COMMUNICATING DIFFICULT NEWS

In the medical literature, it has been extensively documented that improved provider communication results in increased provider-patient satisfaction with treatment.

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by Helen Meldrum

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In the medical literature, it has been extensively documented that improved provider communication results in increased provider-patient satisfaction with treatment. This communication enhances patients’ ability to participate in treatment plans. However, medical practitioners report that they have a very hard time talking with patients whose treatments involve a high probability of serious consequences. Attempts to collaborate with patients in these situations often go badly because the conversation about treatment is often conducted simultaneously with serious, diagnostic information. In these cases, patients learn that significant medical intervention is warranted.

Similarly, in the dental setting, hygienists must share “bad news” with patients. Although the dentist provides the diagnosis, hygienists must often alert patients that treatment beyond routine or preventive care is warranted. For example, the hygienist may notice a lesion that looks cancerous. The hygienist may be the first to note bone loss or decay under a new restoration. As patients catch on that something out of the ordinary is going on, their anxiety level shoots sky high. Whether or not the treatment relationship becomes emotionally charged often depends on whether the patient understands the medical reality. Empathic acknowledgment is the most important communication skill the dental team needs when breaking bad news and discussing treatment options that are likely to involve a serious outcome.

Insulation from feelings

What is empathic acknowledgement, and why is it essential?

In cases involving a serious condition, hygienists often worry they will open a Pandora’s box if they encourage patients to express concerns. However, if hygienists lack empathy, patients may feel they’re not interested or scared by the discussion. Neither response inspires confidence. Research links empathic communication to patient satisfaction, improved diagnostic assessment, less litigation, and better outcomes.

It is essential for the patient to feel honored and heard, especially when he or she is facing a high probability of severe effects. These patients are likely to feel alone in their fears if the dental staff around them is being so “professional” that they have insulated themselves from the patient’s pain.

Sometimes “the professional demeanor” unconsciously protects the hygienist from his or her own discomfort. Unfortunately, it also serves to prevent genuine communication with the patient. Every professional has heard, “Don’t let it get to you,” or something similar from mentors and colleagues. On some level, this advice could be translated into, “Don’t have feelings about the patient.” Without empathy, which includes effective paraphrasing (summarizing the patient’s thoughts and feelings in fresh words), providers often feel like “sitting ducks in a shooting gallery” blown away by their patients’ reactions with no clue about what to do except “stay calm and professional.”

It is clear that hygienists often feel terribly inept in these situations. In my classroom at the Forsyth School for Dental Hygiene, I have observed and role-played many cases in which students unwittingly added to the pain of patients because they lacked empathy.

Here are some factors that contribute to problem communication in these situations:

• The hygienist’s desire to insulate him or herself. Those who work in helping and healing roles hate being the messengers of pain. But since patients must be competent to make decisions, dental providers cannot give any drug to minimize the effect of bad news.

• The hygienist’s feelings of therapeutic impotence. Some patients may think they’re being treated to save a tooth when, in fact, they are being treated for a failed root canal. Dental professionals often fear personal failure in these situations, and unconsciously begin to talk less to the patient so they don’t have to admit that they don’t know what else to do.

• The hygienist’s lack of specific skills training. Many hygienists have no training in basic counseling and communication skills. They often fear that they won’t know what to do if the patient has a deeply emotional reaction. “I’m sorry,” sounds empty and inadequate in the face of such intense feelings.

• The hygienist’s failure to elicit what the patient already knows. Asking simple questions such as “How do you feel about how you are doing?” will enable the provider to assess the patient’s understanding and provide clues about his or her feelings regarding the dental condition.

• The patient “backlash factor.” Patients may feel that their problem is simply part of the professional’s daily duties, and may resent that the interaction is not a deeply felt experience for the dental staff.

• The hygienist’s failure to consider the social impact on the patient. Patients who are seriously ill with something such as oral cancer lose power and prestige in society even if the disease is not immediately life threatening. While processing their loss, patients go through stages similar to those described by Dr. Kubler-Ross (denial, anger, bargaining, depression, and acceptance).

• The physical setting for conversation may be problematic. Discussion of news of this magnitude should take place during a private, face-to-face encounter where other patients cannot hear and the dental professional can assess the reaction. If relatives or friends are present, the patient should decide who else may take part in the discussion of treatment options.

