Communicating effectively with breast imaging patients requires professionalism, empathy, and compassion.

Michael N. Linver, MD, FACR

For those of us in breast imaging, the ability to communicate well with patients has become a necessity in our professional lives. As we have assumed a more active clinical role in patients’ care over the past decade, multiple daily personal interactions with patients are the rule, not the exception. As most of us received no training in the art of good communication, we have had to master the required skills primarily through intuition and experience. Once having done so, we reap the benefits of such skills on many levels. First, we can quickly and effectively dissipate the fear and anxiety experienced by every patient entering through our office doors. Second, we engender the patient’s trust and spawn a sense of loyalty to our practice and ourselves. This in turn sets the tone for our entire facility: the practice culture and the overall attitude of our office staffs toward our patients emanate directly from us. Third, by talking directly with the patients, we often obtain valuable additional clinical information that the patients never shared with their own physicians or any other medical personnel. An important side benefit of good communication is that it decreases our medicolegal exposure: patients don’t sue physicians they like, and physicians who they perceive as caring about them. In addition, since we represent an extension of the patients’ referring physicians, we create a stronger relationship with and loyalty from our referring physicians when the patients report back to them how well we treated them in our facility.

Why have we breast imagers been thrust into this important clinical role? The answer is that we are the only physicians who can put the entire breast imaging, clinical, and pathology findings together in the appropriate way. Therefore, we are uniquely qualified, and indeed obligated, to offer the patient the best possible information and advice, at the time she needs it. In the process, we have assumed yet another valuable role: we have become the “face” of radiology for our individual practices. Through our irreplaceable personal connections with patients, we breast imagers have almost single-handedly prevented the wholesale loss of radiology services to off-site opportunists, thereby preserving the stability of radiology practices throughout the country.

What are the circumstances under which the breast imager should communicate directly with the patient? The answer is quite simple: whenever possible, be it in screening, diagnostic evaluation, biopsy or other interventional breast imaging procedures, giving biopsy results, or dealing with the difficult patient. For any of these situations, the key to success lies in the “Three A’s” we all learned in medical school as the most important attributes of any physician: affability, availability, and ability. Since patients assume we are competent physicians and cannot truly measure our medical ability, we are judged instead on our affability and availability. Skillful direct and timely communication with the patient fulfills both these criteria from our patients’ perspective.

The rules of direct patient communication by which I practice derive from common sense, infused with equal measures of empathy and experience. I begin every encounter by addressing the patient by her last name, unless or until the patient gives me permission to do otherwise. Many patients, especially those who are older, consider it a sign of proper respect. I always wear a white coat and tie, as our patients expect us to be professional. It is important to many (but not all) that we look professional as well. Our physical appearance as well as our manner should project an image of caring and trust.

We should never forget that the basic premise under which every patient labors is that she has breast cancer. Therefore, our initial task is to assure her and create an air of calm. The very first thing I do is extend my hand and establish an immediate physical bond. If the screening or diagnostic examination showed no evidence of cancer, I exclaim, as soon as I shake her hand, “Good news—everything looks fine!,” I try to do so in a warm and upbeat tone with a big smile on my face, thus creating the same feeling with my body language as well. Regardless of how busy or harried I am, I try to be friendly, open, and relaxed, not fidgety or impatient. Before meeting the patient, I always query my technologist as to the patient’s frame of mind (even knowing that the patient will treat the technologist differently from the way she will treat me—patients are notorious for taking out their anger and fear on the technologist, and then being sweet as pie when I walk in the room!). When meeting the patient, I quickly try to size her up: is she overly nervous? Is she angry? Is she sophisticated and scholarly? Is she less bright or perhaps even mentally challenged? Each patient will require a totally different approach in my choice of verbal tone, pace of speech, and vocabulary. I pay close attention to her eyes, to ensure that I am ready with tissue if she bursts into tears. If I have seen the patient before, I try to review any notes I may have made in her record about her family, vocation, or special interests or likes, and then casually insert references to these into the conversation. This is an easy and powerful way to cement the personal bond between us.

It is important never to speak down to the patient—I use only words she will understand (no medical jargon), without being condescending in tone or language. It is equally important to speak to the patient on the same physical level—I sit down next to her, if possible. All of these assist the patient in overcoming the tremendous sense of helplessness she feels in this situation. I never rush my speech or project a feeling of urgency with my body language—I try to give the patient the impression that she is the only one I am evaluating that day. My goal is to treat every patient as if she were a member of my own family.

