Of all the difficult conversations you have with horse owners, delivering bad news likely ranks as the worst. It wasn’t taught in school, and no matter how intelligent and caring you are, it’s not always intuitive. Many of the brightest and most accomplished equine practitioners approach conversations about bad prognoses with a sense of dread and uncertainty. But explaining difficult situations is also one of the most important things you can do for clients throughout your career. It improves short- and long-term client satisfaction and trust. Knowing that doesn’t exactly make it easier, does it? That’s OK, because the following guidelines will.
Why it’s so hard
When giving bad news, you want to get the message across clearly and effectively. At the same time, you need to meet your clients’ needs as they receive the news. Oh, and one more thing: You’ll need to monitor your own feelings and reactions as well. No wonder it’s so difficult.
For those of you who spend your days improving horses’ health, a bad outcome or a poor prognosis can feel very personal. Sometimes you don’t understand your own feelings before you have to help clients with theirs. As a result, you may rush, avoid the subject, or talk a blue streak—all because of your own discomfort. Sometimes you do understand how they feel. For instance, when you tell an anxious owner that her horse didn’t survive emergency colic surgery, you may be very familiar with that emotional sense of defeat. You know that feeling of disappointment when you review results that paint a bleak prognosis. When it comes time to share those results, you don’t want to let that client down.
All those tough emotions should be reassuring to you. Why? If you didn’t feel anything when the news was bad, you wouldn’t fully experience the satisfaction of success either. And you probably wouldn’t have gone to all the trouble of veterinary school. You’re the care provider; you’re invested—and on my behalf as well as that of other horse owners, thank you!
However, we need you around to treat our horses in the long term, and studies show that veterinarians most personally affected by poor outcomes also suffer the worst burnout. (In the UK, for example, veterinarians are twice as likely to commit suicide as other healthcare professionals.) Don’t let that be you. Before you take up the mantle as bearer of bad news, examine your own feelings first, take what you need from them, and then put them in perspective so you can focus and do what needs to be done.
Why it’s so important
This seems obvious enough: If there’s bad news to share, it’s important to share it. But there’s more to it than that. Most of us can remember where we were or what we were doing when we heard a piece of significant national or cultural news—for example, I’m sure you could tell me exactly where you were when you first heard about the 9/11 attacks.
Behavior experts call this “anchoring.” It’s a hallmark of human experience when we receive startling, tragic, or unexpected information. The more serious the news, the more we anchor to the memory of how we received it. When you as an equine doctor are aware of this phenomenon, you can fight the impulse to blow through uncomfortable conversations. No matter what, the client will remember your delivery of the bad news forever. Handle the situation with compassion and strength, and your client will remember those aspects of the conversation vividly.
Photo by: Emily R. Norman, Getty Images
Click here to go to the next page.
Steps in the process
If the ability to deliver bad news well were simply a talent, guidelines wouldn’t help. The truth is that there is a clear process. And you can learn how it works. It’s true that communication skills come more easily to certain people and personalities, but that could be because those people naturally internalized the following process. Good for them, but I wrote the steps down just for you. The more you practice, the more natural they’ll feel.
Step 1: Gather data and prepare. Sometimes the idea of planning for a discussion is more intimidating than responding in the moment. It’s tempting to either procrastinate and avoid the conversation altogether or dive in and “get it over with” so it doesn’t weigh on you anymore. Resist the urge and see this situation for what it is: an opportunity to develop your communication skills and give your client the benefit of a clearly-thought-out discussion. Review the case in your mind. Think about what you want to say. If it’s helpful, don’t be afraid to rehearse your words. Better you realize a statement “doesn’t come out well” in an empty room where you can change it than in front of a wide-eyed, emotional horse owner. Go over the patient record, make sure it’s updated, and keep it handy during the discussion.
