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Ways of giving good news
453
Integral to the difficulties of postgraduate education is the present organisation of the hospital service. Most inpatient care throughout the NHS is being delivered by unsupervised junior doctors trying to complete their medical training and teaching the next generation at the same time. "See one, do one, teach one" is an inappropriate way modem health service. The long-term solution lies in fully trained doctors providing more front-line care, and in a system of organised postgraduate education. The examinations are a symptom of a sick system, not its cause. SIMON J. ELLIS Radcliffe Infirmary, ANDREA H. NEMETH Oxford OX2 6HE, UK to run a
Ways of giving good
news
SIR,-Dr Brewin (May 18, p 1207) describes three ways to give bad news to patients with a newly discovered adverse prognosis. His insights into this aspect of medicine show a wisdom that is difficult to learn other than by long experience. Another important role of the doctor is the imparting of good news-ie, when an investigative procedure is normal. Variations in the presentation of good news parallel those Brewin discusses. The blunt and unfeeling strategy for delivering bad news that Brewin describes may be even more commonplace for good news. Merely telling the patient about negative results of a diagnostic test with little other discussion may allay the patient’s immediate fears but leaves questions unanswered. If symptoms or an earlier abnormal test remain unexplained, the patient may feel that the doctor does not have the expertise to deal with the particular problem. Alternatively, he may feel that the doctor does not believe that the symptoms are real. Too much reassurance while giving good news is the counterpart of the excessive consolation that is obvious in Brewin’s second strategy-the kind and sad way. Dogmatic reassurance solely on the basis of a negative test runs the risk of later criticism, either when a preclinical lesion becomes clinically manifest or when treatment by another doctor purportedly effects a cure. Brewin’s third strategy is a model for any type of patient encounter. The ingredients of flexibility based on patient feedback, positive thinking, reassurance, and planning for the immediate future that Brewin believes provide the best strategy for giving bad news are equally important with good news. The use of feedback is fundamental to the inclusion of the patient in the decision-making process. Grief is the usual response to bad news, but reactions to good news may be more varied, ranging from disappointment to relief. This broad spectrum of patient reaction makes feedback essential in deciding whether a follow-up visit, other diagnostic testing, or empirical therapy should be the next step. Planning for the immediate future is important whether news is good or bad. For a patient with persistent symptoms who is disappointed at not being able to document their suffering by a diagnostic test, the explanation of how time, alternative tests, a repeat test, and empirical therapy fit into the plan should be presented. Asking the patient whether they are happy with the proposed plan ensures that his symptoms are taken seriously, that he feels included in the management of the problem, and serves as a cue to the patient to close the encounter. The conveyance of news of diagnostic testing, whether bad or good, is an aspect of the doctor/patient relationship that receives short shrift in medical education. Junior doctors in training should often have the opportunity to observe other clinicians presenting information to patients. Unfortunately such opportunities are not as common as they might seem, because of fear of the time taken by patients and their family, the relative unimportance of the task, and the perceived need for one-to-one intimacy. This task of giving good news is viewed as time consuming and fairly unimportant-work too trivial for senior clinicians. The delegation of this responsibility to others reinforces the view that communication of good news is unimportant. With attention to reassurance and planning at this point in the doctor/patient encounter, the attending doctor would show the student the potential for saving time and avoiding future misunderstanding. Such teaching for the delivery of the bad news is also prevented by the desire for personal intimacy, which is probably correct. It is
envision how the presence of students who are not in the conversation and who may be even visibly uncomfortable is justifiable when patient confidentiality is at risk. Teaching of strategies in a didactic fashion is worthwhile but is susceptible to the same criticism of teaching of any humanistic aspect of medicine-ie, it is difficult, if not impossible. Emphasis on the doctor/patient relationship has only just begun to take its place in the medical curriculum, and although medical students now gain some exposure to such issues, more could be done, including teaching how to deliver news, good or bad, to the patient.
