The Art of Medicine: Breaking Serious News to Patients

Austinites are helping Dell Med doctors-in-training become better at communicating with patients and their families.

The electronic line on the heart monitor lies flat. Cut to a long hall, where a doctor walks toward a set of double doors, wearily wiping her surgical cap from her head. The news is devastating, and it’s her job to tell the anxious family waiting on the other side.

It isn’t an episode of "Grey’s Anatomy" or "ER" — it’s reality for physicians, who regularly deliver news, some good, some bad, to patients and their families.

Instruction and firsthand experience in delivering information to patients is part of the second-year curriculum at Dell Medical School at The University of Texas at Austin. Faculty have dubbed the training “Discussing Serious News,” and it includes simulated conversations with patients, followed by group discussion facilitated by a faculty physician.

The Doctor

James Marroquin, M.D., an assistant professor at Dell Med, was an early advocate for Discussing Serious News, along with LuAnn Wilkerson, Ed.D., a professor and associate dean for evaluation and faculty development, and Amy Beth Brandes, MPH, an improvement adviser at Ascension’s Seton Healthcare Family, which operates Dell Seton Medical Center at The University of Texas — Dell Med’s teaching hospital.

“There’s more and more recognition that [the way information is conveyed] is a crucial part of the patient’s experience and healing,” Marroquin says.

On a Thursday night in mid-October, he encouraged the five students in his small group to prepare to support that experience and healing by using the GUIDE method to deliver information accurately, effectively and compassionately.

GUIDE stands for get ready, understand what the patient knows and feels, inform, deepen and equip. It’s a roadmap for critical conversations between doctors and patients.

“If you were a patient, what would you want from the doctor?” he asks the group. “The big goals are to feel cared for and supported, to feel like you know what’s going on, and to feel like you have a plan.”

The Patient

S. Lemuel Bradshaw can attest to that. The 48-year-old Austin native was diagnosed with dilated cardiomyopathy (a condition in which the heart is enlarged and loses its ability to pump blood effectively) when he was just 28. Then, in 2014, he learned he had renal cell sarcoma, a rare type of kidney cancer.

Today, he’s a cancer survivor living with a transplanted heart and volunteers with Seton’s Patient Family Advisory Councils, groups of individuals who give Seton patient input on projects and polices. The councils partner with Dell Med on Discussing Serious News, sending their members to participate in simulations with students.

Bradshaw says the physician’s first encounter with the patient sets the tone for everything that follows.

“A doctor is like a mechanic,” he explains. “Most of us don’t know anything about cars. You go in wondering, 'Is this guy ripping me off? Does this guy know what he’s talking about?' And the same is true for a doctor the first time you meet them. They don’t know me, I don’t know them. But if they are trained to acknowledge that when they walk in, and they understand that they need to tailor the delivery of what they know to me as a patient, trust begins.”

For the next hour, the students take turns telling Bradshaw first that he needs a heart transplant, then that he has cancer. He borrows from the experience of the real-life versions of these conversations, at times challenging the “doctors.”

“I came to this hospital because I was throwing up,” he says. “I didn’t want to come — my wife made me come. And now I’m sitting here an hour later, and you’re telling me that I have an irreversible heart condition? I don’t know what to say to that.”

If you were a patient, what would you want from the doctor? ... The big goals are to feel cared for and supported, to feel like you know what’s going on, and to feel like you have a plan.

James Marroquin, M.D.
Assistant Professor, Department of Medical Education

The Students

Most of the students struggle to answer Bradshaw’s questions, their replies halting, stiff or incomplete. They’ll become better versed in how to respond as their medical knowledge increases, as they watch attending doctors interact with patients during clinical rotations in medical school and, later, during residency — specialized, graduate-level medical training.

One student introduces himself as a cardiologist, “surprising” Bradshaw, who arrived at the hospital having no idea that something might be wrong with his heart. But by the second round, their delivery is noticeably better, and they’re able to critique their own performances.

“I had an issue with jumping to the next part of the conversation,” says Houston native Marisa Simon — who, for the record, was incredibly thorough, her compassion for Bradshaw evident. “I should have paused more, waited longer.”

As the session ends — it’s now dark outside, and there are more classes tomorrow — the students summarize what they’ve learned. “You have to stay humble. Let the patient drive the conversation,” says Kevin Elwood, an alumnus of Texas’ College of Natural Sciences and originally from Chicago.

“It’s important to prepare before you walk into the room,” adds Sabah Akbani, who worked as a software developer before refocusing on medicine. “I know all those things,” she says, referring to GUIDE and the factual basis of Bradshaw’s diagnoses. “I just don’t think of them in the moment if I don’t take a minute to get ready.”

Even Marroquin, the faculty physician, has benefitted from the session. “I’m reminded of some best practices that it can be easy to forget,” he says. “The value of avoiding lingo and using understandable words. Of leaving silence — giving patients time to process.”

Across the table, Bradshaw nods. The students take note.