If you’re rushed or unprepared, your client may perceive that as a lack of compassion—“She doesn’t think this is a big deal!”—rather than an expression of your own anxiety. Identify missing information ahead of time so you don’t appear confused as you rifle through papers or walk off in search of test results.
Step 2: Manage your environment. This isn’t always easy, but it’s important. An emergency call to a crowded barn may seem less nerve-racking than a quiet room with two chairs, but the client needs your careful, focused attention.
Of course, in an emergency, you’re often caught between attending to the patient and communicating with the client. You may be able to exchange only enough information for the client to make a critical decision. But after the emergency, clients need your help thinking through difficult outcomes, and it’s your job to provide that help.
If total privacy isn’t available, enlist a technician or someone nearby to help you minimize distractions and prevent interruptions. Silence your pager and cell phone, find a quiet corner with a place to sit down, then pause for a moment and maintain eye contact. Be prepared to explain, listen, answer questions, and listen some more. If the bad outcome was a fatality and your next appointment is routine, consider rescheduling so you can give your client the opportunity to process as much as possible while you are there.
Step 3. Have a plan. Start with what your client already knows about the patient’s status as your starting point. For example: “As we discussed, this was obviously a significant lameness, so we gave your filly some pain medication and took a series of X-rays.”
Then make a preparatory statement: “I wish I had better news to give you.” Follow that with a specific statement about your diagnosis and what it means: “This is a serious injury. It doesn’t appear to be life-threatening at this point, but it will end her career as a racehorse.”
Get to the point quickly and clearly, but recognize that once you deliver the worst of the news, much of what you say afterward will be forgotten or only partially absorbed. This owner may clearly remember “doesn’t appear to be life-threatening” as well as “end her career as a racehorse,” but your careful follow-up about laminitis and other risks might be lost in a haze. Be patient, and be prepared to return to important details later after the initial blow has been absorbed.
Click here to go to the next page.
Step 4. Pause and let the client respond. Once the worst is out there, it’s time to pause and give your client an opportunity to respond. That can be easier said than done. Your anxiety may push you to keep talking and fill uncomfortable silences. Resist! Your client may need a minute before he can form a response, but that doesn’t mean he doesn’t have one.
If the silence continues, you can acknowledge the difficulty of the situation or ask an exploratory question. But unless you know the client well and understand the relationship to the patient, don’t make assumptions about what he feels other than disappointment. “I know this isn’t what you hoped to hear,” or “I’m very sorry I don’t have better news” shows empathy while it avoids clairvoyance. (“I know you’re sad” and “I know you’re angry” are statements to avoid.)
The impact of the news may be financial. It may mean the end of a personal or professional dream. Or it could be the sudden loss of a deep and personal attachment to the horse. Depending on circumstances, your prognosis could be devastating—or it could be taken far better than you expected. As you listen, you may gain insight to guide you, but be careful of blind assumptions.
Step 5: Offer more detail and follow-up. Once you’ve received an initial response, you’ll begin asking and answering questions, giving more detail, and then asking and answering questions again. In human medicine they refer to this as “chunking and checking.” You deliver a small chunk of information, then you check that the listener absorbed it before you add another small chunk. This method makes the whole story much easier to process than an uninterrupted speech of the facts, particularly when someone’s under stress.
Step 6: Develop a strategy for what happens next. As you listen carefully, acknowledge what you hear, and validate it where you can, take cues from your client’s responses to determine the level of detail he is looking for. If one of your goals is to secure a course of treatment, the care you take during this process could make all the difference in creating a good plan. The more organized, relaxed, and focused you are, the more you set the right tone, and that helps your client think clearly and make good decisions.
Communicating bad news is much more than making the best of a bad situation. It’s your chance as the veterinary provider to offer care in one of its finest forms. This care doesn’t come inside a syringe or wrapped in pill form. It comes with a dose of emotion, a helping of communication know-how, and a bottle full of the wisdom that understanding medicine and people. And it can help make you a better equine veterinarian.