Physicians' use of indirect language to deliver medical bad news: an experimental investigation




Del Vento, Agustin

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This thesis examined the delivery of medical bad news as a situational dilemma. When physicians have to convey distressing information, they must apparently choose between two negative communicative alternatives: To convey the diagnosis directly may distress and harm the patient, but to deny the diagnosis, in order to protect the patient and preserve hope, would risk compromising informed decision-making. Following Bavelas’ (1983) and Bavelas, Black, Chovil, and Mullet’s (1990) theory of situational dilemmas, the author predicted that experienced physicians would solve this dilemma by communicating the bad news indirectly (i.e., using honest but mitigated, softened, or hedged language). The experimental test of this prediction compared the language that physicians used when they communicated a diagnosis of metastasized cancer (the bad news condition) vs. a diagnosis of benign hemangiomas (the good news condition). In a within-subjects design, eight physicians with experience in palliative medicine conveyed these two diagnoses to 16 different volunteers who role-played the patients. The physicians and volunteers each had a schematic scenario with the medical background, but they otherwise improvised their interview, which was videotaped in split screen. Microanalysis of the physicians’ language focused on the sections where the physicians presented the good or the bad news for the first time. This analysis reliably assessed whether the physicians used direct or indirect terms in their naming of the diagnosis and in their evaluation of the news; whether they expressed certainty about the diagnosis; how they referred to the receiver of the diagnosis; and who they identified as the bearer of the news. The results of the microanalysis supported the prediction in this thesis: The physicians used indirect terms at a significantly higher rate when the news was bad than when the news was good. These results suggest that indirect language was the solution that these experienced physicians found for the situational dilemma of delivering bad news. In addition, the volunteer patients’ report after the bad news interview indicated that all of the volunteers understood the diagnosis and that virtually all appreciated the way the physician conveyed the bad news. These results provide evidence to support the effectiveness of indirect language in allowing physicians to convey bad news honestly while still being tactful. The findings of this study have direct implications for training physicians on how to break bad news in a manner that is both accurate and humane.



Bad news delivery, Medical interaction, Videotaped observation, Experiment, Indirect language, Discourse analysis