• Overlooking the patient’s needs for control over information. Asking “Would you like me to give you the full details of your options for dental treatments now or later?” allows the patient to signal his or her needs at the moment.

• Missing the disease’s and proposed treatment’s idiosyncratic impact on the patient. What if your patient is a professional musician who plays a wind instrument and must keep his mouth in good shape? To these patients, the treatment plan threatens their self-esteem more than it promises benefits. Providers should ask themselves if what is at risk is integral to the patient’s sense of occupation or self.

The security of a little conversation

Empathy from the provider helps patients feel secure discussing their concerns. When trust is established, patients are more likely to reveal clinically relevant data. The way in which empathic response fosters communication has been studied by a number of researchers, first and foremost by psychologist Carl Rogers.

Rogers presented three conditions necessary for the maintenance of mental health:

• Congruence: people do not feel the need to cultivate a protective facade

• Unconditional positive regard: people feel warmth, interest, respect, and liking from their providers

• Non-judgmental understanding: people get the most benefit when they can share their perceptions, which will be accepted as valid without feedback that communicates approval or disapproval.

Because most of us experience a shortage of these conditions in our lives, we become socialized to express our feelings indirectly. Indirect messages are hard to decode, and the listener’s interpretation of the speaker’s message generally goes unspoken. Indirect communication is one reason why needs and expectations often go unmet.

The indirect expression of concerns is often done through patients’ questions about medication use. For example, patients may present secondary concerns (“What if I forget to take the antibiotic?”) despite the presence of a more primary worry (“What if the treatment will give me worse problems with my heart?”).

Presenting peripheral concerns may “test” the hygienist. If she launches into a lecture about how to remember to take the medicine, she is missing the deeper concern. With this response, the patient may be afraid to ask if the medicine will cause illness. Such a question could be interpreted as an insult to the hygienist. Empathic mirroring (attempting to paraphrase the patient’s thoughts and feelings) reduces the emotional charge during patient education. With the emotional charge decreased, the patient can respond more thoughtfully.

Paradoxically, learning about empathy begins by defining what empathy is not. Think about typical statements that patients might blurt out, like “What do you mean I should have taken an antibiotic already? I need to get this done! I can’t come back another day! I’ll be fine!” Typically the dental staff will respond with something like, “You should know this procedure by now” (judging), “You would do better if you marked a reminder on your calendar” (advising), “What makes you say that?” (quizzing), or “Don’t worry, we are giving you the very best care possible” (placating).

Hygienists very seldom address the real fears behind the patient’s “demanding behavior.” “Sounds like you’re concerned about this treatment” would be a good empathic opener. Patients who are upset may need three or more cycles of empathy to get to the point where information can be exchanged.

The patient’s needs, perceptions, and concerns need to be addressed. It is important to remember that skills in empathy do not necessarily come naturally. Empowerment of patients is more likely if they can express their feelings in an atmosphere of acceptance. If more hygienists learn the skill of empathic response, there should be fewer psychologically painful counseling sessions, and patients may retain more information when not preoccupied with strong emotions. Hygienists can influence patients in positive ways and increase patient satisfaction through the use of this type of active listening.

Helen Meldrum is an associate professor of psychology and communication at the Massachusetts College of Pharmacy and Health Sciences, where she teaches the required Interpersonal Skills for The Health Professions course to the students of the Forsyth School of Dental Hygiene. She wishes to thank Bella Vasherstein, RDH, BS, for her insights on the topic of this article. hmeldrum@mcphs.edu.

References
For additional reading on empathy, see:
• Coulehan,J., Platt, F., Egener, B., Frankel, R., Chen-Tan, L., Lown, B., Salazar, W., “Let Me See If I Have This Right....Words That Help Build Empathy,” Annals of Internal Medicine. Vol. 135 Issue 3, August 2001.
• Lynch, J “A Lesson in Empathy: Among All The Things We Do, What Our Patients Are Most Likely To Remember Is Our Compassion” Saturday Evening Post, Vol. 274 Jan-Feb. 2002.
• Meldrum, H. & Hardy, M. Provider-Patient Partnerships. Boston: Butterworth-Heinneman, 2001.
• Rogers, C. On Becoming A Person. Boston: Houghton Mifflin, 1961.
• Wright, R. Tough Questions, Great Answers: Responding to Patient Concerns about Today's Dentistry. Chicago: Zuintessence Books, 1997.

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