Attentive ears, expanded care: communication in medical practice

Abstract

Communication is fundamental in healthcare, especially in the medical sphere, where the quality of interaction between professionals and patients may influence the understanding of diagnoses, therapeutic choices and the care required. This article explores the complexity and impact of difficult news, highlighting the importance of qualified listening; medical training about the role of empathy and bonding with patients and their families; and the outcome of communication in physical and mental health, highlighting the need for strategies to improve professionals’ communication skills. The methodology applied in preparing this study was epistemological, interdisciplinary and qualitative, based on bibliographical research in scientific literature available on digital platforms. The discussion aims to promote more empathetic and patient-centered practices, highlighting the importance of simple, responsible, sensitive and effective communication in healthcare environments.

Education, medical; Empathy; Humanization of assistance; Physician-patient relations; Mental health

Resumo

A comunicação desempenha papel fundamental na área da saúde, especialmente na esfera médica, em que a qualidade da interação entre profissionais e pacientes pode influenciar na compreensão de diagnósticos, nas escolhas terapêuticas e nos cuidados requeridos. Assim, este artigo explora a complexidade e o impacto das notícias difíceis, destacando a importância da escuta qualificada; a formação médica no que diz respeito ao papel da empatia e do vínculo com os pacientes e seus familiares; e o resultado da comunicação na saúde física e mental, evidenciando a necessidade de estratégias para aprimorar a habilidade comunicativa dos profissionais. A metodologia aplicada na elaboração deste estudo foi de cunho epistemológico, interdisciplinar e qualitativo, baseada em pesquisa bibliográfica em literatura científica disponível em plataformas digitais. A discussão tem por objetivo promover uma prática mais empática e centrada no paciente, destacando a relevância de uma comunicação simples, responsável, sensível e eficaz no ambiente da saúde.

Educação médica; Empatia; Humanização da assistência; Relações médico-paciente; Saúde mental

Resumen

La comunicación es fundamental en la salud, especialmente en el ámbito médico, en que una interacción de calidad entre los profesionales y los pacientes puede influir en la comprensión de diagnósticos, opciones terapéuticas y cuidados requeridos. Este artículo explora la complejidad y el impacto de las noticias difíciles al destacar la importancia de la escucha calificada; la formación médica respecto al papel de la empatía y de la vinculación con los pacientes y sus familias; y el resultado de la comunicación sobre la salud física y mental, con énfasis en estrategias necesarias para mejorar las habilidades comunicativas de los profesionales. La metodología aplicada fue epistemológica, interdisciplinaria y cualitativa, basada en una búsqueda en literatura científica en plataformas digitales. El objetivo es promover una práctica más empática y centrada en el paciente, con énfasis en la relevancia de una comunicación sencilla, responsable, sensible y efectiva en el entorno sanitario.

Educación médica; Empatía; Humanización de la atención; Relaciones médico-paciente; Salud mental

Since the dawn of civilization, humans have tended to distance themselves from what is complex or challenging, often relegating to oblivion what they do not fully understand and what causes them pain. This ancestral behavior not only reflects the difficulty in dealing with the emotional and behavioral complexity of others, but also suggests a reluctance to face the intricate nuances of society and its problems. In this context, attentive and sensitive listening is an essential tool in healthcare, as it involves understanding both the verbal and non-verbal expressions of individuals—paying attention not only to their words, but also to their feelings, gestures and behaviors, which often reflect the adversities and challenges of life in society ¹.

Communication is the foundation that sustains human interactions, enabling understanding, connection and transformation of individual experiences. As we evolve, our capacity for communication expands, incorporating new elements of language, reading and comprehension of both the world and ourselves ². Such complexity is revealed in interactions with others, with each individual assigning personal meanings and interpretations to what is expressed or communicated. Communication is therefore inherently subjective, reflecting the uniqueness of each individual and their perceptions ²,³.

Communication plays a key role in healthcare, especially in the medical field, where the effectiveness of communication between professionals and patients can directly influence the understanding of diagnoses, treatment options and necessary care. Effective communication goes beyond merely conveying information; it involves building an interpersonal relationship that extends beyond the actual message, particularly because those receiving the news may be deeply affected ⁴.

The relevance of communication in medical practice, especially when delivering difficult news, becomes evident in the need to convey sensitive information while also offering emotional support and comfort to patients and their families ⁵,⁶. The quality of this communication may have a profound impact on how individuals face and process unfavorable prognoses, triggering strong feelings, reflections and significant consequences in their lives ⁷.

Given the complexity of breaking bad news in medical settings, a key question arises: how can physicians improve their communication skills to convey sensitive information in a way that is both understandable and compassionate, while respecting the uniqueness of each individual and minimizing emotional distress?

