PA profession

How to Get Better at Delivering Bad News as a New Provider, Phase 1

When considering a career in medicine, most people think about the positive impact they could have. You might imagine how you'll help to ease someone's pain, discover an elusive diagnosis, or intervene at the exact right moment to save a life.

Though training to become a physician assistant will make this future vision a bit more realistic, most of it's focused on the ensuring that you acquire the technical skills and knowledge necessary to provide preventative care, identify conditions, and treat illnesses.

Far less time is spent on training future providers in the relational aspects of practicing medicine. And for good reason.

PA training is compact. There's a ton to learn in a short time frame. PA programs work to fill their classes with students who they believe, along with having the academic ability to be successful, have the relational skills to be a great provider.

The job of a program is then to deliver the medical training needed to help you become a competent clinician. And, hopefully, along the way, your foundational communication skills and maturity will help you to learn additional soft skills from other providers that will be an asset as a new PA.

But, even if you get some training and exposure to giving bad news as part of your PA training, it won't be enough for you to be confident in your ability to navigate these difficult conversations from the outset.

Some clinicians have been practicing for decades and still aren't comfortable with giving bad news. And, if you remain uncomfortable, you’ll inevitably find ways to avoid these vital discussions or miss out on opportunities to better serve your patients.

Delivering disappointing results to a patient isn't easy. In a profession focused on saving lives and stamping out disease, having bad news to share can feel like you're personally failing a patient.

Your training might instill confidence in your ability to work up a set of concerning symptoms, but once you suspect or land on a troubling diagnosis, you may feel woefully unprepared to deliver the news to your patient.

But, it's in these moments when patients are facing potentially distressing information that they need you and your guidance the most.

While these situations may not be the reasons you initially entered medicine, they'll likely be some of the most fulfilling — but only if you're willing to get uncomfortable for the sake of your patients.

It will take time. And it will take a lot of practice. But if you're in, you can start working on these skills even as a brand new PA.

Easing in with the technical aspects

It's normal to have anxiety over delivering bad news to a patient. That feeling is a mix of apprehension over whether you'll do a good job of telling them and empathy over what they're facing.

As someone with a deep history in treating cancer patients, I can tell you that feeling doesn't ever go completely away. But, that sensation will become more familiar over time as you gain experience with sharing disappointing information with patients.

This reality might seem a touch depressing, but being able to navigate these conversations compassionately is a skill that patients will value.

And, working to lessen the tension that patients may feel in these scenarios will help them to be more receptive to the information you're about to share and more comfortable with your ability to act as their guide.

Actions that can work to ease the anxiety of patients can also help to mitigate yours. You can start with the basics that you're probably using in other situations already: be sitting down when you speak with patients, maintain eye contact and your focus on the conversation, and eliminate medical jargon from the discussion.

How to Deliver Bad News to Patients as a New PAlBe a Physician Assistant

These may seem obvious, but they're not to be overlooked, especially that last one. When we feel nervous or insecure in our ability to do something, some of us go into ultra-professional mode.

Maybe you get deadpan serious during job interviews, even when that's not your personality. Or when you write important emails, you use vocabulary and formalities that could easily be mistaken for something written by a quill and ink well.

The new-PA version of this is using all of the technical language and terminology you learned in your training to prove you know what you're speaking about. Talk of obstructed biliary ducts, new left lower lobe nodules, or a positive ANA test will not help to ease the anxiety of your patient.

Instead, use super plain language. Pretend your explaining things to your great aunt or your 12-year-old neighbor. "Positive" and "negative" in the medical realm have very different meanings compared to the rest of the world, and that terminology alone can make a patient's head spin.

Making it easy for your patient to understand is the goal. When they don't have to work to interpret what you're saying, they can concentrate on the information you're sharing and ask the questions they want and need answers to.

Use your patient-provider relationship to guide the format

If you were hoping for a bad-news-telling structure that can be used for every patient, every time, well, I've got some bad news for you.

However, some incredibly helpful general approaches can be implemented, which can be adapted based on your current relationship with a patient. The dynamic of your patient-provider relationship should be the driving force for how you format your discussion.

