Breaking Bad News

Dr. Heiko Jessen, at his family practice in Berlin

In an exam room in his modern clinic in Berlin, Dr. Heiko Jessen takes his patient?s hand; ?I don?t have good news for you? he begins, giving what he calls a warning shot before delivering the bad news. He looks into the young man?s eyes, ?Your HIV test came back positive.? The patient, Joseph, a twenty-three year old American living in Germany, asks a few questions and then breaks down in tears. Jessen rubs his back, his quiet embrace giving him space for the larger emotional release.

The doctor patient relationship is a unique one, a precarious balance of trust and influence. Physicians must ultimately find a compassionate way to give their patients difficult news. Yet, this is not so easy. A study published in February found that physicians struggle with honesty, with over half admitting that they?ve been inappropriately optimistic when diagnosing their patients. Physicians have difficulty giving their patients the open, honest dialogue they need.

To address this, medical schools are adding courses in patient communication. Two decades ago, only a minority of schools taught communication skills, today, almost all of them do, including mock-patient workshops, where students can directly test their ability to talk with patients about complicated issues. One of the first of these courses was at Humboldt University in Berlin, Germany. This course, termed ?breaking bad news,? started in 2000 as a tiny group of only six students practicing role-playing. A decade later, the course has become a mandatory part of the curriculum and a model for physician communication classes worldwide.

Jessen, who has wide experience in giving poor diagnoses, has been part of the ?breaking bad news? course since the beginning. He teaches an especially popular session, where he brings in patients with whom he has had to make particularly difficult diagnoses, allowing students to directly speak to the patient. These conversations get to the heart of which parts of the diagnosis are most difficult for patients and what communication tactics are ultimately effective.

This evening, Jessen has brought Joseph, the young American man he diagnosed as HIV positive, seven years earlier. The setting is intimate, ten students gather about Jessen and his patient. The atmosphere is casual as Joseph begins to tell his story, the students gradually warming up, asking questions. Jessen is there to direct the course but mostly he lets the patient speak, preferring the informal nature of the session. To his surprise, Joseph becomes emotional. Although it has been almost a decade since his diagnosis, the patient begins to break down in front of the class, tears mixing into his difficult story and his memory of what it was like to be told he was HIV positive.

He met Jessen when he was just twenty years old at a club in Berlin. Like many of Jessen?s patients, their relationship encompasses trust and friendship, a bond that makes the difficult business of breaking bad news easier for the patient. In fact, Jessen argues that getting a difficult diagnosis is far easier from a family doctor, a person who has built a relationship with their patient and will be there for the long run, rather than a specialist.

Studies indicate that empathy plays a significant role in the clinical outcome for patients, further underlining the importance of the patient-doctor relationship. Physicians have a connection with their patients unlike any other profession. Doctors touch their patients, both physically laying hands on their heart and head, but also emotionally, representing a safe place to speak about hidden fears. A poor diagnosis involves intricate communication skills: the ability to explain as well as listen, to lead the patient into complex decision-making, and to involve those people the patient is closest to. Predictably, physicians trained in these communication skills are far less likely to suffer from ?burn-out? and psychiatric distress.

As Joseph speaks to the medical students he realizes that he has not entirely accepted his own difficult diagnosis. Despite the support and resources he?s received, the difficulty of his disease still weighs on him. Bad news may forever change the doctor-patient relationship but, at its core, giving patients the honesty and empathy they need is as critical to a diagnosis as any PCR test.

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