The guiding hypothesis of this investigation is that the practice of skilled listening has the transformative power to transcend traditional paradigms of the biomedical approach to care. In addition, this study suggests that the communication skills of physicians can be improved through targeted training strategies and specific protocols. These approaches may not only enhance the delivery of sensitive information but also mitigate adverse emotional effects on patients and medical teams, contributing to a more empathetic and patient-centered medical practice.

Therefore, this study seeks to investigate the existing gaps in communication between physicians and patients, as well as to explore strategies and methods for improving communication skills among healthcare professionals in this context. Another objective is to assess the impact of such communication on the physical and mental health of patients. Based on this analysis, the study also aims to offer reflections on practices to improve the delivery of difficult news, aiming at promoting a patient-centered medical practice grounded in skilled listening and humanized care.

Method

This study adopts an interdisciplinary and contextualized methodological approach to comprehensively and dynamically investigate communication between physicians and patients in the context of difficult news. The method was based on a literature review of scientific publications, including the analysis of works available in virtual libraries and specialized databases, especially those published in the last 20 years. An interdisciplinary method was used to integrate knowledge from different fields, combining medicine with disciplines such as psychology and education in order to holistically understand the complexity of skilled listening in healthcare.

The selection of materials for data collection was aligned with the objectives of the study. Initially, only materials with titles directly related to the outlined goals were considered. The analysis of information followed predefined scopes, providing the necessary support to meet the research objectives and validate the hypothesis.

The initial stage of investigation involved searches across various libraries using descriptors such as “breaking bad news to patients” and “medical communication.” However, relevant results were limited in platforms such as MEDLINE, PubMed, PePSIC and SciELO. Additional searches were then conducted using new terms such as “skilled listening in medicine,” “humanization,” “medical training and empathy” and “delivering difficult news in the medical context,” both in the above platforms and in Google Scholar, in order to enrich the study. In addition, the research was supplemented with materials from academic and hospital institution websites, as well as articles from other sources that observe scientific rigor. Following the literature review, an exploratory study was carried out based on existing theoretical contributions with a view to enhancing the understanding of the phenomenon. As a result, additional articles were consulted.

The research approach used—supported by multiple data sources at different stages, as needed by the researchers—conforms to a scientific-epistemological perspective that, according to Morin ⁸, enriches the scientific community by integrating the voices of diverse authors. This approach enables a broader and deeper understanding of the perspectives influencing the communication process, establishing connections between the fields of education, medicine and psychology, and significantly contributing to the advancement of knowledge in these areas.

Breaking bad news in medicine

Impact and complexity in communication

Effective communication between physicians and patients includes delivering information about prognoses and procedures, and, in difficult situations, breaking bad news related to unfavorable diagnoses ⁴. The communication of challenging information involves anything that may provoke distressing feelings stemming from diagnoses and prognoses of illness ⁹. This type of communication can significantly impact a patient’s future expectations—an aspect that must be assessed by considering multiple factors, such as clinical condition, available coping resources, care context and emotional support, among other subjective, dynamic and complex elements ⁷.

Undoubtedly, communicating poor prognoses is one of the most challenging tasks for healthcare professionals, due to the strong emotional repercussions for patients and their support network. Medical teams are often concerned about how patients will be affected by the difficult news and how they will react ¹⁰. In addition, the emotional consequences also affect the actual professionals, who frequently feel anxious about dealing with the reactions of patients and their families, particularly in such delicate situations ¹¹.

It is worth noting that physicians’ difficulties in breaking bad news may stem from their academic training, as few medical schools include communication training in their curricula. Therefore, investing in methods that enable students to develop and strengthen this skill is of vital importance ¹².

Understanding

Skilled listening in medical practice

Communication in medical practice is essential for establishing a therapeutic relationship not only between physicians and patients but also between physicians and other members of the multidisciplinary team. Within this context, skilled listening goes beyond the simple act of hearing.

Regarding patients, skilled listening involves the ability to offer them one’s full attention, understanding not only the spoken words but also the feelings, concerns and emotions underlying what they are saying ¹³. According to Maynart and collaborators ¹⁴, new approaches to care are emerging that emphasize the practice of skilled listening. This technique involves interactions grounded in dialogue, connection and support, offering a deeper understanding of psychological distress based on the uniqueness of each individual. It values patients’ experiences and seeks to meet their needs by considering the various aspects that make up their daily lives. Besides being a facilitating and transformative tool, skilled listening is also strategic element in fostering autonomy and promoting social inclusion ¹⁴.

In this context, active listening is an essential component of skilled listening. It is not restricted to passively listening to the information shared by the patient, but also involves the physician’s ability to ask relevant questions, express empathy, validate the patient’s feelings and, fundamentally, understand the situation and the nuances behind the spoken words ¹⁵.

