AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Process Issues
• Content Issues
• Personality Issues
• Skills for Specific Situations
• Summary
• Support Services
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Process Issues
• Content Issues
• Personality Issues
• Skills for Specific Situations
• Summary
• Support Services
• References

The importance of effective communication in medicine is often overlooked. For female patients, effective communication is a particular concern, especially for women with obstetric or gynecologic health problems. In a recent study looking at what women want from their physicians, the authors note that female patients consistently stressed the need for their physicians to develop and maintain respectful doctor-patient relationships including good interpersonal communication.¹ 

Several books have been written that discuss the different communication styles of men and women.^{2, 3, 4, 5} Because of these differences, discussing obstetric and/or gynecologic health problems, particularly with a male health care provider, is likely to be problematic for many women. This issue takes on even more importance in an emergency setting, in which continuity, engagement, and educational opportunities are often limited. Formal medical education provides few opportunities to acquire and improve basic communication skills. Consequently, communicating sensitive medical issues with women in an emergency situation is a skill that is often obtained by experience, sometimes negative.

While the problems of gender gap and setting are real, they are not insurmountable. Some thought given to this subject is amply rewarded with improved personal comfort as well as patient satisfaction and compliance.

PROCESS ISSUES

Section 3 of 9  

• Authors and Editors
• Introduction
• Process Issues
• Content Issues
• Personality Issues
• Skills for Specific Situations
• Summary
• Support Services
• References

Men and women communicate differently. Men tend to be more focused on factual issues and tend to be action oriented, asking "What are the facts and what needs to be done?" Women tend to focus more on emotional issues and working out solutions through dealing with emotional aspects. Although these are generalizations and significant overlap exists in communication styles between genders, the stereotypes are nonetheless well supported by research.^{6, 7} In order to optimize communication with female patients, consciously identifying a communication style that is more emotionally oriented than one might embrace with male patients may be helpful.

The process by which sensitive information is communicated is very important, and communication is smoother if the physician considers some basic issues. The first important issue is who conveys information. If sensitive information is to be communicated, it is usually better for the physician, rather than a nurse or a technician, to discuss it with the patient. This demonstrates respect for the patient, the seriousness of the situation, and also bypasses the "I want to speak to the doctor" scenario. Many physicians consciously or unconsciously avoid difficult or sensitive communication scenarios because they may be time-consuming or because health care providers recognize their own inadequacies in communicating. Ultimately, both the health care provider and the patient are better served by a deliberate effort to learn satisfactory communication skills than by the provider simply abdicating communication responsibilities.

If possible, having some support personnel in the room with the physician is also helpful. A social worker or nurse may be able to provide support once the physician has left, and making a connection with the patient while the unwanted news is delivered may be helpful. Also, this helps the patient see that the support personnel have a relationship with the physician. Support personnel may also be able to provide the physician helpful insight that allows further communication skills refinement. At times, having the physician as the communicator of sensitive news is impossible or impractical, but direct physician-patient communication should be the ideal.

After deciding who relays sensitive information to the patient, the setting needs attention. Standing in the middle of the hallway to inform a woman that she has a sexually transmitted disease (STD) is not optimal. The preferred setting would be a room (not a curtained cubicle) where the patient and physician can sit that is not a high traffic area. The physician needs to be at eye level with the patient, preferably sitting. Eye contact is important when talking with a patient, and this is a skill that can be formally rehearsed to improve performance.

Physicians also need to communicate to the staff that uninterrupted time is needed with the patient/family. Attempting to discuss sensitive information while being interrupted by staff or by a pager may increase the patient's anxiety as well as inspire anger. Uninterrupted time in an appropriate setting is more likely to convey care and concern on the part of the physician.

