‘You can show a lot of compassion over the phone’

Evelyn Lewin

21/07/2020 2:05:17 PM

As more patients make use of telehealth, the ability to deliver bad news over the phone is becoming increasingly important.

Doctor and patient on the phone
The need to break bad news via telehealth is likely to become more common during the pandemic, as people avoid seeing their doctor for routine care or when they develop concerning symptoms.

Prior to the COVID-19 pandemic, Dr Cathy Andronis never could have imagined herself delivering bad news to a patient over the phone.
And yet, in these turbulent times, she has had to do just that – more than once.
‘The worst was one where I had a patient who had a test result that came back that was clearly showing signs of cancer – or very, very likely cancer,’ the GP and Chair of the RACGP Specific Interests Psychological Medicine network told newsGP.
Due to the pandemic, this patient wanted to minimise contact with doctors and was ‘reluctant’ to attend a face-to-face appointment.
When Dr Andronis received this patient’s test results, she knew there was no time to waste.
‘And because of that, I had to be very frank with this person over the phone about the results by saying it was very likely this could be cancer, and that this person should also follow this up very quickly,’ she said.
While Dr Andronis knew it was important to convey the information as soon as possible in order to facilitate the patient seeking appropriate investigations and care, she walked away from the consultation feeling uneasy.
The patient had organised the telehealth appointment for while they were at work, taking the call in a separate room.
‘I felt that having broken relatively bad news [over the phone] I wasn’t then able to read his body language or answer any further questions, and I was aware that he was probably not in the position where he could show much vulnerability … and that made him unable to want to talk any more than was absolutely necessary,’ she said.
‘So at the end of it, even though I tried to be as sensitive as possible, I still felt like I wasn’t doing my job properly, because I think those situations require you to slow down, have a bit more active reflection, to explain things, to hear about concerns, and about to be able to explain potential pathways forward.’
Associate Professor Vicki Kotsirilos, GP and founding Chair of the RACGP Specific Interests Integrative Medicine network, has also had to break bad news via telehealth.
When she received results that showed her 86-year-old patient had worsening heart failure, Associate Professor Kotsirilos wanted to organise a specialist appointment as soon as possible.
The patient was unable to physically attend a consultation with Associate Professor Kotsirilos that day, so the GP squeezed her in for a telehealth consult.
It was ‘not an easy consultation’ that presented a number of challenges, Associate Professor Kotsirilos told newsGP. 
Her patient is hard of hearing and struggled to understand the information, despite Associate Professor Kotsirilos’s use of simple language, delivered slowly. The lack of visual cues compounded the issues.
‘There was a definite disconnect with the communication,’ Associate Professor Kotsirilos said.
‘When we hung up I felt she was not quite satisfied in understanding what was going on.’
Consequently, Associate Professor Kotsirilos asked her patient if she had permission to then contact her son. Her patient agreed, and Associate Professor Kotsirilos felt far more comfortable after speaking to him.
‘As a general rule, I’ve found telehealth to be excellent, really useful,’ she said.
‘The patients have loved it for convenience and issues of safety, and I’d love for the item numbers to progress.
‘But there is a crunch time when a patient should be face-to-face, and I think that when it’s severe conditions like progressive heart failure, or giving a diagnosis of cancer, for example, I think there’s a real role to bringing patients in.
‘And we can still protect patients and doctors through wearing masks.’
Dr Andronis agrees.
‘Ideally, what we should be doing is asking people to come in and see us and we should be aiming to do that as routinely as we’ve always done, because that’s usually the best opportunity to [break bad news] in the most compassionate and carefully considered way,’ she said.
However, both doctors acknowledge that is not always possible in this current climate.
And when it is not possible, they agree telehealth plays a pivotal role in conveying important information quickly and conveniently, while getting the ball rolling on urgent investigations and care.
‘In fact, I think patients appreciate that you are thinking about them and wanting them to get results as quickly as possible,’ Dr Andronis said.
‘They do appreciate that.’

Dr Cathy Andronis says patients are very understanding about the need to break bad news via telehealth given the current climate.

The need to break bad news via telehealth is likely to become more common during the pandemic, Dr Andronis says, as people avoid seeing their doctor for routine care or when they develop concerning symptoms.
In May, newsGP reported that the pandemic had resulted in nearly 100,000 fewer GP visits and that as many as 10% of patients are estimated to have put off cancer screening since it started.
Dr Andronis says those factors, combined with patients’ reluctance to then see their GP face-to-face for results, will likely lead to an increase in delivering bad news via telehealth.
‘We’re probably seeing a lot more serious [conditions] because people are avoiding doing routine testing or routine GP visits, which means that more things get left for longer and people present later which means that the chances that we will see more serious things has increased,’ she said.
‘So we have to be prepared for it.’
After their experiences, both doctors have reflected on ways to improve breaking bad news via telehealth.
Ideally, they say, it is best to book patients in for a longer consultation, which allows the doctor to slow down and not rush.
Verbally acknowledging the limitations of conducting an appointment over the phone may also help, according to Dr Andronis.
‘People will be understanding under these circumstances that a lot of things are more difficult to do face-to-face. But if you can, acknowledge the difficulty of having to do it over the phone … and validate the difficulty of doing that as a patient,’ she said.
Dr Andronis believes it is also important to be prepared before such consultations.
‘Think ahead about what we want and need to say, be prepared for [the patient] to be surprised or shocked or upset, and allow time to have that consultation over the phone carefully,’ she said.
‘If you’re going to do it over the phone, then you need to make sure you’ve got a good plan of action about what will happen next and how you’re going to help facilitate that.’
When possible, Associate Professor Kotsirilos says patients should also be asked whether they can have a family member or carer with them.
Aiming for a telehealth appointment with a visual component – for example, via video call – is also preferable when possible, because it allows visual cues and body language to be seen.
Lastly, Dr Andronis says it is vital to conduct the appointment as though you are face-to-face with your patient.
‘You can show a lot of compassion over the phone through your tone of voice, through the careful use of words, how you frame things [and] by being confident in having a good action plan,’ she said.
‘Really, it’s no different to how we would do it face-to-face, except we have to make an allowance for the fact that we’re not doing it [that way].
‘Essentially, we need to otherwise keep things as normal as possible because that’s the most reassuring thing for patients; to feel that even though we’ve had to do things remotely, we’re still doing everything that needs to be done, and are providing hope and optimism by the fact we’re following practices as closely as possible.’
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