Robert Den, MD, a radiation oncologist in Philadelphia, constantly reminds himself that while he’s in the ‘cancer world’ every minute of the day, his patients aren’t.
“As oncologists, we may be meeting with the third patient that day with a newly diagnosed metastatic cancer, but for this individual, this is their first time hearing news like this,” Den told Medscape Medical News.
That’s just one reason Den says words matter. In fact, what not to say to patients is as important as what to say, especially when a patient is facing a difficult diagnosis. A paper published in Mayo Clinic Proceedings titled Never Words: What Not to Say to Patients With Serious Illness offers a model of words and phrases physicians shouldn’t use with patients, such as “there is nothing else we can do,” the words “fight or battle,” and “withdrawing care.”
The authors said that the words and phrases lack benefit and cause patients emotional harm, which doesn’t represent the compassionate communication needed in these serious settings.
About Medscape Data
Medscape continually surveys physicians and other medical professionals about key practice challenges and current issues, creating high-impact analyses. For example, in Medscape’s Hot Topics in the Medical Profession Report 2024, Part 2
- Only 8% of physicians surveyed think it’s okay to withhold certain aspects of a patient’s condition from them.
- Almost one third said that competency tests are a good idea for doctors after a certain age.
- 57% think that they have an ethical duty to maintain their physical and mental health.
Listen Before Speaking
Listening to the patient during these moments is critical because that patient needs to feel that they’re being heard by someone who cares about them and because the goal is to build rapport as you map out a treatment plan.
“It’s important to discern what a patient understands and what they want,” Den said. “It’s your job at that moment to listen and find out what they’re thinking about and what their wants and desires are. From there, you can formulate a plan.”
Body language matters, too, said Omar S. Khokhar, MD, a gastroenterologist at Illinois GastroHealth in Bloomington, Illinois.
“I feel like the generation before mine was wearing the white coat and sitting across the desk, telling a patient all this information and data,” said Khokhar, who has been in practice for 15 years. Whereas he’s in scrubs, sitting alongside a patient. “I’ll show that person the pictures, explain what is happening, and do as much as possible to be with that person in the moment.”
Where you sit when delivering difficult news can make all the difference, too, Den said.
“I try to sit in a position where I’m lower than my patients, so if they’re on the exam table, I will try to sit on a chair that’s lower than that,” he added. “Oncology patients can feel like they’ve lost control, so I try to put them in a position of control. Part of that is having them sit above me. I try to hold their hand and look them in the eye when I speak. This is all very important.”
Five Things Docs Shouldn’t Say
When meeting with a patient facing a serious diagnosis, the physicians Medscape Medical News spoke with said you should banish these and other negative words and phrases from your lexicon. Here are five to avoid:
‘Everything is going to be okay.’
The most difficult conversation Marc Richards, MD, a nephrologist in Boca Raton, Florida, can ever have with a patient is when he has to tell them they will need to start dialysis or refer them for a kidney transplant.
“After 12 years in practice, it still has not gotten any easier,” he said. “When I encounter these patients, I feel like my goal is to be as honest and as supportive as possible. There is no sugarcoating that a patient may need to come to a clinic to sit on a machine for four hours at a time for 3 days a week. However, I try to reiterate that no matter what, I will be with them every step of the way.”
Saying that everything will be okay is not only condescending but may also be an unknown early on. Plus, patients want reassurance that you will help them, be with them, and guide them, not blanket statements that they’ll be fine.
‘It might be time to get your affairs in order/take that dream trip.’
It’s way better to tell patients you’ll do the best you can for them and help them understand that they don’t need to be defined by the disease than to tell them they should take an around-the-world cruise, Den said.
“Yes, we want patients to live their lives, but that doesn’t mean they should give up everything they ever did, change their entire value system, or abandon their family and go have a once-in-a-lifetime experience.” What it does mean is that maybe the patient can reprioritize what’s important to that person.
“I always try to help patients organize their treatment around their life vs organizing their life around their treatment.”
‘We definitely found cancer during your scan.’
While you don’t want to downplay a finding, it’s more important during that immediate post-scan appointment to be truthful about what you know — and what you don’t, Khokhar said.
“I generally say, ‘this looks like a cancer,’ but I won’t know for sure until the biopsy is back in 48 hours,” he said. “That’s how I say it. I don’t want to sugarcoat it, and I don’t want to overcommit. I want to tell the truth about what I saw and what I think.”
‘You have X months to live.’
If a patient has a terminal illness or incurable disease, providing this information is important, but giving a patient an exact prognosis is often ill-advised and may be incorrect, said Gail Saltz, MD, an associate professor of psychiatry at the New York Presbyterian Hospital, Weill-Cornell School of Medicine in New York City.
“Saying that for this particular stage of this type of cancer, we often measure time in 5 to 10 years is one thing, but giving someone an exact number is generally not helpful to a patient,” Saltz said. “It can only serve to raise their anxiety.” Also, it’s rare that a doctor can say exactly how long a patient has to live.
‘I wish you had done something differently.’
Telling a patient that you wish they hadn’t smoked or that they should have come in sooner is not helpful, Saltz added.
“All this serves to do is make a patient feel guilty, self-blaming, or regretful, which harms their mood. A person cannot change the past. If it’s a current issue, like smoking or keeping appointments, then say, this is important to do now, and explain why.”
“Ultimately, if you shame a patient, he or she is less likely to tell you much in the future,” Saltz said. “They may not want to come back, and this will harm their care, too.”
In the end, banning unacceptable words and phrases and creating an alternate language for never words helps you deliver compassionate care, perfect your communication skills with patients, and improve your bedside manner and patient experience.
One of the things patients remember long after their cancer is in remission or their serious illness has been treated appropriately is the compassionate hand-holding doctor who sat below them, looked them in the eye, and empathetically and truthfully told them about their serious diagnosis — without sugarcoating it and without using platitudes like they’ll be just fine.
Lambeth Hochwald is a New York City–based journalist who covers health, relationships, trends, and issues of importance to women. She’s also a longtime professor at New York University’s Arthur L. Carter Journalism Institute.
Admin_Adham