I make an effort to reach out and touch the patient’s arm softly at some time during the encounter (if I believe that this is culturally acceptable to this particular patient). That direct touch is extremely reassuring to most patients. Because every patient initially believes that she has breast cancer, her level of fear and shock is often so high that she will hear almost nothing I say to her. For this reason, I always give the patient the opportunity to contact me if she has any questions later by handing her my card, complete with my e-mail address. I often turn the card over and write down any key words from our discussion (eg, “fibroadenoma” or “cyst”) to act as a further aid to her understanding and recollection later on. (Since most patients go home and immediately look up these key words on the Internet, they may as well be looking up the correct words!)

At the conclusion of the encounter, I always extend my hand for a handshake, and if I know the patient well, especially if she is a follow-up breast cancer patient, I give her a hug. This has a healing effect on both the patient and myself.

One word of caution should be added here: you cannot predict any patient’s perception of you, or her state of mind. Therefore it is wise, especially for male breast imagers, to have a female escort with you. The escort serves as a third party, if one is needed, for any medicolegal issues arising from the encounter in the future.

Delivering Bad News

If a diagnostic workup is suspicious for cancer, then an additional skill set is involved: the art of delivering bad news. This requires a more comprehensive discussion beyond the scope of this article, but can be accessed in more detail in specific treatises by others and me.1-3 However, some comment regarding the basic rules that apply here is in order. First, the discussion with the patient should always take place in a more private area, in which I allow no interruptions from outside. I try to include other family members or friends in the discussion to offer additional support, and to function as “active listeners” who can recount the salient points to the patient later on, in the likely event that the patient’s fear and anxiety prevented her from absorbing the information at the time. I always try to have all the follow-up appointment information available for the patient before beginning the discussion. During the discussion, I try to give gentle yet firm guidance to the patient regarding my choice of action, assuring her that my advice is the same that I would give to my own family member. Patients want and need that personal connection and assurance during this difficult encounter.

After delivering the news, I allow a period of silence, and then ask the patient and/or her friends or family members if they have any questions. Should they have any, I try to be a good listener, never interrupting as they express their concerns. I always attempt to put a positive spin on the findings and expected consequences, painting the best picture I can. However, I do use the word “cancer” at some time during the discussion, to act as a “warning shot” that this is still a possibility. At the same time, I make every effort to give the patient hope. If indeed she does have breast cancer, she will need these words of encouragement to survive the arduous and frightening course of treatment ahead. It is amazing to me how many cancer patients come back and tell me that I was the only one in their entire treatment course who ever told them that they were going to be alright, and how grateful they were to me for those words.

Once the biopsy results are available, I now have the choice of giving her the news in person, over the phone, or through a third party. If the biopsy results are benign, then I often choose to have a trusted and well-trained assistant contact the patient, or will do so myself. If the results are malignant, then I must be the one to contact her. This is easiest to do in person, especially for the most anxious patients, following the same basic tenets covered above. I contact most patients by phone instead. Surprisingly, I have been very successful with this approach, but only if I talk directly to the patient and not to her answering machine.

Talking with patients does take extra time, but if done well and with caring and compassion, the rewards are invaluable, and potentially life-changing: if the patient’s experience with you is a bad one, she may never come back. If, on the other hand, her experience with you is a good one, you may be saving not only her life, but potentially those of the many friends and family members she will tell about her positive experience.

In summary, make every effort to follow these five key rules:

-Remember the three A’s: affability is far and away the most important!

-Dress and act like a professional.

-Treat every patient with the dignity, respect, and kindness that she expects, and that she deserves.

-Every patient thinks she has breast cancer. Therefore, do everything possible to relieve her anxiety. Always stress the positive!

-The patient hears very little of what you tell her. Therefore, leave the door open for future communication.

Every day I am inspired by the quiet courage and strength of my patients—they remain my best teachers. But the words of Leo Buscaglia, the first true motivational speaker, inspire me equally so: “Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.”

Michael N. Linver, MD, FACR, is Director of Mammography, X-Ray Associates of New Mexico, PC, and Clinical Professor of Radiology, University of New Mexico School of Medicine, Albuquerque.

References
  1. Linver MN. Delivering bad news: a vital skill for professionals involved in breast cancer care. Breast Cancer Online. 2009;12(2):3-6.
  2. Harvey JA, Cohen MA, Brenin DR, Nicholson BT, Adams RB. Breaking bad news: a primer for radiologists in breast imaging. J Am Coll Radiol. 2007;4:800-808.
  3. Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press; 1992.