Learning how to deliver disappointing news to patients and getting comfortable with doing it are two different things.
But, the space between them can be bridged by small actions that help you move from theory to practice and, eventually, help to make you into a pretty good bad-news deliverer.
Last week, we covered the logistics of how to prepare for difficult conversations. This element is not to be overlooked as it will lay the foundation for what comes next. So, if you missed it, be sure to double back and check out phase 1.
But, this week, we're moving past the planning stages and laying out the exact steps you can take as an early career PA to build the communication muscles that will help you to guide your patients through the tough times.
Watch others at work
Hands down, the best way to learn how to give bad news well is to watch how others do it. There are subtleties in these patient-provider interactions — quiet pauses, the phrasing of words, the use of body language — that can only truly be appreciated by seeing them in action.
Witnessing how another provider approaches these difficult conversations is invaluable.
Not only will it give you confidence that you, too, can adopt the same techniques to facilitate successful interactions, but you can essentially appropriate someone else's methods while you work to develop your own style.
So, ask other providers if you can come along to observe any tough discussions. As a new PA, asking this may feel a little strange; you might feel pressured to already know how to handle these situations.
However, consider that you just spent the last two or so years as a constant creeper. When you were a student, it wasn't weird at all for you to tag along with your preceptor to a patient encounter. By now, you're surely accustomed to awkwardly hanging out in the corner as an interaction takes place.
So, if you want to improve your ability to navigate challenging conversations, be willing to let this dynamic play out a little longer. If you've chosen your first PA position well, you'll be in an environment where other providers are happy to mentor you in this area.
And, if you're still currently in your PA training, jump at opportunities to listen in on these discussions to start building these skills early.
The act of delivering the news
Despite the anxiety you may feel over having to deliver bad news to a patient, it should come as some relief that patients generally want the truth.
Even when what they’re facing is scary, the vast majority of patients want full disclosure — details of the diagnosis, expected prognosis, and potential treatment options.
But, not everyone does. And some people will eventually want the full details but will need a little time to process.
If you've planned for a results-focused encounter (as in phase 1) and asked a patient to bring along a friend or family member to their appointment, this additional person may want more or less information than your patient.
So, it's essential to set a framework early in the discussion and determine the goals of your patient. The lead-up to the bad news will depend on your current patient-provider relationship, as outlined in phase 1.
But, after accounting for the differences in how familiar you might be with a patient, the act of sharing the information can follow a similar format.
1ｌTell the truth in plain language and with compassion.
We've covered the importance of using patient-friendly language while mapping out the logistics of delivering bad news, but keeping it in mind as you embark on providing the information is vital.
You don't need to go deep just yet. Once a patient hears the bad news, it will take a little time to process, so keep it simple — a sentence or two will do.
"Unfortunately, the biopsy showed that the mass is cancer."
"Your blood work indicates that your kidney function is getting worse."
"It seems the treatment is no longer working, and we have to consider other options."
In addition, work to add compassion to your delivery.
When we're a little unsure of ourselves and exploring new territory as a provider, sometimes we mistake the appearance of emotionlessness for professionalism. As a new PA, you might feel compelled to exhibit your "professional boundaries."
But having and showing compassion is not unprofessional. You can incorporate compassion professionally as part of the conversation.
"I'm sorry I don't have better news to share with you."
"I wish I could tell you that the treatment was more successful."
"I know you've worked really hard to have a better outcome than this."
Your patients want to be cared for by people they believe care about them. There's no weakness or unprofessionalism in showing empathy for what your patient is facing.
2ｌ Let the bad news linger.
Once you're over the hump of the first couple of sentences that share the unfortunate news and show compassion, take a pause.
This part is extraordinarily difficult as a new PA.
Before going in to chat with the patient, you probably conferred with colleagues about treatment options. To feel prepared, you likely researched what follow up tests might be likely or recruited the help of a specialist who can guide the next steps.
But, instead of sharing additional information, try to be quiet for a few beats.
There's a power in intentionally adding silence to a patient encounter. In this space, a patient will feel welcomed to ask the many questions that are bubbling up in their mind.
As a new PA who might be concerned about your ability to field all of these potential questions, this prospect can be a little intimidating. But, you don't have to have all of the answers yet.
When patients have this space, they'll begin to guide you on how much they want to know about the diagnosis, prognosis, and treatment options.