Physicians also need to be conscious of their communication style, including such issues as speed of delivery and nonverbal cues. Speaking at a slower speed and in a lower tone helps to reduce anxiety. While the physician may be feeling enormous pressure to complete the conversation and move on to other tasks, very little time is lost by techniques such as sitting down, pacing the delivery of news, and maintaining appropriate tone and speed of speech. Indeed, time may be saved if patients comprehend information more clearly on the first transmission. Nonverbal cues also play an important role in effective communication. Patients will receive and interpret nonverbal cues, perhaps incorrectly, faster than they will the actual words being spoken. Physicians should understand their own nonverbal communication as well as that of the patient.⁸

Timing is also important. A good time to present bad news does not exist; however, bad times to present bad news do occur, such as when the patient and/or family have been awake all night and are fatigued or when a large family group has just arrived and emotions are intense. While one cannot always wait for the optimal time, consideration of this issue is important. Less urgent tasks, such as acquiring consent for autopsy, may be deferred until the family has had a chance to recover from the initial emotional blow.

Providing the patient with an opportunity for follow-up questions and clarification of issues is also very important. If the physician cannot provide this opportunity, having the patient and/or family contact someone who can answer any questions is imperative. This allows closure to the current event and allows patients and/or families to know that someone will be able to help when they are ready to deal with some of the emotional issues. Many support groups exist to provide patients with information and assistance beyond what the doctor can provide. Some useful numbers for national agencies are listed in Table 1. Having a similar list of local resources available (preferably in a pocket card format) for all care providers in a particular institution is helpful.

CONTENT ISSUES

Section 4 of 9  

• Authors and Editors
• Introduction
• Process Issues
• Content Issues
• Personality Issues
• Skills for Specific Situations
• Summary
• Support Services
• References

Content issues might seem more straightforward than process, but they may in fact be equally difficult when communicating sensitive news. Using terminology that the patient can understand is important. Remember that the patient receiving unwanted news may hear only a small portion of what is being said and may not understand the implications of certain medical terms. A tendency also exists for patients to nod as though in understanding, thus leading the provider to believe communication has been successful. The words used by the provider need to be simple and basic in order to increase understanding.

Do not provide too much information too soon. If the patient and/or family does not appear to comprehend the situation, back up and repeat the information in even smaller segments. Physicians may find themselves repeating the same news a number of times or in several different ways. Open-ended questions such as "What do you know about herpes?" are time-consuming but can provide great insight into what information needs repeating or reframing.

One of the most important issues in communicating unwanted news is that the physician be honest and direct. More often than not, the patient or family has an idea that a potential for bad news exists and that they will need to begin to deal with it on an emotional level. Providing hope, but not false hope, is important. Sometimes physicians can be vague when communicating sensitive news. This may be due to their own discomfort and is generally not what the patient wants or needs. One way to compromise between withholding information and overwhelming the patient is to let the patient guide the conversation with questions such as "What would you like to be told about this problem?" or "Do you have concerns about how this might affect you?"

Many physicians are uncomfortable with their own emotions. When discussing a sensitive medical issue with a patient or family, the physician often attempts to remain emotionally detached. A physician who demonstrates some emotion may comfort patients or families more than a physician who does not. This allows the family to feel that the physician is engaged in their situation and cares about them. Even having the physician express sorrow can be very helpful to the patient or family; expressing sorrow can change the tone of the statement "we did everything we could" from a defensive comment to one of shared loss and frustration.

Some physicians are very uncomfortable when the patient or family has very intense emotions. The physician may attempt either to squelch the expression of the emotions or to remove him or herself from the emotional environment. Allowing the patient or family freedom of expression is important. Becoming comfortable with the emotions of others requires practice but allows the provider a much broader scope of healing than would otherwise be possible.

The most important skill that a physician can acquire in dealing with sensitive news is the ability to listen. The ability to listen communicates respect, caring, and empathy. In addition, it provides the physician with guidance as to the direction the conversation needs to take. Most people complain more about not being listened to than any other single issue in their medical care.

PERSONALITY ISSUES

Section 5 of 9  

• Authors and Editors
• Introduction
• Process Issues
• Content Issues
• Personality Issues
• Skills for Specific Situations
• Summary
• Support Services
• References

Each individual involved in a communication situation brings aspects of his or her personality to the interaction. Physicians need to be aware of their personality type as well as the personality type of the patient with whom they are communicating sensitive information. The physician, like any other person, has a particular way of looking at such things as death, the role of the physician in the treatment process, and appropriate ways of expressing and coping with intense emotion. The physician's perspective affects the communication interaction. For example, if physicians believe that they represent health and wellness when serious illness or death has to be communicated, they may have a sense of failure. If physicians believe that they are facilitators working with the patient to obtain optimal health, the view of illness or death may differ.