Skilled listening in medical practice is a multidimensional competence that requires the ability to interpret and synthesize the information provided by the patient. It involves developing a receptive and empathetic attitude that makes it possible for physicians and patients to build a relationship based on trust and confidence ¹⁶. Once again, it is important to stress that skilled listening is not limited to verbal communication; it also incorporates the careful observation of non-verbal cues, such as body language, facial expressions and other forms of non-verbal communication that help reveal the patient’s emotional state and needs ¹.

Limited eye contact hinders the development of meaningful emotional connections. MRI studies indicate that the emotional bond created through eye contact is mediated by a cerebello-cerebral network and is associated with the amplification of shared attention ¹⁷. Therefore, actions as simple as the physician making eye contact with the patient help foster connection. The relationship established between physician and patient contributes to improved diagnostic accuracy and positively influences treatment adherence, increasing both satisfaction and loyalty to healthcare services. The commitment to understanding patients’ feelings toward their illness enables the formation of powerful emotional bonds ¹⁸.

Bonding in communication with patients

Medical training and the role of empathy

In recent years, it has been observed that the idealization of the medical profession is often associated with considerable prestige and expectations of economic success, despite a precarious, distorted and vulnerable job market, as well as health policies that neglect the essential conditions for proper medical practice ¹⁹.

Moreover, it is essential to consider that the decision to pursue a career in medicine is not merely a job choice, but an undeniable commitment to empathy and compassion. Being a physician is not just about practicing a profession—it is about embracing a way of life grounded in sensitivity, genuine concern for the well-being of others and the ability to understand and alleviate human distress. Hence the importance of discussing this subject. A constant commitment to empathy and compassion lies at the foundation of humanized medical practices and remains an unquestionable pillar of the profession ¹,²⁰.

The communication of difficult news includes delicate situations such as disclosing serious diagnoses, presenting risky surgical procedures or conveying unfavorable prognoses. Therefore, being properly prepared to deliver such information is essential, beginning with the establishment of a setting conducive to the conversation. This involves creating an empathetic bond, listening attentively to patients’ concerns and responding clearly and compassionately to their questions. Choosing simple, accessible language—and avoiding complex medical jargon—is key to helping patients gradually understand and process the information being shared. Beyond delivering the news itself, it is equally important to acknowledge and validate patients’ feelings, offering emotional support, understanding and sensitivity in response to their distress ¹,²¹.

The physician-patient relationship has undergone continuous change over the centuries, deeply affecting the notion of empathy. Costa and Azevedo ²⁰ draw attention to the dehumanization of patients in hospital settings, illustrating how, in wards, ill individuals lose their identity when they are referred to as “bed 10” or “stroke patient.” Frequently exposed to poor communication practices in clinical settings, medical students often learn valuable lessons about the kind of physician they do not wish to become ²⁰. A study carried out in Finland and published in 2005 showed that early immersion in medical practice helped students better understand the experience of “being a patient/being ill,” acknowledging the seriousness of the physician-patient relationship and identifying role models for professional behavior—an aspect closely linked to empathy ²².

Often challenging and feared, the delivery of difficult news in healthcare settings raises an important consideration: the need to convey such dense information to patients in a more sensitive and humanized manner. According to the psychologist and researcher Carlos Rozeira ¹, this approach goes beyond mere changes in vocabulary, calling for a paradigmatic shift in the mindset of healthcare professionals and encouraging them to recognize that behind every diagnosis or prognosis there is a unique individual with a history, emotions and expectations. Therefore, the aim is to humanize care by moving beyond strictly clinical aspects and appreciating each patient’s uniqueness. A sensitive approach to difficult news seeks to establish an empathetic connection between healthcare professionals and patients, fostering a relationship based on mutual understanding and trust ¹.

Greater emphasis should be placed not on the nature of the bad news itself, but on the failure to convey it with more sensitivity and empathy. This shift represents a powerful step toward a more humanized, patient-centered medical practice—and, as a result, a more effective one in terms of care and treatment ¹.

In both medical and psychological approaches, empathy stands out as a core skill for ensuring treatment adherence and building a productive therapeutic relationship. This relationship has many aspects, involving genuine commitment to treatment, deep understanding of the patient’s concerns and perspectives, and authentic expression of empathy in therapeutic actions ²¹. A positive therapeutic bond between professional and patient enhances collaboration and commitment to therapeutic goals, making it easier to effectively resolve the issues raised by the patient ²³,²⁴.

It should be noted that, following the initial communication, it is essential to present treatment alternatives, if any, and to refer the patient for psychological support when necessary. Ongoing follow-up and the willingness to answer any subsequent questions are key to ensuring the patient feels supported throughout the entire process, including emotionally ¹.

