Breaking bad news in healthcare: why we shoot the messenger

Breaking bad news is a cornerstone of healthcare delivery. From the doctor delivering blood test results in cancer services to the sonographer communicating the discovery of a pregnancy loss, healthcare professionals regularly find themselves in this challenging situation.

But why is it so challenging? In theory, the healthcare professional is simply the messenger: the person relaying information about an event they did not cause and had no influence over. The reality is nothing like this, though. Research tells us that healthcare professionals find these situations highly stressful, particularly when the news is unexpected or seems unusual or unjust. Some end up coping in unhelpful ways; distancing themselves from the patient by using technical language, delaying the communication of the news or avoiding it altogether and passing the task on to someone else. These coping tactics often backfire by creating a more negative experience for the patient and further increasing the stress the healthcare professional feels.

breaking bad news

A recent study has shed light on these conversations, identifying some of the underlying reasons for why these events are quite so difficult for healthcare professionals. This study conducted a series of 11 experiments, which together showed that:

  • After receiving bad news, people feel a need to try and ‘make sense’ of it
  • To help them ‘make sense’ of bad news, people dislike the person who told them, even if they clearly are not to blame for what has happened
  • People dislike the messenger even more if the news is unexpected, or if it is particularly unjust or unusual
  • The reason that people dislike those who tell them bad news is because they think these messengers have bad motives: they mean badly
  • This effect is reduced if recipients of bad news have reason to think the messenger has benevolent motives or means well

This study used a range of news delivery scenarios, including one where a person was told that they had not won a $2 bonus and another where their scheduled flight was running late. However, I think this study has important implications for healthcare settings for three main reasons:

  1. It brings a new perspective to why these events are so challenging for healthcare professionals. It’s not logical, but the truth is that patients will like professionals less when they deliver bad news, and consciously or subconsciously, professionals know this. Building good professional-patient relationships is a key part of healthcare delivery, and having to deliver bad news works against this.
  2. It highlights the situations where delivering bad and difficult news is going to be most challenging. Specifically, these are likely to be where the news is unexpected or where it is particularly unusual or unjust. I think that two key settings where staff should be better supported with this task are obstetricultrasound and maternity services more broadly, as the news is often unexpected and paediatrics, where bad news could be more likely to be perceived as unusual and unjust. In these situations, the recipients of bad news may have to work harder to make sense of the information they have received, and as such, may be more likely to ‘shoot the messenger’.
  3. It offers a suggestion for how healthcare professionals can reduce the ‘shoot the messenger’ effect: namely, by communicating their benevolent intentions. For example, this could involve saying ‘I’m so sorry, I hoped to bring you better news than this. This must be so difficult for you to hear’. However, doing this requires professionals to be forthcoming and open. Unhelpfully, the impact of stress often has the opposite effect: it inhibits people, making them more careful and wary of saying ‘the wrong thing’; therefore increasing the chance that they’ll say very little. What this research shows is that by going against the natural instinct to say little in stressful situations, healthcare professionals can reduce the ‘shoot the messenger’ effect and help create a better experience for both themselves and their patients. It is also consistent with findings of a review I conducted which showed that training healthcare professionals in breaking bad news works: it enhances their confidence of how to manage these difficult situations and improves their skills.

Six ways that breaking bad and difficult news in ultrasound is different to other settings

Not all pregnancies follow the textbook. Around 1 in 6 are lost to miscarriage or stillbirth and in 1 in 20 there is an unexpected finding on an ultrasound scan which could suggest the baby has a health condition (Ahman et al., 2014; Blohm et al., 2008; Skupski et al., 1996). Altogether around 150,000 families in England and Wales are affected by one of these complications each year (ONS; 2016). These events are deeply upsetting; parents who experience them are at higher risk for depression, anxiety and even symptoms of trauma (Blackmore et al., 2011; Cumming et al., 2007; Korenromp et al., 2005).

The role of ultrasound

Ultrasound is an important tool for diagnosing these complications and in the UK sonographers are the first to break the news to parents about what they have found. The way this is done is important, as it has a strong emotional impact on expectant parents (Bijma et al., 2008; Johnson et al., 2018). However, there is currently no evidence-based training to support sonographers with news delivery. The training which is available is generally based on research which has been conducted in oncology and other healthcare settings.

