Telling it like it is, when the news is bad, should be best practice

The verdict on the cervical cancer scandal blames two aspects of the HSE: Communication and culture.

The communication failure is women not being told that their smear tests, initially announced as clear, were not clear at all.

An exchange of letters between the then head of CervicalCheck and a consultant inspired an online cartoon, showing dozens of people standing around saying “you tell her,”; “No, YOU tell her,”; while the woman in the middle of the circle asked “Tell me what?”

The avoidance of delivering bad news is not confined to the HSE or to Ireland. It’s a natural instinct. A natural instinct that should be trained out of every medic, before they start to work with patients.

But it’s not a part of medical training, which is frankly bizarre, given that every single doctor and nurse, sooner or later — probably sooner — has to deliver bad news to their patients.

Vested interest alert: Every now and again, some specialist organisation, such as those involved in the care of older people or of patients with cancer, dementia or diabetes, comes to my company, because we provide training proven to develop, in doctors and other medical professionals, the skills to deliver bad news.

What’s interesting is how rarely it happens. Medics want lots of training, but not necessarily in how to tell it like it is to patients whose prognosis is dire.

The first reason for that unwillingness is self-deception. Doctors and nurses believe they’re good at what they’re not good at, and this false belief is exacerbated by the failure to include it in training.

The logical assumption is “if it’s not part of essential training/education, then it can’t be a problem, can it?” Yes, it can.

Research has, for decades, established that medics believe they have told the blunt truth to patients, when, in fact, they have presented a sugar-coated version the patient does not understand at all. Medics are not alone in this.

Large commercial firms have to hire external consultants to train their middle and top management in how to deliver negative feedback, because they so frequently find a major discrepancy between what a staffer believes their boss has told them (“Pretty good and nothing to stop me making director/partner”) and what their boss believes he or she has told them (“Disastrous lack of attention to detail and zero people skills.”)

It’s not that, as a nation, we’re bad at criticism. We’re geniuses at it, and the more vicious you want it, the more vicious you’ll get it.

On social media. Or in mainstream media columns or appearances by people whose fees partly depend on how inflammatory they are. Or in Oireachtas committees, where rude delivers headlines.

Where we’re bad at criticism is where we have to deliver it, one-to-one, face-to-face, to someone we know.

That’s where the boss who knows her subordinate is messy, easily distracted, and dangerously unfocused fafs it, using such vague terms that the subordinate ends up happy out, when the boss intended to make the subordinate “consider their position”.

That reality is worsened when the negatives have to be delivered, one-to-one, face-to-face, to a vulnerable patient. Consultants reluctant to deliver bad news advance a myriad of justifications.

The patient is too frail to cope. It’s not the consultant’s right to take away hope. If the patient wants to know the full truth, they’ll pursue it. The patient’s family have given instructions that they’re not to be told the full truth, because they’d never manage it.

To cut through all that, two actions are sufficient. One is making it mandatory. It’s just amazing the focus middle class professionals develop when faced with the possibility of jail time — witness the current anxiety in almost every company, big and small, about the new data protection rules.

Once a duty of candour is mandatory, the second action comes into place: training. Training medical professionals to deliver the truth sounds easy. It isn’t. We all mistake self-protection for other-directed concern.

We all project onto others desires that let us off the hook. We all, untrained, blurt out negatives in a way that gets us quickly out of the room, but may leave destroyed and desolate the person on the receiving end of our data.

Untrained, medics have no clue that some words or phrases, including “cancer” and “dangerously high blood pressure”, can close down the cognitive processes of the patient being informed, so that all they remember from the encounter is their appointment in Samarra, Indeed, in some instances, patients and their families may need one initial briefing and a subsequent one to deal with their emerging questions, including ‘how much time do I have?’ which, again, according to research, is mostly over-estimated by the medic involved.

It’s not that the doctor tells the patient what the doctor believes the patient wants to hear, it’s that the doctors themselves genuinely over-estimate the time left to the patient.

Communications training, whether in how to deliver bad news to the patient or deliver it in media, is one of the least-valued, most essential skills in healthcare.

Let’s be clear. The controversy of the last fortnight started with bad communication. The CervicalCheck head wasn’t in Ireland. Puzzling, given how important Vicky Phelan’s case was. The consultant did a long-distance interview by phone.

This, together with another interview given by a HSE doctor, set the thing alight, because both talked gobbledygook understandable only to people in their business.

It’s widely believed that media training is about helping people to tell lies. In fact, it’s about helping people tell the truth, so that it is interesting, understandable, and memorable in a way that serves customers/patients, rather than speaking to peers or sloganeering about ‘international best practice,’ which is what, untrained and under pressure, the best medical professional will do.

The other essential aspect of media training is to ask the questions before the interviewer does. Gavin Jennings’ question to the former head of CervicalCheck, about the 208 women who’d been given false negative smear test results, was neither unfair nor an ambush, but rather an obvious query, yet it floored the interviewee.

Much talk of ‘culture’ within the HSE has been bandied about, without specific remedies suggested, perhaps in the belief that once a new CEO is appointed, the culture will magically change. Lash up a new mission statement, make sure everybody on staff has access to it, and the culture will magically change. Won’t it?

No, it won’t. Culture changes when, in groups mixing newcomers and frontliners with top managers, people are forced to specify what behaviour is implicit for them, as individuals, in the high-minded generalities that characterise mission statements.

Only when people hear themselves reacting to simulated situations in real time, surrounded by their peers, does real, measurable culture change happen.