By Jennifer Jabaley
August 2, 2017
Informing patients that they have a sight-threatening eye disease like macular degeneration can be painful for both doctor and patient. Taking the time to think about your approach to this challenging conversation, and how you can best help the patient, will help you become a better doctor and grow your practice. After all, what patient wants to return for treatment to a doctor who didn’t treat them with sensitivity during a trying time?
Recently, I had a new patient with the complaint of sudden blurry vision in one eye. On initial evaluation, the macular region was swollen, and I assumed central serous chorioretinopathy. However, once she was dilated, I found a large elevated mass in the peripheral retina which appeared to be a melanoma. If the central retina was swollen, and the patient confirmed she had been seeing flashes of light, I assumed the mass was growing and splitting the retinal layers. I had a discussion with the patient, and set her up for a referral with our retinal specialist.
Two days later, I found out that the patient had not shown up for her consultation. The staff at the retinal specialist called the patient to reschedule, but the patient seemed unconcerned and refused to make another appointment.
I called my patient at home, and told her I was concerned that she had missed her appointment. I stressed the importance of the referral. She admitted that she had cancer in the past, and had not disclosed that information to me. She didn’t want to think that it could have metastasized to her eye. She admitted she was avoiding the diagnosis. The next day she called the specialist and was seen immediately.
Few studies have sampled patients on their opinions about hearing unfavorable medical information. However, there is a protocol developed by Walter F. Baile, MD, an oncologist at MD Anderson, and the late Robert A. Buckman, MD, Ph.D., formerly an oncologist at Toronto-Sunnybrook Regional Cancer center. Referred to by the acronym, “SPIKES,” the protocol gives a systematic strategy for delivering bad news. Here is how that system works:
Step 1: SETTING. Choose a Private Setting
It is important to choose the proper setting for delivery of bad news. Use an exam room, or a private office that offers uninterrupted privacy, and gives the patient an opportunity to freely ask questions. Sit down to relax the patient and show them you will not rush the discussion. Maintain eye contact to establish rapport. And offer silence as a way to allow the patient to digest the information and ask questions.
Step 2: PERCEPTION. Evaluate the Patient’s Perception
Find out how the patient perceives the news. This can help determine if the patient is in denial or has unrealistic expectations. Some patients may have grand misunderstandings about a diagnosis. For example, they may think if they are told they have macular degeneration, that they will definitely go blind. Using open-ended questions can help guide you to understand your patient’s knowledge. For example: “What is your understanding of macular degeneration? Do you know anyone who has had this disease?”
Step 3: INVITATION. Ask before you tell.
This is the moment in the discussion when, if the patient wants more information, they will express a desire to know. Most patients do want to know everything, but they will be eased that you had the courtesy to ask before you unloaded information. This is also the time where you may ask if your patient has a family member in the waiting room that they would like to be present for the discussion.
Step 4: KNOWLEDGE. Put it in layman’s terms.
This is when the optometrist imparts their knowledge of the diagnosis, treatment plan and prognosis. Be sure to use layman’s terms. It is a good idea to break the discussion into small, digestible chunks and ask, “does that make sense?” before you proceed.
Step 5: EMOTIONS. Observe and respond to the patient’s emotions.
Acknowledging the patient’s emotions is what distinguishes a sensitive listener from an insensitive one. Bad news is situational. An elder patient being told they have glaucoma might not be as distraught as a younger person learning that they need bifocals. Being empathetic, and offering support to all emotions in all situations, is a skill that will comfort the patient.
Step 6: STRATEGY AND SUMMARY. Help them retain information and make a decision.
Patients who have a clear plan are less likely to feel anxious. Often, patients like to be included in their decision-making. Having a dialogue like, “I’d like a 30 percent reduction in your eye pressure. I’ve calculated a target pressure of 12. Does that sound good to you?” makes the patient feel like they are involved in the treatment plan.
Clinicians are often uncomfortable when they must discuss unfavorable diagnoses. Having these difficult discussions can be facilitated by using this six-step strategy in the exam room.
Even experienced clinicians would benefit from reviewing this well-developed, organized protocol for delivering bad news so that there is no chance for miscommunication, denial or lack of compliance.
How do you deliver difficult news to patients? Do you have a structured approach? Do you have to consciously try to remember to be sensitive, empathetic and patient, or does it just come naturally to you?