Breaking Bad News Over the Phone
Am Fam Physician. 2009 Sep 1;80(5):520-522.
I had a patient who was awaiting the results of her computed tomography (CT) scan. She was a 39-year-old woman with a family history of ovarian and breast cancers who presented to the office with bloating, early satiety, and lower abdominal discomfort. She was anxious about the possibility of ovarian cancer. I instructed her to schedule a follow-up appointment with me once her CT had been conducted. She called to schedule the appointment and told my staff that she needed to know the results of her CT right away. Knowing how worried she was, I was able to tell her the good news that the results were negative. However, I have had several patients with mammograms suggestive of breast cancer who also wanted me to give them the results over the phone. Despite conventional wisdom, I do not think it is intrinsically wrong to give a diagnosis over the phone; in fact, my patients have been grateful for it. Are there any guidelines for doing this? In which situations is it appropriate? What is the best way to phrase the conversation?
As a general rule, it is preferable to give test results to your patients in person. When ordering a test, many physicians instruct their patients to automatically make a follow-up appointment to discuss their test results. This practice protocol allows patients to have a set time when they can expect to get the results and to ask questions. An abnormal test result (e.g., CT scan, mammogram,) is rarely definitive, and more tests (e.g., biopsies) are usually needed. Thus, scheduling a follow-up appointment to discuss the results and next steps is a good way to allow adequate time for discussion. If a normal or negative test result comes back, the physician can telephone the patient with the “good news,” and patients have the option of canceling the follow-up appointment.
Although it is preferable to give bad news face-to-face, there may be times when giving bad news over the phone is unavoidable. When the test result is positive and treatment must be initiated right away (e.g., a positive chlamydia or gonorrhea test), giving test results over the phone is the most efficient way to notify patients to arrange for follow-up care. Most patients want to know the test results (diagnosis); what the results mean (prognosis); and what they should do about it (next steps). This information often can be conveyed adequately by telephone in situations where the “bad news” is treatable, such as with a sexually transmitted infection.
However, when the news is grave (e.g., a diagnosis of human immunodeficiency virus or cancer), it may be more challenging to convey all of the information over the phone. As mentioned above, in most cases it is best to discuss this type of news in person. Nevertheless, situations arise when giving a test result over the phone is necessary. For example, a patient may be unable to quickly return for a follow-up appointment, and more tests or treatment should begin as soon as possible. Or, as in the above case scenario, a patient may request to know the test results right away. In this age of instant messaging and e-mailing, asking patients to wait to come into the office to know their diagnosis may be unacceptable and may cause unbearable anxiety. Even with a grim diagnosis, patients often prefer to know right away than to have to wait to get their diagnosis in person.
When giving bad news over the phone, there are some general guidelines. First, confirm the test results and relevant clinical information. Second, ensure that there is T adequate privacy and time for the call (e.g., turn off pagers, instruct the office staff not to disturb you). When the patient is reached by phone, ask if it is an appropriate time and place to have a serious discussion. If the patient is on a mobile phone while driving or is in a public place, he or she may need to call back when the setting is appropriate.
When sharing the results with the patient, use simple language and avoid medical jargon. Be truthful, but also caring and compassionate. It is important to convey empathy by using one's voice, because non-verbal communication will be difficult over the phone. Encourage the patient to express emotions by asking questions, such as, “How are you feeling?” The patient's immediate reaction may be stunned silence or disbelief. Because of the distressing nature of the information, the patient may not retain much of what is said after the initial bad news. Thus, it is important to assess the patient's understanding of what was said by asking the patient to state his or her understanding of the situation. Give the patient specific next steps to take, and provide support in coordinating follow-up care. It is extremely important to offer follow-up visits, on the same day if necessary, to answer questions that will arise after the initial phone conversation. In addition, ask the patient whom he or she would like to tell about the diagnosis. Offer assistance and support in speaking to spouses or adult children, if the patient wishes to do so. Finally, document in the medical record the details of the conversation and the patient's response.
When the patient is not your own, breaking bad news over the telephone can be even more challenging. With cross-coverage, physicians often discover an abnormal test result of a colleague's patient. Unless there is urgency, it is usually best to wait for the primary care physician to give the news if waiting a few days is not clinically harmful. The primary care physician has an ongoing relationship with the patient, and that therapeutic relationship can be beneficial to the patient during difficult times.
Delivering bad news is a difficult but necessary aspect of caring for patients. Excellent resources exist on how to give bad news to patients.1–4 However, these references only address giving the information face-to-face, not via the telephone. Communication skills training for physicians should include more instructions on how to better communicate with patients by telephone and e-mail. Training physicians on how to do so more effectively will result in greater satisfaction for physicians and their patients.
1. Fallowfield L, Jenkins V. Communicating sad, bad, and difficult news in medicine. Lancet. 2004;363(9405):312–319.
2. Girgis A, Sanson-Fisher RW. Breaking bad news. 1: Current best advice for clinicians. Behav Med. 1998;24(2):53–59.
3. Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients who suffer. West J Med. 1999;171(4):260–263.
4. VandeKieft GK. Breaking bad news. Am Fam Physician. 2001;64(12):1975–1978.
Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous.
Please send scenarios to Caroline Wellbery, MD, at email@example.com. Materials are edited to retain confidentiality.
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