As an early career PA, I often assumed everyone would want to know everything, just as I would — until I'd catch a few patients looking away as I pulled up their CT images on a screen. Just because I'd want to see representations of my innards didn’t mean everyone else did, and it took practice to break the habit of immediately overloading my patients with information.
Pausing after delivering bad news will help to control your urge to divulge more than a patient wants.
When you give them space to ask some questions, you'll have a better sense of what a patient is looking to learn and can naturally guide the discussion to asking how much they'd like to know.
If you get questions that you can't yet answer, tell a patient that you'll follow up on them or run their concerns by another team member. It's okay not to have all of the answers, but the goal is for your patients to feel the freedom to ask any question.
3ｌ Control your instinct for optimism.
Next to being silent after a bad-news delivery, reining in your instinct for misplaced optimism is a serious struggle as a new PA.
It can feel like a knee jerk reaction to tell a patient that "it will be okay" or about your other patient who, against all the odds, overcame what was thought to be a terminal diagnosis.
Let me be clear: it is not your job to take away all hope from a patient. You should never do that. In no universe should you ever utter something about "getting your affairs in order." That does nothing to help a patient in a meaningful way.
But, it is your job to be truthful and realistic while providing as much information as a patient wants. As a new PA, this might mean that you have to let someone else finish these conversations, at least for a while.
The instinct to please patients is a strong one. You'll want them to like you and feel terrible about disappointing them, even when it's not at all your fault. But, it's better to acknowledge your limits than to lead a patient astray.
So, start getting comfortable with these conversations by doing the early parts — deliver the news, leave room for questions, and answer what you can. Have a plan for coming back as a team (ideally, during the same visit) with your collaborating physician to go deeper, which will allow you to learn additional techniques for responding to the more difficult questions.
Balancing the truth while allowing room hope is a delicate one. But, with practice and experience, you'll be able to feel the distinction between compassion and misguided optimism to ensure you are serving your patients well.
Build a safety net
After receiving bad news, patients can feel adrift as they wait for testing to be scheduled or for an appointment with a specialist to be arranged.
So, consider what arrangements you could make to help them feel like they have a built-in safety net.
If they're hospitalized, this is likely already in place. You can recruit the oncology, neurology, or surgery team for input, and they'll get answers quickly.
However, if you're in the outpatient setting, you can create a "home base" for a patient so that they don't feel untethered after receiving challenging news.
If you're referring a patient out to a specialist, set up a follow-up visit as a touch point. You can tell a patient they are welcome to cancel it down the road, but that you want to make sure you have the time dedicated for further discussion if needed.
If you are the specialist and delivering bad news on a first visit, set a follow-up visit for a more in-depth discussion for after the mental fog clears. If a patient is hearing difficult news for the first time, they're likely to come up with many more questions once they have time to gather their thoughts.
If logistics makes these plans difficult, do your best to ensure that a patient has a familiar touch down point. If they're coming for a second opinion, be sure they have a visit with an established provider to follow up. If they're established with you, be the one to have that follow up appointment or call in place, even if their diagnosis is out of your wheelhouse.
Knowing that they have a visit with someone they know in the immediate future will provide some level of reassurance to the patient, even if the overall plan is still being determined.
Allow yourself to do an okay job
As you get more comfortable with giving bad news, some amazing things will happen.
Patients who receive awful news will thank you for being honest with them. Others will say they're sorry for you for having to be the one to deliver the results. (Honestly, people can be just incredible.)
One day, you'll be glad to give someone bad news — not because you want to deliver bad news, the bad news was coming with or without you. At least by giving it yourself, you'll be sure a patient was told in the best way possible.
But, all of this is only feasible if you let yourself be just okay to start. I know, ideally, you'd be fantastic from the get-go. That's how I like to approach all things too.
However, just like taking blood pressures, learning suture knots, or conducting a routine physical, building the new skill of guiding difficult conversations will take time and hands-on practice.
If you hope to get better at delivering bad news, you have to be willing to be mediocre at it to start. You have to avoid the temptation to consistently let someone else who's "more qualified" or "more experienced" take the lead.
By engaging before you’re an expert, you can be an incredible support and resource for your patients in times of their greatest need.
Becoming great at delivering bad news doesn't require an incredible level of intelligence or endless studying, just a readiness to be very uncomfortable for a while and a desire to get incrementally better for the good of those you serve.