In addition to physicians being aware of their own personality issues and belief systems, understanding that each patient's personality affects communication is important. Not all women express their emotions in the same manner, and if a physician waits until the patient expresses her emotion in the manner that is expected, discomfort and misunderstanding may exist for all parties involved. Some patients are prone to anxiety that may be expressed in several different ways, such as crying, anger, or pacing. While a provider cannot possibly know all patients equally well, some attempt to identify the patient's personality type and needs is rewarded with greatly enhanced communication patterns.

Another factor that needs to be considered is the patient's social environment. Having some information as to what is going on in the patient's life may facilitate communication. For example, if a woman has been attempting to have children for several years and has experienced a fetal death, her reaction may be much different from a woman who was not aware that she was pregnant and has experienced a spontaneous abortion. If a woman is going through a conflictual divorce, her reaction to any bad news may be compounded by her already fragile emotional state. The level of support that an individual has from other sources, such as family, clergy, and friends, also greatly impacts her ability to receive sensitive communication. While the physician cannot know all these things, simply remembering that social context affects the transmission and interpretation of information is helpful.

Patients may have mental health issues in addition to their presenting symptoms, and the mental health issues can sometimes overshadow the physical ones. Two categories of mental illness are of particular concern to physicians caring for women. The first is schizophrenia. Patients with this diagnosis often have difficulty establishing ongoing relationships and, thus, may receive most or all of their health care in an emergency setting. These patients can be extremely frustrating because of noncompliance with prescribed care regimens and their disordered and often disruptive thought processes. Obviously, every effort should be made to establish a connection with a mental health professional. These patients require a great deal of time and energy, but this investment may be rewarded with improved compliance as the patient musters the trust necessary to continue the care regimen.

The second mental health disorder of particular significance to women's caregivers is borderline personality disorder. Less room for optimism exists in this situation. This axis II disorder is 3 times more common in women than in men and often goes undiagnosed. It is not highly amenable to treatment, but the highly disruptive effects of a borderline "acting out" can be contained if the provider is alert to the possibility of the diagnosis. Women with borderline personality disorder are extremely seductive, although this may not be enacted as sexual behavior. They may be victims, ceaseless caregivers, lost newcomers, or any other role calculated to win sympathy and special treatment. They are often excessively flattering regarding their current care situation, while being vituperative in their denunciation of the previous caregiver who somehow failed them.

Underlying all the actions of a patient with borderline personality disorder is the insatiable need for attention. While initial interactions may be quite gratifying to providers, such as being told by the patient that they are marvelous, the patient with borderline personality disorder inevitably becomes disillusioned when the interaction fails to escalate to what her fantasies lead her to expect. At this point, she may become angry, vengeful, and abusive. At this stage, the special efforts her physicians may have exerted on her behalf inevitably are used against them.

Physicians should not be discouraged from providing genuine care to particularly needy patients. Certainly, patients exist with extraordinary problems worthy of extraordinary care measures. The provider should be alert to patients dressed seductively, those who describe outrageously inappropriate behavior on the part of previous caregivers, or those who actively campaign to elicit sympathy. Providers are cautioned particularly to pay attention to their interaction style and how that may change from patient to patient.

If the physician begins taking extraordinary measures on behalf of a patient whose needs at face value do not merit such effort, disengaging quickly is best. Such patients are best managed by a team approach with active involvement of a mental health professional, and physicians should never allow patients to manipulate them into being alone for any portion of a physical examination. Once a patient with borderline personality disorder has been identified, having a chaperone, even for interviews, helps contain inappropriate self-disclosures or solicitations.

Unfortunately, the seductive behavior patterns of patients with borderline personality disorder, along with their explosive interaction patterns, tend to put them at high risk for rape, domestic violence, and battery. Awareness of the patient's underlying personality disorder in no way lessens the tragic nature of these situations, nor does it diminish the need for provider concern and compassionate care. However, providers must protect their interests as well as those of the patient.

