On the Art of Delivering Bad—and, of Course, Good—News in Medicine and Oncology

Every physician may sometimes have to give patients bad news. But how can it be delivered in the best possible way?

Dr. Jalid Sehouli, director of the Gynecology Clinic and Surgical Oncology Center in Berlin, Germany, has addressed this issue for more than 20 years. He has conducted extensive research among physicians and medical students (How to Break Bad News) and has also written a book (Von der Kunst, schlechte Nachrichten zu überbringen = The Art of Delivering Bad News). Below is a translation of an interview with this expert conducted by Medscape Medical News:

Question: You surveyed 1300 physicians and medical students about bad news. What were the main findings?

Dr. Sehouli: Most respondents said they struggled to deliver bad news because they tended not to learn the relevant techniques. They also lacked good, structured training. Generally, however, they expressed willingness to engage with the subject. It was also very clear that respondents feared delivering bad news .

Question: Only 31.2% of physicians in your study said they had learned appropriate communication skills. Did this surprise you?

Dr. Sehouli: First, it is wonderful that the physicians were so honest. Still, I think the proportion is much lower. It cannot be measured during the study or higher education, since this is not something included in medical training. A great deal of self-reflection is needed.

Their honesty encouraged me to say, "If someone identifies a problem, that is a good foundation to work from." If everyone surveyed had said, "We have no problem with this," I would see things differently because those people would be unreachable. I regard this admission as a very loud cry for help.

Question: You said the distinction between the person delivering bad news and the person receiving it is too simple. In what way?

Dr. Sehouli: People need to free themselves from this stereotype. Someone delivering difficult or bad news is also a recipient. The person receiving it will also become its messenger, because they must tell their partner or children.

This means the role is always two-way and simultaneous . People first need to understand this fully.

Question: How important is successful communication for physician and patient satisfaction?

Dr. Sehouli: From a healthcare perspective, this is all about the patients receiving the news. Satisfaction therefore matters, but so does patient safety. Better communication helps a patient prepare and leaves fewer problems to manage if complications occur.

From another perspective, physicians see a good discussion as meaningful and strengthening the relationship. We are social beings who live through social interaction. I think physicians with communication difficulties in a field already full of problems do not last long—I have experienced this with my own team. With effective communication and stronger relationships, I believe we would see far less burnout .

Question: Should there be a standard for good communication skills?

Dr. Sehouli: This is a question we need to ask ourselves as a society. I believe there should be a communication standard. We need it to protect ourselves and maintain professionalism without losing empathy. We also need it because patients like to be seen and heard. This is part of the relationship and the backbone of every diagnostic and therapeutic intervention. I think such changes are possible.

The real question is how to achieve them. Today, you can study medicine and become a physician without attending a communication course. This is true not only in Germany but worldwide.

Question: Why is communication not given more importance? Is lack of time the reason?

Dr. Sehouli: Yes, time is a problem. But not everyone recognizes its importance either. If I gave a seminar on a new surgical technique, the room would overflow. In contrast, motivating people to attend a conversation course takes enormous effort because everyone thinks, "I can already do this. Why should I go? I don't need to." That is their view.

Raising the subject, however methodically, may initially upset the balance. It may reveal that you communicate much less well than you think. Without tools to improve, it is easier to avoid it and deal with difficult situations.

Communication is like death or sexuality. We always hear, "Nobody talks about it." Clearly, nobody does. The reason is relatively simple: it cannot be delegated, and no structure exists for it. If your clinic had a sex therapist, raising the subject would be easy. If you had to discuss it yourself without knowing how to answer questions, however, you would prefer not to bring it up. Delivering bad news is the same.

Question: You have worked on bad news for more than 20 years. It is not an appealing subject. Was there a particular reason you wanted to face it?

Dr. Sehouli: As a young doctor, I assisted with difficult cancer operations and saw that complications could occur. I also saw colleagues often fail to visit patients or adequately explain complications, and struggle greatly to communicate with them.

I thought that being able to communicate was part of being a good surgeon. As a young doctor, I organized the gynecology department's "first course in delivering bad news." I had heard the first approaches came from England and thought we should arrange something similar at Charité.

