Anyone who has watched the BBC’s drama “This Is Going To Hurt” will no doubt have something to say about the main protagonist Adam’s bedside manner, or lack of it. The glib, patronising way in which he breaks potentially life-changing news to his patients leaves a lot to be desired.
In our journey to becoming health care professionals, we undergo training on how to deliver bad news relating to life-changing conditions. I have vivid memories of doing such training during medical school and recall there even being a "breaking bad news" station at the end of year clinical assessment.
There are protocols in place for imparting a “You have cancer" news or “Your loved one has passed away” clearly, honestly and sensitively so that patients and family members can both understand and feel supported. But in my experience, when it comes to musculoskeletal (MSK) conditions and sports injuries, we may not be as sensitive to or as effective at delivering bad news to our patients as we perhaps should be.
The professional athlete vs the weekend warrior
When dealing with an injured professional athlete, there is a heightened awareness of how their personal identity is intrinsically linked to their physical prowess, and how not being able to play can directly affect their livelihood. Hearing that they're going to miss the FA Cup final or the Superbowl is a major blow to any athlete so we deliver this news as sensitively as we can.
However, MSK injuries are not the exclusive domain of the elite athlete or competitive sportsperson. They can happen to anyone. It may not mean the end of a promising career in sport, but it can be as equally devastating to the weekend warrior who gets told that the marathon they’ve fundraised and been training for is now out of the question. Or the retiree who has to miss out on playing doubles at the local tennis club.
Such news will clearly have a profound effect on the individual who can now no longer turn to the exercise that helps them maintain their physical fitness, helps them to relax and be less anxious and offers them the social inclusivity they may have come to rely on for their mental wellbeing. And yet as healthcare professionals, we can be flippant when delivering the news. Is it because we believe there is less jeopardy for the individual? Even the use of the phrase "weekend warrior", used as a catch-all to describe anyone who only exercises on a weekend, trivialises the importance for those individuals who manage to pack in their weekly recommended 150 minutes of moderate-intensity physical activity into two days.
Historically, orthopaedic specialists have gained an unfortunate reputation for having a more insensitive disposition… “You have arthritis” or “You need a knee replacement” is big news for the individual hearing this for the first time, but perhaps not always imparted with the greatest degree of sensitivity. As health professionals, we should consider the impact such news will have on a patient and plan how best to deliver it. I'm sure you'd agree that telling a 17-year-old that they’re unlikely to play football again - even socially - within an hour of coming out of theatre is not only bad timing but bad practice (true story!)
Some may consider this "hand-holding" approach soft medicine. After all, most MSK conditions and sports injuries are not life-threatening, but they can be life-changing. The sociologist Douglas W Maynard articulates this perfectly:
"Bad news represents a severe disruption in the life-world of those who are its recipients. When the news is delivered, they must move from their previous taken-for-granted world into a new one."
It’s all in the delivery…
As I mentioned at the start, there is an accepted framework for delivering bad news in medicine learnt by healthcare professionals. Although this framework will apply to most situations, when it comes to MSK and sports injuries I’ve found that a nuanced approach to every patient means I am able to hone down on these fundamentals:
- Allow enough time to talk, appreciating that patients may not take it all in at first - 49% of patients successfully recalled all of the key information without prompting 1 week after a consultation. More questions inevitably arise after the consultation, so point them to reliable resources and encourage them to get back in touch if they still have questions.
- Choose your words carefully. Medical jargon and terminology can be confusing so try to make the content easy to understand. This may involve doing some sketchy drawings or better yet using digital apps like Visible Body to illustrate the problem and treatment options.
- Empathy is everything. It may be the fourth patient I may be giving the same news to that day but it’s the first time the patient sitting in front of me will be hearing this about themselves.
- Put some spin on it! Focus on the positives but remain realistic - "In my experience, 90% of these injuries will be back playing after 3 months...". But don't fail to highlight that around 10% may take longer to recover.
- Highlight the alternatives. Similar to the previous point, try to adopt the cup half-full approach so that instead of reeling off a list of things the patient will no longer be able to do try to highlight the things they can still do or will be able to do once they're recovered. " Yes, you will be out for the next 6-8 weeks with your calf strain, but you can use this time to focus on your core and shoulder strength so that when you're back you'll be overall in a better position than before the injury".
The linked study shows that the words your doctor chooses when formulating the message can affect how well patients adhere to treatment so it is important to set the right balance between being negative or being overly positive.
At the end of the day, it doesn't matter what level you're operating at. Whether you sit at a desk, exercise for leisure, or are an elite athlete, when you get injured the sense of loss that comes from being side-lined can be just as great. As a healthcare professional working in the musculoskeletal sector, the responsibility of delivering bad news is no less diminished. We must take our time to impart this information in a timely, sensitive manner so that the patient is able to understand and appreciate the impact it will have on them and their support structure and influence their attitudes towards their journey to recovery.