SKILLS FOR SPECIFIC SITUATIONS

Section 6 of 9  

• Authors and Editors
• Introduction
• Process Issues
• Content Issues
• Personality Issues
• Skills for Specific Situations
• Summary
• Support Services
• References

Pregnancy Loss 

Emotional response to a fetal death may be influenced by several factors. Gestational age of the fetus is highly likely to play a role. Generally, the more advanced the pregnancy, the more intense the grief reaction. This is true not only because of the expectancy of a live birth but also because of the amount of planning the mother and family have carried out to welcome a new baby. The more preparation that has been made, the more difficult recovering emotionally will be.

Life experiences of the parents may also play a part. Young parents who have experienced very little grief in their lives are likely to respond with greater difficulty to a fetal death than older parents who have had other grief experiences. On the other hand, a woman who has undergone an extensive infertility workup in order to get pregnant is more apt to experience an intense grief response than a woman whose pregnancy was unintended.

Social support is quite important in helping a mother deal with a fetal loss. Women who have a high degree of social support are more likely to be able to handle the situation better than women who are socially isolated.

The most difficult area to evaluate in regard to grief experience is the importance of the pregnancy to the mother. The issue of planned versus unplanned pregnancy may have an effect on the emotional response. If the pregnancy was unplanned and termination of the pregnancy was considered, feelings of intense guilt may result. If the mother felt somewhat ambivalent toward the baby, feelings of guilt may result. If the pregnancy was planned and looked forward to with anticipation, the emotional response to the loss is likely to be significant.

Each individual woman is different, and her grief is acknowledged, felt, and expressed in a unique way. Providers should be aware that a broad spectrum of emotional responses may occur and that many full-blown grief reactions occur after the patient is sent home with the diagnosis of miscarriage. Every effort should be made to ensure both adequate medical follow-up care and availability of appropriate emotional support. Most communities have fetal loss support groups, and every patient should be provided this information for possible future reference.

Sexually transmitted disease

Communicating the presence of an STD should be straightforward and matter-of-fact, without expressing judgment. Most patients accept this information without significant emotional reaction, particularly in an urban medical environment. However, for some patients, notification of an STD, such as herpes, can be devastating. All patients should be approached with some consideration that they may have an intense emotional reaction to the news.

A frequent diagnosis in women is that of pelvic inflammatory disease (PID). Women who are diagnosed with PID are often not told that it is the consequence of an untreated STD. This leads to social embarrassment as well as high likelihood of reinfection if sexual partners or behaviors are not modified. Because of social and medical consequences, the diagnosis should not be made without careful consideration of a differential diagnosis, and the patient should be informed of the etiology of PID so she can make informed decisions regarding her lifestyle habits.

Domestic violence

Domestic violence is more prevalent today than many would like to acknowledge. The most likely medical arena in which domestic violence is discovered is the emergency department. Additionally, providers of prenatal care have to be especially alert for individuals who have experienced domestic violence. Studies show that each year approximately 1.5 million women in the United States are raped or assaulted by an intimate partner.⁹ This includes more than 324,000 women who were pregnant when the violence occurred.¹⁰ When discussing the possibility of domestic violence with a woman, the partner should not be in the room. Most women who have experienced domestic violence are unlikely to acknowledge the problem without some probing. This is a situation where the ability to communicate sensitively is important.

One of the convenient ways many providers have to converse with a woman privately is to have a standing policy that no family members are present in the examination room when a pelvic examination is being conducted on an adult. This allows for an opportunity to talk with the woman without creating suspicion in her partner. If the partner is reluctant to leave the room, this may be a warning sign.

Questions regarding abuse should be frank and explicit. Many abused women do not consider being slapped or punched by a partner to be abnormal, so specific questions should be asked about the etiology of injuries. Many women also collude to hide abuse, either because of fear of retaliation or because of a genuine desire not to see the partner harmed. If a high index of suspicion exists that domestic violence is occurring but the patient refuses to acknowledge it, information regarding shelters and victim services should be made available in such a way that she can secure it for future use. Consider having this information available in the waiting room or in women's bathrooms. Some women use this information later, even if they are not prepared to do so at the time of presentation. Additionally, each state has specific laws regarding suspicion or knowledge of domestic violence. Providers should be aware of the laws in their state.