The book grew out of those courses. While researching and writing, I found few guidebooks and almost no scientific studies on the subject. It became clear that the evidence needed developing, so I started two projects: the survey for physicians and medical students, and a patient study that would begin soon.

Question: What will the patient survey involve?

Dr. Sehouli: I aim to interview 1000 female patients. Final preparations are underway. We want to know how women cope with bad news, what they want, and how they believe they could be better prepared.

I have also developed a checklist for them. I want patients to comment on it regardless of whether they would find it useful to carry one. Would they be willing to learn more about communication at a patient academy? The study will begin soon at Charité and continue across Germany.

Question: How can a doctor prepare to deliver bad news?

Dr. Sehouli: You should ask yourself: Am I ready? Can I do this? How much time do I have? What are the foundations of the conversation? It is important to prepare myself explicitly.

Many physicians make no preparation for such conversations, entering without knowing who the patient is, their sociocultural context, or how much they will understand. There is a difference between knowing whether a patient is prepared or simply expects reassurance after an examination, and thinking you only need to tell them they have dozens of liver metastases .

• First step: "Preparation" and "awareness." I see this like a pole-vaulter reviewing details before jumping.
• Second step: How I respond during the conversation. I observe—and of course respect—the patient's emotions.
• Third step: It is also important to be silent, listen more than speak, then try to interpret what you hear and ask the other person: What does this mean for you? What should we expect next?
• Afterward, it is equally important to summarize the process for myself and prepare for the next conversation. It is a kind of algorithm.

Question: How long have medical students received communication training?

Dr. Sehouli: We have improved over the past 10 years. There are language courses and even simulated patients. Many universities use them, and they simulate illnesses to a very high standard. They also give students feedback. This approach is attracting growing interest, but it is still insufficient. I believe

you can truly learn only by taking responsibility . If you discuss communication without taking responsibility for mistakes or treatment decisions, learning is less powerful and lasting than when you must accept that responsibility.

I think training in delivering bad news must be integrated into professional life after graduation.

Question: Do you think younger healthcare professionals find easier ways to deliver bad news?

Dr. Sehouli: The idea that younger generations no longer have this problem is wrong. On the contrary, they face greater challenges because they are insufficiently prepared for face-to-face communication. I fear communication will deteriorate further because we have not thought carefully about analog or digital strategies.

Conversations will be the first important step. There are several examples: How can I conduct a consultation by email or through an app? How can I provide a good video or online consultation? How do I develop my approach to patient relationships while considering digital media?

We also plan to study handling digital media and its effects on the patient–physician relationship.

Question: What do you think of mentoring systems for learning to deliver bad news?

Dr. Sehouli: In principle, that would always be possible, because we learn best from role models. I would welcome mentoring, but it should transcend hierarchy and ideally come from outside one's own field. Otherwise, conflicts can arise. A team member from another department or discipline, or a mentor from another institution, would be worth considering.

The reason mentoring has not developed is time and money. A mentoring program is a job in itself and must be structured. Appropriate resources are therefore needed, and team members must be given time for it. "Nice to have" must give way to a quality standard. Mentoring must become a quality criterion .

Question: So far, we have discussed only bad news, but you also developed a checklist for delivering good news . What does it look like?

Dr. Sehouli: There are 5 golden rules for delivering good news.

• Rule 1: Take time to prepare and pay closer attention to good news, such as normal findings, no signs of recurrence, or an excellent treatment response.
• Rule 2: Deliver the positive information or message.
• Rule 3: After conveying the main message, give the other person time to absorb it. Pause to recognize your own emotions and the patient's.
• Rule 4: Discuss the practical implications and consequences of the good news.
• Rule 5: Do not miss the opportunity good news offers you and your patient; use it—for example, keep a diary or "celebrate." Talk about it if you wish, including with colleagues and your social circle.

Finally, giving good news may also be the best time to explain potential risks or bad news. In advanced cancer, for example, a good response to current treatment does not guarantee future treatment success or that things will always remain this way. Doctors may know that the cancer has a high risk of developing resistance. Similarly, completing treatment for early-stage cancer does not mean recurrence risk has fallen to zero. Good-news conversations are therefore also suitable for improving understanding, discussing future risks, and emphasizing follow-up.