difficult
to
participating
Department of Internal Medicine, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina 27157, USA
JAMES L. WOFFORD
Kidney trading in Hong Kong SIR,-Dr Kandela has drawn attention (June 22, p 1534) to the illegal trade of kidneys in India. Similar events take place in Hong Kong. Although about 1000 patients are waiting for renal transplantation in Hong Kong only 50 such operations are completed annually. Half of these kidneys come from living-related donors and half come from cadaveric donors, mostly as a result of traffic accidents. The poor development of the Hong Kong renal transplant programme might be because of the traditional Chinese belief of dying in integrity. During recent years, nephrologists in Hong Kong have referred patients to China for renal transplantation. Kidneys are usually obtained from prisoners who are executed for offences such as rape, burglary, or political "crimes" against the state. No consent for organ removal is given by either the prisoner or the family. Furthermore, the family rarely collects the body after execution for fear of harassment by government authorities. Operations have been completed in regional teaching hospitals in Guangzhou (a southern city 80 miles from Hong Kong). Patients are discharged a few weeks later if no major complication occurs, and follow-up is undertaken by the referring physician in Hong Kong. The fee for the entire procedure is about CIO 000. Preoperative testing of blood group, hepatitis B surface antigen, antibody to human immunodeficiency virus, and HLA-tissue type is rarely done, and the frequency of graft rejection is high. Both the Hong Kong Medical Association and the government has condemned this practice. The government has also refused to supply cyclosporin to those patients who had transplants in China. Even these measures do not prevent people from going to China to buy a kidney. Organ trading occurs throughout the world. Doctors must ask governments to impose tighter controls over these practices and must also encourage more people to opt into voluntary kidney donation programmes. Department of Obstetrics and Gynaecology, Mary Hospital, Hong Kong
Queen
SIU-KEUNG LAM
Cosmetic surgery SiR,—The note (July 6, p 48) to which Mr Skanderowicz (July 27, p 260) responds clearly states that the plastic surgery work load is within the National Health Service. With few of the 140 consultant plastic surgeons in the UK exceptions, do private practice, possibily up to 80% of that time being spent on cosmetic surgery. With the possible exception of surgery to the aging face, all aspects of cosmetic surgery are taught late in training (senior registrar level) within NHS practice whenever possible, and what cannot be covered there is taught in the private sector. Surgery of the cleft lip/nose and breast reductions, reconstructions, and augmentations are all available to NHS patients along with dermabrasion, suction, lipolysis, and blepharoplasty. No-one would be qualified in plastic surgery if they were not familiar with all cosmetic aspects of this type of surgery. The Specialist Advisory Committees in plastic surgery rigorously examine training posts and have a representative of the British Association of Aesthetic Plastic Surgeons (BAAPS) as one of their members. His job is to examine the cosmetic experience of
referred
to
most
Integral to the difficulties of postgraduate education is the present organisation of the hospital service. Most inpatient care throughout the NHS is being delivered by unsupervised junior doctors trying to complete their medical training and teaching the next generation at the same time. "See one, do one, teach one" is an inappropriate way modem health service. The long-term solution lies in fully trained doctors providing more front-line care, and in a system of organised postgraduate education. The examinations are a symptom of a sick system, not its cause. SIMON J. ELLIS Radcliffe Infirmary, ANDREA H. NEMETH Oxford OX2 6HE, UK to run a
Ways of giving good
news
SIR,-Dr Brewin (May 18, p 1207) describes three ways to give bad news to patients with a newly discovered adverse prognosis. His insights into this aspect of medicine show a wisdom that is difficult to learn other than by long experience. Another important role of the doctor is the imparting of good news-ie, when an investigative procedure is normal. Variations in the presentation of good news parallel those Brewin discusses. The blunt and unfeeling strategy for delivering bad news that Brewin describes may be even more commonplace for good news. Merely telling the patient about negative results of a diagnostic test with little other discussion may allay the patient’s immediate fears but leaves questions unanswered. If symptoms or an earlier abnormal test remain unexplained, the patient may feel that the doctor does not have the expertise to deal with the particular problem. Alternatively, he may feel that the doctor does not believe that the symptoms are real. Too much reassurance while giving good news is the counterpart of the excessive consolation that is obvious in Brewin’s second strategy-the kind and sad way. Dogmatic reassurance solely on the basis of a negative test runs the risk of later criticism, either when a preclinical lesion becomes clinically manifest or when treatment by another doctor purportedly effects a cure. Brewin’s third strategy is a model for any type of patient encounter. The ingredients of flexibility based on patient feedback, positive thinking, reassurance, and planning for the immediate future that Brewin believes provide the best strategy for giving bad news are equally important with good news. The use of feedback is fundamental to the inclusion of the patient in the decision-making process. Grief is the usual response to bad news, but reactions to good news