A woman sits down and says: ‘I’m pregnant’. Pause. Context is so important here. How I respond is likely to affect our person-professional relationship, perhaps for some time. Is this good news or bad news or perhaps she hasn’t decided yet?
One definition of bad news in the health care setting is ‘any news that drastically and negatively alters the patient’s view of her or his future’.[i] There has been a lot written about how to break bad news as a health professional. Less it seems to me about that point when news could be interpreted as bad or good. Years ago I gave a woman what I assumed was ‘good news’ in that her most recent cervical smear (this was well before HPV testing) was normal and therefore she no longer needed to have yearly tests. She had previously been treated for pre-cancerous cells and the follow-up protocol involved annual examination for 5 years. Her response to the result didn’t seem consistent with its positive message and when I probed it turned out it was not all that good for her. She was scared of developing cancer and had not had sex with her husband since the first abnormal smear. Only being able to have regular follow-up tests reduced her anxiety.
It is easy to make assumptions about a person’s reaction to ‘news’ based on how we might react in a similar position. A patient is advised she will be going home tomorrow – but that’s not good news as she lives alone and prefers the companionship of the hospital ward. A student fails the exams at the end of his first year at medical school – but that’s not bad news because now he can now leave a course his parents wanted him to do but in which he has no interest himself.
I remember a man in his thirties who complains of pain when passing urine (dysuria). During our conversation I ask him if he could have a sexually transmitted infection (STI). He denies this possibility strongly. I ask again when filling out the request form to test for a urinary tract infection (UTI) because, as a I tell him, I would need to specifically ask for STI testing. No need, he says. The mid-stream urine specimen (MSU) shows no evidence of infection. I ring him with the result. He says that is good news but doesn’t sound happy. He again declines an STI check. I ask him to come back if the symptoms persist. Next day he returns. He was hoping he would have a UTI as he still has dysuria. Now he says he has had unprotected sex on a one nightstand and hasn’t told his partner. The negative urine test is bad news, and on further testing, he did have chlamydia.
It is important when requesting tests to prepare the patient for the results, what would be good or bad for them, and to make sure to get consent for each test. When a woman asks for a pregnancy test during a consultation there is time to ask about what the result would mean for her.
In terms of consent, challenging consultations occur when a patient returns for test results that have been ordered by another health professional. It is not always obvious why certain tests have been requested and if consent was specifically given. I have had women who attended the Emergency Department return for results (‘go see your GP for the results’) who have had pregnancy and STI tests without being told. Or, at least if they were told, they don’t remember in the stress of the circumstances.
In terms of language when a health professional says a test is negative this is usually good news but ‘negative’ may not convey this to patients. A positive pregnancy test may be good or bad news, but a positive HIV test is (usually) bad news. Even saying a test is normal is problematic depending on the context, and may not be the reassurance the health professional assumes.[ii] [iii]
Remember context, consent and communication.
[i] Buckman R. How to break bad news: A guide for health professionals. Baltimore: John Hopkins Press, 1992.