April 23, 2001
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 doesnt jeopardize their relationship
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, theyll
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 ones death to family members,
to delivering a poor prognosis.
Its easy to work with patients when you like them, when they
like you and the treatment is going well, Banja said. But
its hard when you dont particularly like them, they dont
like you and treatment is going nowhere.
Its interesting how insecure many health care providers are
about themselves, he continued. For example, even if they
dont fully understand a question or dont fully know the answer,
many believe they have to appear authoritative in offering some sort of
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 dont know.
Another problem is some physicians inability to tolerate silence.
Theyre like radio announcers, Banja said. They
believe they have to fill up the room with talk, and they often dont
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
In an upcoming seminar, residents will participate in didactic, small-group
roleplaying using standardized patientsactors 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
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 hes 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 dont stop talking, probably because
they feel anxious, and their monopolizing the conversation helps them
feel theyre in control.
Alan Platt, a physicians 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.