The need for an evidence-based training intervention

When I have suggested that new research is needed to understand how bad and difficult news can be better delivered via ultrasound, one question I have been asked is whether this is really needed. Isn’t there plenty of research in other settings to inform training? In this blog, I will present six ways that breaking bad and difficult news via ultrasound is different to breaking bad news in other settings.

1. There is no time for sonographers to prepare before delivering the news

A large body of research tells us that expectant parents study the sonographer’s face as they do the scan: they are attuned to their body language and facial expression and quickly sense when something is wrong. The sonographer is unintentionally communicating news before they even speak, and they have no time alone at all to mentally prepare before sharing what they have found with parents. In cancer care, this would be the same as a doctor having to open test results, read and interpret them while the patient watches them.

2. Having a baby isn’t primarily a healthcare event, it’s a rite of passage

Few people will spend years thinking about their future with a diagnosis of cancer, but many people, consciously or subconsciously, gather quiet expectations about what their future will be like with a child. When you deliver difficult news as a sonographer, you deliver it into a world of positive expectation, which is further fuelled by people sharing scan pictures on social media, and television shows like One Born Every Minute. Because of this, the situation is particularly high stress for both those delivering and those receiving the news.

 3. The need for a second opinion

When a sonographer identifies a miscarriage, stillbirth or fetal anomaly a second opinion is necessary to confirm his. The sonographer needs to leave the scan room to find another qualified healthcare professional who can confirm what has been seen. This is a difficult point, and one that is not encountered in other areas of healthcare. Sonographers are often torn over how much to disclose to the expectant parent before the second opinion has been gathered, especially if they are not confident themselves in what they have seen. Failing to disclose their concerns to the parent can result in parents feeling anxious when they find a second professional has been invited into the scan room without explanation. However, immediately disclosing concerns to parents that are then not confirmed can cause unnecessary anxiety. It’s a dilemma that sonographers regularly face which is not found in other difficult news delivery scenarios.

4. The news may be uncertain

When receiving difficult news in other settings, patients can rightly expect that the healthcare professional telling them this news will be informed about their condition and be able to provide detailed information on this. However, sonographers do not have this luxury. While scanning technology has advanced significantly in the last few decades, it is not always possible to provide accurate diagnoses and prognoses immediately. Because of this, sonographers are often communicating difficult news which is uncertain, and which could change in light of subsequent investigations.

5. Ultrasound presents opportunities and raises challenging choices

Unlike other areas of healthcare, ultrasound often provides a diagnosis before anyone’s health has been compromised. It can enable expectant parents to have missed miscarriages diagnosed and allow them to choose whether they want to shorten the length of their pregnancy by accepting a medical intervention. Ultrasound can also detect some fetal abnormalities.  If a baby is found to have a disability (or a possible disability) parents may need to decide whether to have invasive testing; whether to terminate the pregnancy; or in rare cases, whether to have prenatal interventions. These kinds of decisions introduce a huge weight of responsibility – could prenatal investigations and interventions put the baby or mother at risk? Is it morally wrong to terminate a pregnancy? Will not terminating a pregnancy detract energy from any existing children? When sonographers deliver difficult news they know they are often placing a burden of responsibility on expectant parents to make choices, in a way that is not encountered elsewhere in healthcare.

6. The warning shot is not always wanted

Most models for breaking bad news recommend the delivery of a ‘warning shot’ before the main news is imparted (e.g., Baile et al., 2000). This is designed to prepare patients that bad news is coming, and might run like this: “I’m afraid we have identified some concerning findings in your results”. My research has identified that this warning shot is not always wanted in ultrasound settings because parents have already received their warning shot from the sonographer’s body language and facial expression (see my blog on parent experiences here). These kinds of warning shots only extend the overall duration of the event and serve to increase expectant parents’ anxieties.  Furthermore, if the news being delivered is that the baby has a disability, this kind of warning shot can be taken as a negative value judgement by the healthcare professional, which may offend the expectant parent. Instead, parents prefer to be told things directly but kindly, in simple language. In my previous study in parents of children with limb differences, parents most preferred it when healthcare professionals simply said something like: “I can’t currently see your child’s arm below the elbow” (Johnson et al., 2018).

Summing up

There is strong evidence from other healthcare settings that training to improve news delivery is highly effective (see my blog on this here). However, there are clear differences between breaking bad and difficult news in ultrasound compared with other settings. Assuming that the same principles can be transposed from other healthcare settings into ultrasound without adaptation could at best reduce the effectiveness of training, and at worst, increase parental anxiety.