Rape

Rape or attempted rape is one of the most difficult situations that a woman may experience. The reaction is often far more severe than even that of aggravated assault, in part because rape threatens a woman's deepest sense of self and personal control that. Upon the arrival of law enforcement officials, the patient is often drawn back into what feels much like a second assault, first by having to repeat her story in detail and then by submitting to the most meticulous and invasive medical examination imaginable. Being able to communicate with a woman who has been raped in an empathic and sensitive manner is of vital importance.

In some cases, the patient believes litigation is not under consideration and the patient wants a medical evaluation that is briefer and much easier. However, some patients subsequently change their minds, and the best time to collect evidence is immediately after the assault. If any potential for litigation exists, evidence should be collected immediately and following the standard protocol. The patient may be very poorly suited to make this decision immediately following an assault. The job of the provider in this case is to be the patient advocate in assessing opportunity for improving litigation outcome versus immediate cost to the patient.

Careful communication with the patient is vital. As with any severe emotional trauma, patients who have been raped may not be able to hear or understand information and instructions. All information should be presented often and in many different ways so that the patient can absorb it. The patient should be informed of what is to happen at each phase of the examination and, whenever possible, should be allowed choices about her examination and treatment. This begins to restore some sense of control. If the protocol involves plucking hair or scraping nails, the patient should be allowed to collect these samples herself rather than having medical providers reenact her assault. Psychomotor retardation is very common in women who have been sexually assaulted and can be maddening to busy providers, but the patient must be allowed to move at her own pace.

Law enforcement officials often have their own agendas regarding reporting of sexual assault. They may push for access to the patient before she has been fully evaluated or before she is emotionally able to communicate with them. Again, the provider may need to serve as the patient advocate in controlling access.

Potentially serious diseases

In her book, On Death and Dying, Elizabeth Kübler-Ross discusses the 5 stages of grief (ie, anger, denial, depression, bargaining, acceptance) and notes that patients may move often and at varying speeds back and forth through each of these. Expect patients who are informed of having a serious disease to begin to traverse these stages almost immediately. The physician is unlikely to know where a particular patient is in her grief process unless extended previous contact has occurred.

When breaking the news of a serious or life-threatening disease, the following issues should be considered. First, never lie. Physicians should acknowledge that they may have a limited knowledge base about the problem, and they should provide enough information to get the patient to the next level of care.

Second, do not overstep the knowledge base even though the patient or family may press to do so. For example, if a gynecologic patient has been told that she has pancreatic cancer, do not tell her that she only has 6 months to live. The information may or may not be true and will not be helpful regardless. As much optimism should be expressed as the situation allows, along with the repeated emphasis that prompt treatment by the best-qualified specialist is vital to the patient's emotional, as well as physical, well-being. If possible, connect the patient to the next level of care prior to her leaving the office or emergency department. This connection is potentially the most important thing that the physician can do for the patient.

Thirdly, and in keeping with earlier sections in this chapter, be prepared to repeat and rephrase information frequently. Do not expect a patient to understand phrases such as "radiation therapy" or "exploratory laparotomy." Patience with what seems like endless repetition will be rewarded with increased patient trust and, ultimately, a smoother transition through Kübler-Ross' grief stages. Open-ended questions are an effective way to measure the degree of comprehension on the part of the patient and may provide valuable insight for the sensitive provider.

SUMMARY

Section 7 of 9  

• Authors and Editors
• Introduction
• Process Issues
• Content Issues
• Personality Issues
• Skills for Specific Situations
• Summary
• Support Services
• References

Attention to global aspects of patient care rather than the chief complaint is essential in order to assure compliance, continuity, and patient satisfaction. The skills necessary to accomplish this may not be intuitive and almost certainly were not taught or emphasized in medical school; however, they can be learned if the caregiver values them. Many sources are available from which to learn these skills, including textbooks, the references below, and good mentoring from clinicians respected for their ability to communicate. Such effort will be amply rewarded by generally shorter, less conflictual patient interactions and by better compliance with prescribed therapy. Resources are available for patient support and should be used liberally.

