Dreaded conversations: moving beyond discomfort in patient-physician communication.

Sensitive, respectful, and clear communication is one of the cornerstones of good medical care. In this issue of JGIM, papers by Bell et al.1 and Golin et al.2 provide further evidence of why good communication is necessary. Bell et al.1 reveal some of the pitfalls of failed communication: not responding to patients' expectations is associated with poorer symptom resolution, decreased patient satisfaction, and increased use of health care resources. Golin et al.2 report some of the benefits of good communication: facilitation of patient participation, even more participation than patients say they want, is associated with improved patient satisfaction. Among the challenges physicians face during the clinical encounter, delivering bad news is one of the greatest and requires particularly careful attention to the patient and family's emotional response. Yet in another article, Orlander et al.3 report that medical residents recall being ill prepared and infrequently supervised the first time they delivered bad news and, presumably, did not learn the skill as well as we might wish. These findings reinforce what we know from earlier studies.4–6 If we already know how we should change our behavior, and we appreciate the benefits that come from doing so, why is it so hard to improve communication with our patients? Perhaps this is because addressing patient expectations and delivering bad news are so uncomfortable. Asking patients to tell us what they want potentially opens an imagined Pandora's box of outrageous requests, and it requires energy both to negotiate this tactfully and to manage the countertransference such negotiation produces in ourselves. Similarly, supervising learners as they give bad news requires us to confront our own perceived or real inadequacies in this skill and to experience the powerful emotions displayed by patients and families. We may naturally want to avoid these emotionally demanding interactions and the uncomfortable feelings they generate. Yet we are capable of more constructive responses. On a personal level, we can start by recognizing the feelings—dread, distaste, an intense desire to leave the room—and accept that this is how it feels to engage in uncomfortable conversations. It is tempting, but not useful, to project such feelings on the patient or others and to tell ourselves that we may avoid the issue. Rather, we should recognize these feelings as windows of opportunity, moments that give us a chance to stretch our communication skills, connect with patients more deeply, and become better doctors. We should congratulate ourselves when we brave these moments and stay with the patient or student and the task. On an interpersonal level, it is critical that we talk to colleagues about these emotions (“I felt so uncomfortable when….”“I thought I was going to go crazy when….”) and consider the roots of our discomfort and how we can do better. Of whom or what does this situation remind me? What other skills do I need? We also must be responsive to our colleagues' need to talk, and help create an environment that allows for these conversations. We should be alert for burnout (emotional exhaustion, depersonalization, and decreased achievement7) in ourselves and our colleagues,8 and find ways to cope.9 It may even be appropriate at times to disclose one's discomfort to the patient (“It's hard for me to share this with you….”“I wish I could tell you something different….”). When doing so, however, we should be mindful that such disclosure is for the patient's benefit, to give him or her the comfort of one's empathy, rather than to comfort ourselves. Finally, at an institutional level, we must create systems for health care that allow us to address our patients' concerns.10 By providing more time for visits, and more staff to deal with issues that can be better managed by others, we will have more time and personal resources to explore patients' expectations and respond empathically to their needs, and to teach others how to do the same. Thankfully, many of us have learned that with time, practice, and patience, the dread of difficult conversations diminishes. This takes some energy, but delivers rewards. As our communication skills improve, we are better able to help our patients cope with the physical and emotional burdens of ill health. And in becoming more like the physicians our patients want us to be, we may find more pleasure in being physicians.