The Financial Implications of Delivering Bad News

Rene Mayo, MSW, LSWA, has been working with physicians in training for nearly 20 years. As a leader in MedStar Health’s palliative care program, she has seen—and national and local surveys concur—the need for further training among medical resident physicians in communicating difficult topics with patients and their families.

It’s a need, Mayo says, has been overlooked for a long time.

“There’s an assumption in the scientific body of medicine that this is innate; that people should naturally know how to communicate well,” Mayo says. “And so, it has never been considered something that physicians should waste their medical school time studying.”

But we all know what happens when we assume. And as more training initiatives similar to the one conducted by MedStar Health appear, it’s clear that assumption, and its impact on physicians, patients, and their families, is no longer being taken for granted.

Overcoming Assumptions

Mayo explains that overcoming assumptions can be the biggest challenges in training medical resident physicians—or practicing physicians, for that matter. There are also many practicing physicians among the 1,000 clinicians she’s trained.

“They assume everyone understands the language they use,” she says. “So although they may be able to communicate in the scientific language that they’re used to, they aren’t used to (explaining things in) laymen’s terms at all. And they don’t know how to break it down for people.”

A 2-fold challenge Mayo has to overcome is getting physicians to understand that communication is a skill that can be learned, and that the physicians don’t necessarily have the skill.

“You’re talking about a group of professionals who are among the best and the brightest people you can find,” she says. “And for them to have someone tell them that they aren’t good at this isn’t going to work.”

Mayo designed the training so that it starts with one of the residents and a group of their peers engaging in a standardized patient/family meeting, which is recorded on video.

“Usually the person who thinks they’re the best volunteers first to go in and sit with the standardized patient and do a case,” Mayo says. “The rest of the class watches them do the simulated family meeting, and the realize they’re not very good at it. They know it, and everyone else knows it, and then you’ve got a ripe audience. So, you can’t just tell them that they’re not good at it, or that there’s room for improvement … they need to see it for themselves.”

A Recognized Problem

MedStar Health isn’t alone in the work it’s doing. Debbie Field, associate vice president for public affairs explains that the Texas A&M Health Science Center College of Medicine has put a program in place to help better prepare future physicians to compassionately and clearly deliver a terminal diagnosis.

According to a 2-part article in Vital Record, the College of Medicine’s newsletter, Dr. Steven Moore instructs medical students not to use euphemisms in their communication with patients and their families.

“Someone has died,” he explains to students. “We also need to be culturally sensitive. Not everyone who comes into the hospital and dies is Judeo-Christian. Euphemisms like ‘passed on’ presume a certain range of beliefs and comforts. Don’t make assumptions.”

Giving medical students confidence is key, says Mayo. They may have the knowledge, they may even have the skill, but if they’re not confident enough to sit down with a family and respond to their emotional needs, nothing else matters.

Multiple Impacts

The inability to deliver bad news to patients and their families can negatively impact physicians physically, emotionally, and financially. For example, Mayo explains that, over time, when physicians are unable to communicate or share an emotional response with a patient, a disconnect develops and contributes to burnout.

“You can’t ignore patients and families indefinitely and think that’s not going to have some kind of impact on you,” Mayo explains.

But that’s not how physicians have been trained, as evidenced by these pre-simulation comments by medical students Mayo shares:

“Talking to families of very sick and dying patients is so different than what I learned in medical school. No one ever said how hard it would be.”

I’m a physician. I was trained to remain detached from the emotional issues of patients and families. It feels impossible, and I am not sure it is right.”

And there’s a financial impact. Mayo says that sometimes, even after the simulations and feedback, there are outliers who still don’t believe being able to have difficult conversations is important. So she explains that some of the students will end up in private practice, and patients, as their customers, will choose to come to them. If the physician is unable to communicate, unable to have what patients consider a fair and trusting bedside manner, they’ll go elsewhere.

“If I can help these physicians see that their poor communication skills will impact the bottom line financially, then a percentage of them will listen,” she says. “They tune in, because they want to have a financially successful and sustainable practice.”