BREAKING BODE NEWS BY PHONE?

Communicating the news that a biopsy result indicates malignancy by telephone may be better than delivering the news in person, a team of researchers from the University of Michigan, in Ann Arbor, suggests. Two outside experts do not altogether agree.

"Telemedicine approaches can potentially relieve much of the anxiety associated with in-person consultations while delivering bad news in a timely, compassionate, and patient-centered manner," write Naveen Krishnan and colleagues in a viewpointpublished in the November issue of JAMA Oncology.

Getting the bad news over the telephone can give patients time to absorb their diagnosis and take greater advantage of their next in-person consultation, Krishnan and colleagues write.

"The initial in-person office visit to communicate malignant biopsy results is arguably less interactive than expected. Patients are not only trying to absorb devastating news but also engage in challenging conversations," they write. "On the other hand, communication of biopsy results through telecommunication can serve as a buffer to the initial in-person visit and provide time for patients to process the results alone or with family."

The authors cite examples of oncologic services delivered through telemedicine.

One is the Arizona Telemedicine Program's Telehealth Rapid Breast Care Process, which lets patients receive their breast cancer diagnosis the same day as their biopsy. The program is conducted under the auspices of the University of Arizona.

Another example is the Ontario Telemedicine Network, located in Canada. With more than 1600 sites and 3000 systems, the OTN is the largest teleoncology service in North America, according to the authors.

"The Ontario Telemedicine Network has overcome a number of barriers, including cost, physician compensation, and resistance to telehealth technology adoption," they write. "In fact, telehealth technology is now an everyday part of health care delivery in Ontario."

Krishnan and colleagues claim that for patients, message content and timeliness are the two most important factors in relaying biopsy results. Patients are less interested in nonverbal communication on the part of the physician delivering the bad news, they say.

"In this respect, telemedicine allows physicians to focus on content rather than nonverbal communication that patients may not appreciate at the initial in-person visit," the authors write.

"With increasing clinical time constraints and the shock of hearing a cancer diagnosis in person, telemedicine encounters can facilitate more meaningful future in-person discussions of complex therapeutic options and their adverse effects," the authors write.

Telemedicine Ignores Patients' Emotional Needs

Medscape Medical News asked two experts not associated with the viewpoint article for their views on the use of telemedicine to deliver the news that a biopsy result indicates malignancy.

Philip Bialer, MD, is an attending psychiatrist at Memorial Sloan Kettering Cancer Center in New York City.

He is also director of training for the Center's Communication Skills Research and Training Laboratory, which develops research initiatives to find the most effective way to train healthcare providers to communicate in a sensitive and productive manner.

"I certainly agree with the idea of telemedicine. It can be very helpful, especially in more rural areas where there may be fewer providers, and I also agree with respecting individual preferences about how patients prefer to learn results of tests and about making the process as patient-centered as possible," Dr Bialer said.

"But I also have some concerns. The authors cite literature that says that patients want to focus on message content and timeliness rather than being told in person. I don't know if I totally agree. The literature also says that patients, especially in cancer settings, have many unmet needs in terms of impact of the communication, their emotional response, and so on, so my one concern about giving bad news just with telemedicine is that it disregards the humanistic aspects of medicine that are more likely to happen in person," he said.

"At the very least, if we are going to be conveying this sort of information through telemedicine, I think a video needs to be included too, such as Skype, so there is some visual contact. It's not as good as in-person contact, but at least there is some visual contact," Dr Bialer said.

"This is their opinion. They seem to be advocating that delivering biopsy results via telephone is preferable before the first patient face-to-face meeting, and I don't agree with that. I don't think there is any literature to back this up. That's why I say this truly is their opinion," he added.

"Telemedicine can be very useful, but when it comes to two very emotionally charged issues, like breaking bad news or discussing a bad prognosis, I would disagree that this is preferable to a face-to-face meeting. We need to go back to the humanistic side of doctor-patient interaction," Dr Bialer said.

"We also have to check with patients how much they want to hear and what they are ready to hear. Some of them will say, 'I can't talk about this right now,' and if they're not ready, I'll say that we can set up another time to talk about it. It's not a cut-and-dried approach, and each patient is different," he said.

The Telemedicine Approach May Be Useful

Alicia K. Morgans, MD, MPH, from the Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, has done work in delivering bad news to oncology patients.

She believes that telemedicine used in this way represents a paradigm shift regarding the delivery of bad news.

"As a medical oncologist, I'm coming from a perspective where I have a long-term relationship with patients, so as I deliver bad news, I want to be with them to read their faces. I want to be with their families to make sure that I understand and can answer all of the questions, concerns, and anxieties that they have," Dr Morgans told Medscape Medical News.

However, delivering biopsy results via telemedicine might be helpful, especially in cases in which patients are separated from their doctors by distance or when there are scheduling conflicts, she said.

"Getting the results of a biopsy by phone is done at a time when the patient does not have that established knowledge of their doctor who is ultimately going to be treating them for their cancer, so perhaps in that case, it may be one method of communicating the unwelcome news, but it must be done by people who are very well trained to deliver bad news in that kind of situation," Dr Morgan said.

"And what happens when you hang up the phone and the patient has another question that just popped into his or her head? If you're in the office, they can grab you or grab your nurse and ask that question, but it's much more difficult over the phone," she said.

Another concern is reimbursement, Dr Morgans said.

"It's hard to quantify what we do in the office, let alone what we do on the phone, and phone calls are not always brief with patients," she said.

One of the viewpoint authors receives support through a Veterans Affairs Health Services Research and Development Career Development Award. The other authors, Dr Bialer, and Dr Morgans have reported no relevant financial relationships.