SPR: Rads need better training for the ethical communication of bad news

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BOSTON–“In essence, our practice commonly involves the utilization of direct patient skills for which many, if not most of us, have had the least formal training,” said keynote speaker Stephen D. Brown, MD, of Children’s Hospital Boston and the department of radiology at Harvard Medical School in Boston, during a session on ethical issues in prenatal imaging this week at the Society of Pediatric Radiology (SPR) conference on Thursday.

During his session, which focused on the challenges surrounding the conveying of difficult or unexpected information and the discovery of unique clinical and ethical features of prenatal care in the setting of prenatal abnormalities, Brown noted that prenatal counseling and patient communication of difficult information takes place in practices very often.

Because many physicians do not undergo formal training in the delivery of potentially upsetting news, physician fear and anxiety can often times impede optimal communication, noted Brown. “These conversations are difficult.  Most physicians experience stress during bad news transactions, and this does not decrease with frequency of bad news delivery,” he said.

Citing physician fears, including saying the wrong thing, being blamed, causing pain and possible legal action on the part of the patient, Brown said that these fears could potentially lead to compromised care coordination, loss of trust and lack of overall satisfaction from the patient, as well as patient trauma even after the shock of the news has passed.

Despite these fears, Brown noted that the literature has also pointed out that good communication traits of the physician, including sensitivity, courtesy, appropriateness, compassion and good listening skills when conveying difficult news can lead to improved medical experiences for the patient. Brown reminded the audience that physicians should be communicating bad news, not “breaking” or “delivering” the information.

Prenatal care is an area in which Brown referred to as a “highly variable clinical landscape that is constantly changing.”

“Our generation of practitioners and patients alike face new decisions for conditions,” noted Brown, including prenatal, delivery, and postnatal management alternatives. In addition, early detection and further information does not necessarily lead to more certainty in prognosis, he said.

Offering an example, Brown explained, “When we talk amniocentesis, we are discussing the risk of the loss of a healthy pregnancy, for the benefit of information, for which the pregnancy may be terminated.”

With this in mind, Brown noted that the practice of pediatric radiology and imaging is not isolated from deeply entrenched cultural and societal biases regarding disabilities, pregnancy termination, or the expectations for the behavior of pregnant women.

Pediatric radiology is becoming increasing “fetus-centric,” said Brown. However, he said that the clinical concerns with this attitude could undermine the physician’s recognition of the considerable psychosocial challenges to prenatal decisions faced by pregnant women and their partners, and noted that these challenges to prenatal decision-making are growing, as the focus on fetal conditions with ever-improving resolution and sophistication is increased.

Brown noted further challenges that can be attributed to “considerable cognitive dissonance and moral distress for the practitioner,” including the variance of clinical experiences, possible psychosocial and cultural differences, and different clinical and political interests and priorities being brought to the table by pediatric-based specialists. “Decisions must be supported for which the practitioner may be morally opposed,” he said.

Research has shown that clinician representation of facts, as well as emphasis on positive or negative aspects of news and information, could influence patient experience, decision-making and clinical outcomes, said Brown. Serious thought and consideration must be paid in order for physicians to incorporate any preferences and values into their communication with patients, so that it is done in a way that  bolsters, not weakens, their ability to make informed decisions, he said.

“It’s expected that as radiologists, our evolving roles in patient care will require us to acquire better communication skills,” he concluded.