On Being A Doctor - Whatever Happened to Bedside Manner?

When I went to medical school over 25 years ago at University College London we were taught about bedside manner. One definition of bedside manner  - "a term describing how a healthcare professional handles a patient in a doctor-patient relationship."

Why bring up bedside manner? A couple of my friends were recently informed that their biopsy results (one a breast biopsy and the other a prostate biopsy) were positive for cancer. Both were informed on the phone. Both calls were impactful and traumatic. I had always been taught that you should talk about a cancer diagnosis with the patient in person. However, I was surprised by a blog piece earlier this year by Jennifer Frank in Physicians Practice. She writes:

"Our group — composed of patients, radiologists, breast surgeons, family physicians, an OB/GYN, nurses, and others — worked to find the most patient-centered way to standardize how results were given. The biggest surprise to me was what our patients told us. They didn’t care that much who gave them the results and they didn’t want to wait for an office visit. They wanted to know their results ASAP. Whoever gives them the results needs to be kind and knowledgeable and competent, but doesn’t need to be their primary-care physician or even be someone they’ve met before.

When we jettisoned the whole notion of relaying bad results that I and most other physicians were taught — tell them yourself, do it in person, your presence is important — we relooked at which doctor in the process should be relaying the results, or even if it needed to be a physician at all. Different physicians had vastly different perspectives. On one end of the spectrum was a local OB/GYN group that didn’t want to relay the results at all and were happy to have the radiologist do it. At the other end were those of us who wanted the opportunity to be involved in this process."

In an article in the NY Times from 2009, Tara Parker-Pope writes about the anxiety of waiting for the biopsy result. She quotes Dr. Elvira V. Lang, an associate professor of radiology at Harvard Medical School and Beth Israel Deaconess Medical Center: “Even when patients hear they have a cancer, they can start doing something. But if you hang in there for five days and you still don’t know what direction it goes, it’s just very stressful.’’

But, the article that hits home for me was published in 2009 in the Journal of Clinical Oncology (JCO). Dr. Len writes about this article in his blog: 

"The sad news... is that too many of these folks will start their journey hearing those fateful words in a less than appropriate manner in a less than appropriate setting. To me, that is not only dismaying, it's appalling. And if we physicians can't understand, empathize and even sympathize with our patients when we tell them their life is at risk, then we are in serious trouble as a profession."

The study published in JCO where all of the 437 patients surveyed had been referred for treatment. The researchers asked them how they learned of their diagnosis, what the doctors told them at the time they received the news, where they were located when they had the conversation, and how long the conversation lasted

The authors reported that a little over half the patients were told their diagnoses in their doctor's office, 18% over the phone, and 28% in the hospital. 44% of the conversations lasted less than 10 minutes, and 53% lasted more than 10 minutes. In about 31% of the conversations, no treatment plan was discussed. It is no surprise to anyone that patients were more satisfied with the experience-if you can say that you can be satisfied with hearing you have cancer--with in person discussions rather than by telephone, with longer time and with an explanation of treatment options.

So what have I learned from all this? As a general rule, I am going to be more disciplined about sharing bad news with patients on the phone - I will bring them into the office to do this. While I don't routinely have to tell patients that they have cancer from biopsy results, it re-emphasizes in my mind the importance of communication. I have to often talk about results of a kidney biosy or whether a donor is cleared to donate to a patient - less of a big deal than telling someone that they have cancer, but probably better told in person.