 4th St., SW, Mason City, IA 50401.

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