The Serious Conversation: Delivering Bad News by Telemedicine

by Judy George, Senior Staff Writer, MedPage Today

A serious diagnosis or prognosis can be life-shattering. Breaking difficult news to a patient involves complex and nuanced communication, which can be more difficult with telemedicine.

"The greatest challenge with the medium is the loss of the ability to read and display nonverbal cues," said Andrew Robinson, MD, an oncologist at Queen's University School of Medicine in Kingston, Ontario.

"Pre-COVID, I probably would not have delivered a diagnosis of multiple sclerosis by telemedicine," noted Marisa McGinley, DO, of the Cleveland Clinic's Mellen Center for Multiple Sclerosis in Ohio. But now, new patients in all specialties are being seen through virtual visits, especially in places where COVID-19 cases are climbing.


In a way, video or telephone may allow for deeper conversations with patients, McGinley observed.

"In telemedicine, we're actually afforded a great opportunity: we can just listen and converse with our patients," she said. "That sounds kind of crazy because we don't have the human touch factor of being in the same room, but we have nothing else to do: we're not trying to do an exam and check boxes. There's no distraction."

"Telemedicine almost forces the visit to be more focused on the conversation," she continued. "It actually can be a meaningful kind of provider-patient interaction."

When a serious in-patient discussion is replaced by a virtual visit, video offers advantages over other forms of telemedicine, said Steve Ommen, MD, a cardiologist and associate dean of the Mayo Clinic Center for Connected Care in Rochester, Minnesota.

"As human beings, we want to be able to communicate, to have sympathy and empathy," Ommen said. "And you can do much of that by video. What you can't do is offer patients a Kleenex across the room, or put your hand on their shoulder as a sign of support."


"The more nuanced the conversation -- or the less you already know the patient -- the more likely you're going to want to use video technology as the way to communicate," he added. "If I can see someone looks concerned or confused, if their brow wrinkles, if they look scared, if their eyes roll, if the corner of their mouth turns up or down when you're giving bad news, that's important."

SPIKES for Telemedicine

"In oncology training, we're used to the SPIKES protocol, which has been taught for the last 20 years," Robinson said. "That protocol can be amended for telemedicine, whether it's a telephone or video conversation."

SPIKES -- which stands for setting, perception, invitation, knowledge, empathy/emotion, and strategy/summarize -- is a method of breaking down the complexity of discussing serious news into small steps to improve communication.

In telemedicine, the setting aspect of SPIKES means not just preparing for the conversation, but arranging for privacy and silencing pagers, cell phones, and computer notifications before the call starts.


The technical setup is important, too, Robinson said. "You can't assume everyone has perfect Internet access," he pointed out. "You need to make sure you have a backup, like a telephone, if video isn't working so you can always switch to audio, which is much more reliable."

Some patients want to have family members or others involved in serious conferences. Telemedicine can make that easier; multiple support people can be present, either with the patient or from afar using their own electronic devices. This is especially important during the COVID-19 pandemic, when many hospitals and healthcare centers are not allowing family members to accompany patients at office appointments, Robinson noted.

The perception, invitation, and knowledge parts of SPIKES need slight adjustments in telemedicine, he added: it's important to check in frequently to make sure the patient heard the information being delivered and can summarize what's been said.


Empathy can also be delivered through telemedicine, Robinson said: a prolonged silence sometimes can take the place of offering a tissue or an understanding touch. While patients' emotions may be easier to observe in an office visit, they still need to be acknowledged and validated, which may take extra time in a virtual encounter.

"Telemedicine and video medicine takes more time," he pointed out. "You need to account for pauses, for delays, and for glitches. And you need to account for taking extra steps to ensure the message is received properly and that you understand what the patient is saying, too."

There's a good chance patients won't retain some information shared in a serious telemedicine conversation, just as they might not during a serious in-person visit, Robinson noted. Setting a follow-up plan is important. It also may be possible to offer handouts or summaries electronically, he added.


Families Involved; Diagnosis Delivered Faster

Can a virtual visit be as good, or better, than the experience patients expect in an office visit? In some cases, the answer is yes. "It allows patients to have more family members or caregivers present if they choose to," Ommen noted. "Their brother or sister can be there. Their kids can be there during the video conference, and they all get a chance to participate."

Virtual visits also can help patients receive a diagnosis more quickly, said McGinley. "A lot of the anxiety patients have around getting a diagnosis is waiting," she said. "If telemedicine can break down the barrier of patients having to wait months for an appointment, that helps a lot. We have the potential with telemedicine to improve access to patients, which can lead to faster diagnoses, more information to patients, and faster treatment."

A virtual visit may replace an office visit entirely, so physicians need to be comprehensive and not assume the conversation will be followed by an in-person appointment, McGinley added.

"It may seem out of place to give these weighty diagnoses from a remote standpoint, but there's potential to do it very well and very effectively," she said.

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