SUPPORT SERVICES

Section 8 of 9  

• Authors and Editors
• Introduction
• Process Issues
• Content Issues
• Personality Issues
• Skills for Specific Situations
• Summary
• Support Services
• References

Table 1. National Agency Support Services

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Process Issues
• Content Issues
• Personality Issues
• Skills for Specific Situations
• Summary
• Support Services
• References

1. Houle, C., Harwood E., Watkins A. and Baum KD. What women want from their physicians: a qualitative analysis. Journal of Womens Health. May 2007;16(4):543-550. [Medline].
2. Tannen, D. You Just Don't Understand. New York: Balantine; 1990.
3. Tavris, C. Shouters, Sulkers, Grouches, and Scolds - Which sex has the anger problem?. In: Anger the Misunderstood Emotion. Revis ed. New York: Touchstone; 1989:193-219.
4. Griffen EM. A First Look at Communication Theory. New York, NY: McGraw Hill College Div; 1994.
5. Gray, J. Men are from Mars, Women are from Venus. New York: HarperCollins Publishers, Inc.; 1992.
6. Tannen, D. Gender and Discourse. New York: Oxford University Press; 1994.
7. Briton NJ, Hall JA. Beliefs about female and male nonverbal communication. Sex Roles: A Journal of Research. January 1995;[Full Text].
8. Mast MS. On the importance of nonverbal communication in the physician-patient interaction. Patient Educ Couns. Aug 2007;67(3):315-8. [Medline].
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10. Gazamarian JA, Peterson R, Spitz AM, Goodwin MM, Saltzman LE, and Marks JS. Violence and reproductive health: Current knowledge and future research directions. Maternal and Child Health. 2000;4(2):79-84. [Medline].
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16. Creagan ET. How to break bad news--and not devastate the patient. Mayo Clin Proc. Oct 1994;69(10):1015-7. [Medline].
17. EM Griffin. Gender and Communication Styles. In: Hilary Jackson and Jean Akers. A First Look at Communication Theory. 2^nd ed. New York: McGraw-Hill, Inc; 1994:427-440.
18. Fallowfield L. Giving sad and bad news. Lancet. Feb 20 1993;341(8843):476-8. [Medline].
19. Flocke SA, Miller WL, & Crabtree BF. Relationships between physician practice style, patient satisfaction, and attributes of primary care - Original research. Journal of Family Practice. October 2002;[Full Text].
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21. Gray J. Men Are from Mars, Women Are from Venus: A Practical Guide for Improving Communication and Getting What You Want in Your Relationships. New York, NY: Harper Collins; 1992.
22. Heggar A. Emergency room: individuals, families and groups in trauma. Soc Work Health Care. 1993;18(3-4):161-8. [Medline].
23. Hickson ML, Stacks DW. Nonverbal Communication: Studies and Application. Los Angeles, Ca: Roxbury Publishing Company; 1985.
24. Horn S. Tongue Fu! How to Deflect, Disarm, and Defuse Any Verbal Conflict. New York, NY: St. Martin's Griffin; 1996.
25. Houle, C., Harwood E., Watkins A. and Baum KD. What women want from their physicians: a qualitative analysis. Journal of Womens Health. May 2007;16(4):543-550. [Medline].
26. Krahn GL, Hallum A, Kime C. Are there good ways to give ''bad news''?. Pediatrics. Mar 1993;91(3):578-82. [Medline].
27. Kubler-Ross E. On Death and Dying. New York, NY: Collier Books; 1973.
28. Lichter ED. Obstetrics and gynecology in the emergency room: a teaching opportunity. Obstet Gynecol. Dec 1987;70(6):936-7. [Medline].
29. Lyon DS, Benrubi GI. The gynecologist and the dying patient. Gynecology and Obstetrics. 1998;6:95-1-95-10.
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Article Last Updated: Aug 15, 2007