Physicians work on colleagues' bedside manners

By Michael Alpert

Cancer. The word is a double-syllabled blade that slices to the marrow of fear when heard by a patient or family member of someone afflicted.

But if Emory medical ethicist John Banja has the impact on health care professionals he hopes to, they will learn that delivering such jolting news can be couched in a way that doesn’t jeopardize their relationship with patients.

“Medical training needs to include ample time to teach health professionals how to ... have an emotionally uncomfortable conversation with a patient,” Banja said. “If health care providers are not taught techniques about handling the way their emotions influence their communications, they’ll have a lot of trouble managing psychologically painful conversations.”

Banja, an associate professor in the Center for Ethics, frequently gives lecturers and workshops on the challenge to “relate” better. His lectures address a range of uncomfortable situations, from disclosing medical errors to disclosing a loved one’s death to family members, to delivering a poor prognosis.

“It’s easy to work with patients when you like them, when they like you and the treatment is going well,” Banja said. “But it’s hard when you don’t particularly like them, they don’t like you and treatment is going nowhere.

“It’s interesting how insecure many health care providers are about themselves,” he continued. “For example, even if they don’t fully understand a question or don’t fully know the answer, many believe they have to appear authoritative in offering some sort of answer.

“Medical school might be to blame for this tendency as student doctors start learning, at least by their third year, how to answer every question a resident or attending physician asks them. They may not even understand the question, let alone the answer, but many feel it is simply unacceptable to say, ‘I don’t know.’”

Another problem is some physicians’ inability to tolerate silence. “They’re like radio announcers,” Banja said. “They believe they have to fill up the room with talk, and they often don’t pay much attention to whether the patient is listening or not.”

Most difficult, Banja said, is the disclosure of death and being prepared to handle family responses, which can range from utter bewilderment to inconsolable grief to uncontrollable rage.

Banja said one key to delivering such news artfully is to practice, like the role-playing he and hired actors will do in a research project designed for emergency room residents by Tammie Quest, assistant professor for emergency medicine.

In an upcoming seminar, residents will participate in didactic, small-group roleplaying using “standardized patients”—actors who are given particular “survivor” roles to play and told to react with various strong emotions. The project is funded through a University Teaching Fund grant Quest received last fall.

“I remember when I had my first patient die, and there was a family to go talk to,” said Quest, who stumbled through that initial meeting with help from her attending physician. “When you have one patient die, your second patient is the survivor sitting in the family room. Until you are faced with telling a survivor for the first time, you may have had little or not training in this area.”

To help with the project, Quest has assembled an interdisciplinary team that includes Banja, Alan Otsuki (medicine), Sheryl Heron (emergency medicine), Nadine Kaslow (psychiatry), Robert Morris (pastoral care), Donna Arena (Renaissance Project on Death, Dying and Donation) and Kathy Hall-Boyer, emergency medicine). Funding allows for 16 of the 48 emergency medicine residents to participate in the project, in which they will be evaluated by observing faculty members.

“The real meaning of empathy,” Banja said, “is not feeling what the patient feels, but being able to [demonstrate] that you understand what he or she is experiencing. So when a patient appears distressed or sad, the empathic response might simply be, ‘This must be very distressing for you.’”

Word choice, tone of voice, speed of communication and body language can make all the difference, he said. Banja believes that telling family members that their loved one “has died” is better than using the phrase “he’s dead,” because the former implies that this is something the loved one did, not something that occurred because of what the family or the health staff might have done.

“Physicians who deal most poorly with emotionally uncomfortable conversations commit three cardinal errors,” Banja said. “They stand when they should sit; they speak ‘medical-ese’ instead of ordinary English; and they don’t stop talking, probably because they feel anxious, and their monopolizing the conversation helps them feel they’re in control.”

Alan Platt, a physician’s assistant at Grady Hospital and part-time faculty member, teaches a course on empathic listening, interviewing and history taking. He pointed out that managed care has made time with patients more hurried than ever.

He said making clients feel important is more challenging than might at first be apparent.

“The art of medicine is making patients feel like they are the most important persons at that very moment,” Platt said. “When you deliver news like that, a patient wants to feel he has your undivided attention, and most importantly, that you care.”