may be more varied, ranging from disappointment to relief. This broad spectrum of patient reaction makes feedback essential in deciding whether a follow-up visit, other diagnostic testing, or empirical therapy should be the next step. Planning for the immediate future is important whether news is good or bad. For a patient with persistent symptoms who is disappointed at not being able to document their suffering by a diagnostic test, the explanation of how time, alternative tests, a repeat test, and empirical therapy fit into the plan should be presented. Asking the patient whether they are happy with the proposed plan ensures that his symptoms are taken seriously, that he feels included in the management of the problem, and serves as a cue to the patient to close the encounter. The conveyance of news of diagnostic testing, whether bad or good, is an aspect of the doctor/patient relationship that receives short shrift in medical education. Junior doctors in training should often have the opportunity to observe other clinicians presenting information to patients. Unfortunately such opportunities are not as common as they might seem, because of fear of the time taken by patients and their family, the relative unimportance of the task, and the perceived need for one-to-one intimacy. This task of giving good news is viewed as time consuming and fairly unimportant-work too trivial for senior clinicians. The delegation of this responsibility to others reinforces the view that communication of good news is unimportant. With attention to reassurance and planning at this point in the doctor/patient encounter, the attending doctor would show the student the potential for saving time and avoiding future misunderstanding. Such teaching for the delivery of the bad news is also prevented by the desire for personal intimacy, which is probably correct. It is
envision how the presence of students who are not in the conversation and who may be even visibly uncomfortable is justifiable when patient confidentiality is at risk. Teaching of strategies in a didactic fashion is worthwhile but is susceptible to the same criticism of teaching of any humanistic aspect of medicine-ie, it is difficult, if not impossible. Emphasis on the doctor/patient relationship has only just begun to take its place in the medical curriculum, and although medical students now gain some exposure to such issues, more could be done, including teaching how to deliver news, good or bad, to the patient.
difficult
to
participating
Department of Internal Medicine, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina 27157, USA
JAMES L. WOFFORD
Kidney trading in Hong Kong SIR,-Dr Kandela has drawn attention (June 22, p 1534) to the illegal trade of kidneys in India. Similar events take place in Hong Kong. Although about 1000 patients are waiting for renal transplantation in Hong Kong only 50 such operations are completed annually. Half of these kidneys come from living-related donors and half come from cadaveric donors, mostly as a result of traffic accidents. The poor development of the Hong Kong renal transplant programme might be because of the traditional Chinese belief of dying in integrity. During recent years, nephrologists in Hong Kong have referred patients to China for renal transplantation. Kidneys are usually obtained from prisoners who are executed for offences such as rape, burglary, or political "crimes" against the state. No consent for organ removal is given by either the prisoner or the family. Furthermore, the family rarely collects the body after execution for fear of harassment by government authorities. Operations have been completed in regional teaching hospitals in Guangzhou (a southern city 80 miles from Hong Kong). Patients are discharged a few weeks later if no major complication occurs, and follow-up is undertaken by the referring physician in Hong Kong. The fee for the entire procedure is about CIO 000. Preoperative testing of blood group, hepatitis B surface antigen, antibody to human immunodeficiency virus, and HLA-tissue type is rarely done, and the frequency of graft rejection is high. Both the Hong Kong Medical Association and the government has condemned this practice. The government has also refused to supply cyclosporin to those patients who had transplants in China. Even these measures do not prevent people from going to China to buy a kidney. Organ trading occurs throughout the world. Doctors must ask governments to impose tighter controls over these practices and must also encourage more people to opt into voluntary kidney donation programmes. Department of Obstetrics and Gynaecology, Mary Hospital, Hong Kong
Queen
SIU-KEUNG LAM
Cosmetic surgery SiR,—The note (July 6, p 48) to which Mr Skanderowicz (July 27, p 260) responds clearly states that the plastic surgery work load is within the National Health Service. With few of the 140 consultant plastic surgeons in the UK exceptions, do private practice, possibily up to 80% of that time being spent on cosmetic surgery. With the possible exception of surgery to the aging face, all aspects of cosmetic surgery are taught late in training (senior registrar level) within NHS practice whenever possible, and what cannot be covered there is taught in the private sector. Surgery of the cleft lip/nose and breast reductions, reconstructions, and augmentations are all available to NHS patients along with dermabrasion, suction, lipolysis, and blepharoplasty. No-one would be qualified in plastic surgery if they were not familiar with all cosmetic aspects of this type of surgery. The Specialist Advisory Committees in plastic surgery rigorously examine training posts and have a representative of the British Association of Aesthetic Plastic Surgeons (BAAPS) as one of their members. His job is to examine the cosmetic experience of
referred
to
most