1lIf you're meeting a patient for the very first time and they're looking for a second opinion on a known condition, explore what they know first.

Early in my career, there were a few instances where I launched into what I thought was a great discussion with a patient, assuming they already knew that they couldn't have surgery or that their cancer was incurable. But sometimes, even after years of prior treatment, this came as news to them. Feeling as if I hit them in the gut, I'd be left to back peddle, never really regaining my full confidence in the discussion nor their trust.

As brand new providers, we might be so anxious to prove our ability that we end up doing far more talking than we should, especially on the front-end of an encounter.

Those early lessons taught me that regardless of a patient's education level, prior treatment, or story their records might tell, you can't be sure what their knowledge or perception of their condition is without asking.

So, for these kinds of interactions, first, find out what a patient knows. Ask what their understanding of their condition is and what treatment options have been discussed previously.

If you're worried they'll think you're coming in unprepared, you can say that you thoroughly reviewed their records but would like to get their take on things. (My go-to approach after learning this lesson the hard way.)

2lFor patients with whom you have an established relationship, develop a routine for how you'll approach potential bad-news situations.

If you're ordering outpatient testing to evaluate a new breast mass or suspected Lyme disease, schedule a follow-up visit to discuss the results as you order the testing. Or ask in advance if the patient would like a visit or a call to discuss the results if you, as a provider, don't have a preference.

A patient can then have the chance to plan if they’ll like a friend or family member to accompany them to the visit or, in some cases, decide if they want someone else to field your call.

But, do not tell a patient you'll call with the results, get the bad results, and then ask your staff to set up a visit for the patient so you can give the bad news in person.

Patients are wise to you if you do this, and even if it's less than a 24-hour wait, you've created unnecessary anxiety and increased the pressure on the eventual visit.

Instead, make a plan for how you’ll deliver potential bad-news results from the outset, and you can avoid adding extra stress to the situation for your patients.

3lFor established patients who will definitely be receiving results at a visit, feel free to break from your routine sequence.

When you're a brand new provider, the format of your patient visits often looks like a clinic note — history first, then exam, followed by diagnostic testing, and then a plan.

But for patients who are coming in primarily to receive testing results, this sequence can feel excruciating.

They know they had a colonoscopy, biopsy, or blood work and are there for the results. If you're not giving them the results and, instead, are focusing on further discussion of their symptoms, they'll feel like you're avoiding the discussion.

And they may presume you're avoiding it because what you have to share is really bad, even if it's not.

Nothing dictates that you have to run a results-oriented visit like any other clinic visit. You can create a format unique to these kinds of discussions.

In my practice with cancer patients, I'd swap the order of the visit when patients were getting significant results — like CT scans. Within moments of starting these visits, we would discuss the status of their cancer and often look at the CT images together. We'd eventually get to how they were feeling and any changes that occurred since their previous visit.

But having the results first meant that patients weren't distracted when we eventually got to talking about the details of their symptoms or their treatment schedule.

Good or bad, the relief of knowing usually led to a more engaging visit.

It can feel a little disruptive to break from your routine as an early career PA, especially as you're still getting the rhythm down.

However, think of a results-oriented meeting as a different category of visit. You can still have an organized, structured interaction that helps you feel as if you're steering the things in the right direction, but the format doesn't have to be modeled the same as a routine physical or daily hospital rounds.

Consider what would be a patient-centered approach and what works for your practice and develop a replicable process. Having a structure to rely on will help you to feel as if you have your bearings during difficult conversations and allow you to get more comfortable over time with these kinds of interactions.

That was a lot — and we haven’t even given bad news yet. But, preparation is key to feeling more confident in difficult conversations, and you’ll need all of it to be ready for what’s coming in Phase 2.

Next week, we'll be getting into the act of delivering bad news, what new-provider pitfalls to avoid, and how to quickly increase your effectiveness during difficult conversations.

Until then, I hope you’ll join us in the Be a PA Community as we dive a little deeper into this topic in the weekly blog bonus video, which you’ll only find inside the group.