Many nondermatologists do not realize how many times in a day that dermatologists have to deliver news that a condition is difficult to treat or not curable. At the American Academy of Dermatology (AAD) Summer 2015 meeting, there was a session on “breaking bad news” where participants were given the task of delivering a terminal diagnosis of melanoma to an actor patient. The goal of this session was to help dermatologists practice their communication skills in a challenging simulated clinical scenario. This session is a reminder that having these difficult conversations with patients is an inevitable reality for physicians, no matter what specialty they practice.
Many physicians find these interactions stressful and fear that they are ill-equipped at guiding their patients through the emotional fallout of receiving bad news. Luckily a number of studies have shown that clinician skills in these conversations can be taught and improved through practice.1-9 In the past 20 years, several initiatives, like the AAD session, have helped introduce guidelines, protocols, and general advice for physicians to follow when breaking bad news. Conditions like hair loss where there is such an emotional impact on the patient can be time-consuming and draining for the treating physician. This can be a deterrent for treating hair loss in a busy clinic.
In this article, we discuss how to break bad news regarding hair disorders with a focus on how to conduct these difficult conversations with patients. It is our hope that these recommendations can help dermatologists feel more comfortable discussing hair loss with their patients.
What Is Bad News?
Defining what constitutes bad news in medicine is challenging. Bad news is subjective and has certain gradations, effecting individuals differently depending on their life experiences, expectations, personality traits, beliefs, perceived social supports, and emotional resilience.10 Most of the medical literature defines bad news as “any news that drastically and negatively alters the patient’s view of her or his future…”11 or that “results in a cognitive, behavioral, or emotional deficit in the person receiving the news that persists for some time after the news is received.”10 Interestingly, none of these definitions incorporate the perspective of the person delivering the bad news, for example, the physician. But physicians also know intrinsically what constitutes bad news in medicine, because they feel uncomfortable and/or dread having these difficult conversations with their patients. Thus, in the simplest form, bad news is any information that patients do not want to hear and that physicians do not take pleasure in delivering.
How Does Bad News Relate to Hair Disorders?
Hair loss has been shown through multiple studies to have an impact on the quality of life of patients, especially women.12-15 Patients with hair loss report loss of self-confidence and lower self-esteem.14 While hair loss is not a life-threatening disease, it can be perceived just as poorly. For some patients, it is almost like a death—perhaps the death of the self they knew and recognized in the mirror for many years. Patients can often get emotional when discussing their hair loss, and their emotions should not be trivialized.
Bad news related to hair disorders, usually occurs at 2 times in the medical visit. First, it starts with delivering the actual diagnosis and prognosis. Any kind of hair loss may elicit sadness or anxiety for a patient. Secondly, it occurs when addressing patients’ expectations about treatment. Many patients expect medications to restore their hair to what it once was, and too often this is not possible.
Some patients expect to get the same response to a medication that anecdotally helped a family member or friend with hair loss. For example, patients with primary scarring alopecia may expect regrowth of their hair with topical minoxidil when, actually, their form of hair loss is less likely to improve on minoxidil alone compared to nonscarring, androgenic alopecia. Ultimately, when patients’ expectations cannot be met—however, unrealistic they may be—physicians need to be sensitive about how to deliver this bad news.
How Can Dermatologists Best Deliver Bad News to Hair Loss Patients?
There are a number of step-by-step models and guidelines for physicians to follow when imparting bad news to their patients. They were developed to facilitate the flow of information and provide physicians with several strategies for addressing their patients’ distresses.16 Though these models were not developed specifically for hair loss patients, they are applicable to all medical specialties. Examples of these models are summarized in the Table.16-19 The effectiveness of using these models on patients has not been well studied, and thus no specific model is reportedly better than another. Essentially all the models follow a similar format consisting of preparation for disclosure and follow-up.20