• The Happy V

Delivering the life changing diagnosis that could turn a patient’s world upside down

Dr Sneha Wadhwani 

When we think about the moments inside the doctors’ office that could alter a patient’s path, we imagine a cancer diagnosis; something fatal perhaps or something that will prematurely terminate a person’s existence.

While these scenarios do indeed occur, they are infrequent. However, delivering a diagnosis that is life-changing is not. It may involve delivering a diagnosis of a lifelong but not life-threatening diagnosis. It may involve delivering information about fertility (or lack of), and so much more. The impact of course, is great because it lies beyond the physical health problem and expands into the life and existence of the patient.

Breaking such news is considered part of a physicians’ routine, though the actual impact on both doctors is massively misunderstood. In fact, if we did indeed understand this better, then there would be greater consistency and standards of quality in the consultation when information like this is imparted. And, the patients would be better able to express and communicate their needs in that context, safely.

Some studies have demonstrated that physicians may experience an increase in heart rate, in pressure in the great arteries (big blood vessels) and cardiac output (volume of blood pumped out by the heart). These symptoms are expressive, aggressive and present on a frequent basis.

On occasions, so expressive that they may experience hypertension (chronically high blood pressure). Additionally, they may also demonstrate elevated cortisol (stress hormone) levels and an exaggerated immune response in these situations. This will undoubtedly triggers signs of the ‘fight or flight’ response, which we have all come to experience when under extreme stress or shock. Doctors have described, in the moments of delivering life-changing news, that they may experience a sense of ‘losing control’ in the consultation impacting emotions, professionalism and confidence. It is indeed a challenge to deliver such a complex package of information within the limitations and constraints of the consultation room and the allocated, consultation time.

At medical school and in post graduate training, often young doctors are trained in the art of being empathic and communicating effectively; keeping the patient and their needs at the centre of the consultation. However – personality type, life, work experience and the varying age groups within the health care system, can affect a doctors ability to do this and with what degree of calibre, is somewhat unknown.

Equally we know that patients too experience stress when receiving life-changing news! We, the doctors, assume that they too respond physiologically and to some extent, will mirror the complex reactions of the doctor opposite them! Uniquely, both the patient and the doctor are experiencing similar physiological processes during the diagnosis window!

The difficulty lies in the fact that patients have differing requirements emotionally and practically in consultations. Some patients simply want to know all the facts and need to leave with a sense of full disclosure. Others choose to be less inquisitive with what lies ahead or how short their tie may be. Some require the full empathic ‘hands on experience’, with verbal and non-verbal responses and interactions, laden with understanding and empathy. While others simply want the facts – they are high on detail, clarity and react best to concise communication.

Generally, a doctor who is to deliver life-changing news is one who has known the patient well, and is perhaps better attuned to their emotional and cognitive needs. However, the physicians’ own life experiences play an important role in their ability to deliver well in consultations. Perhaps their own health problems and experiences; the recent loss of family or friends can significantly impact a delivery of news on a sympathetic and sub-conscious level. Conversely, a doctor may feel confronted emotionally by the gravity of the diagnosis on the patients’ life and feel conflicted regarding how or if they should to express emotion.

Medical education has long focused on developing skills to obtain information from patients, then process it in the context of physical examination and interpreting test results.

However, in General Practice, there has long been a willingness and desire to investigate the dynamic of the consultation, and to explore the effect it has on patients.

In the last couple of decades, the idea of patient centredness and keeping the patient and their needs paramount in the consultation, have become a much greater focus, particularly in General Practice. Whilst frameworks have been developed and studies revisited, there still exists varying patient experiences in this domain.

The reasons for this are indeed varied. The reality lies in the fact that there are so many variables involved.

After 17 years of medical practice, I believe that medicine is indeed a science but it is the practice of medicine that is in fact an art.

There is no single way to conduct the consultation or deliver life-changing news. It varies between practitioners and patients, as indeed it should in order to suitably adapt to the varying needs and requirements in each circumstance. I believe the physician most proficient in this domain, is one who knows the patient well. A doctor who can adapt and respond quickly to the emotional needs of the patient in the consultation, and most importantly one who wears their own identity, personality and emotions with confidence, while tempering this to the needs of the patient is a doctor I advocate for.

Furthermore, physicians must also ensure they do their “housekeeping”. That is, they must understand and be aware of the impact of challenging consultations on their own wellbeing and emotional state. They must be able to reflect on the consult and debrief if necessary, before moving on to the next consultation in order that they do not carry over this emotion into the next scenario.

Mastering the ability to delicately balance the patient needs with the physicians’ needs, in the context of delivering life-changing news takes, practice, time, experience and an ability (and willingness!) to empathise and understand.

It is a journey for most physicians as they advance through their career; honing and refining this skill as they progress and reflecting on each experience.

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