A study ²⁰ on the teaching of empathy as an essential skill in physician-patient interactions in medical school, based on semi-structured interviews with physician-professors at the School of Medical Sciences of the University of Campinas (FCM/UNICAMP), showed divergent views. The opinions expressed suggest that such learning depends on multiple factors, ranging from family background, educational experiences and medical training to personal interactions encountered throughout one’s academic journey. One approach proposed by some interviewees argues that the best way to teach empathy is through example: by demonstrating this skill in front of students and creating opportunities for discussion and reflection to foster understanding and practice. The role of example and attitude is emphasized as a key tool in conveying this knowledge, as noted by one of the study’s participants, who stated: “It’s impossible to teach this if you don’t do it. It doesn’t come automatically with being a professor” ²⁵.

However, it is acknowledged that this ability to convey empathy is not consistent across faculty members, which suggests differences in the value placed on empathy in the physician-patient relationship. Therefore, there is a clear need for greater faculty involvement in encouraging discussions and creating practice and training settings, despite the limited time available for interaction with students and the challenges present in the educational environment, which stem partly from the heavy burden of teaching responsibilities ²⁰.

Regarding the decline of empathy over the medical course, identified as a possible emotional detachment in students, there appears to be a correlation with the ideal image of a physician students aim to emulate. Certain events and perceptions, such as the excessive admiration for specific professional figures and the difficult transition from student to self-perceived medical professional, were found to influence students’ behavior. Factors such as limited consultation time, behavioral models acquired during medical school and the challenges of balancing the roles of learner and practitioner—often in the face of patient loss—were cited as contributing to the diminishing emphasis on empathy in the physician-patient relationship ²⁰.

The aforementioned study concluded that there are significant gaps in the development of medical identity during medical education, with scant structured support for students, aside from a few isolated initiatives. The interviews revealed a conception of empathy more closely tied to feelings than to cognition, while the physician-patient relationship was viewed either as a means to an end or as human contact enriched by nonverbal elements. Transmitting empathy to future physicians is more often seen as a behavior to be observed rather than something to be formally taught, and its practice throughout medical school is fragmented and dependent on faculty initiative. Curricular reforms that prioritize training in communication skills and relationship-building—grounded in empathy—are recommended to bridge these gaps in medical education ²⁰.

One notes that improving communication skills is essential in clinical practice and goes beyond mere technical and scientific knowledge. These are key abilities for building empathetic relationships and offering high-quality care. Adequate training focused on strengthening the physician-patient bond is especially important in preparing future professionals, particularly in the context of clinical rotations. This connection enables a more comprehensive understanding of patients’ concerns, values and challenges, and hence a more holistic approach to care ¹,²⁰.

The contemporary challenges faced in medical education require ongoing reviews to meet the emerging demands of clinical practice. Issues such as the emphasis on socioemotional skills—including empathy, effective communication and teamwork—stand out as critical concerns. The ability to interact with patients in a humanized way, respecting their individuality and building trust-based relationships, is now seen as just as essential as technical competence in medical practice ¹,²⁰.

Communication

Impact on physical and mental health

So far, this study has outlined elements that suggest the substantial impact of effective communication on improving health outcomes, especially in sensitive situations where conveying unexpected information may trigger additional complications, particularly of a psychological nature. Inadequate or insensitive communication may intensify emotional distress, cause stress, anxiety and hopelessness, and hinder the coping process. Often, a physiological problem, when poorly processed by the patient’s cognition, results in mental health issues and/or additional physical symptoms, a process known as somatization and psychosomatization ¹.

Somatization occurs when physical symptoms appear without any identifiable organic cause. These symptoms originate from emotional distress; for example, in panic disorder, a person may experience physical symptoms that mimic a heart attack, even though no organic problem is detected in medical tests ¹. In turn, psychosomatic illnesses involve observable changes in clinical tests. The body exhibits physical symptoms, and test results confirm them. Although these are conditions with organic manifestations, they are triggered by emotional disturbances such as anger, anxiety, anguish, fear or feelings of revenge. These feelings can lead to real and tangible illnesses, including depression, abdominal pain, diarrhea or tremors, for instance ¹.

Within each of us resides an unparalleled wonder: the brain. It is the stage upon which life unfolds. Although we tend to believe we are in control, that we are rational beings who govern our brains and make our own decisions, the reality is often the opposite. We are at the mercy of internal brain circuits that drive us to act through habits, stereotypes and decisions that frequently occur without our full awareness ²⁶.

In recent years, books and studies devoted to neuroscience, particularly those focusing on the human brain, have highlighted the historical neglect in understanding and caring for this vital organ. Interestingly, more attention has traditionally been given to other bodily organs than to the very center of our cognitive and sensory activity. The brain weighs approximately 1.5 kg, accounting for 2% to 3% of total body mass, and can be seen as a complex machine filled with neural circuits (akin to neuron-based microchips), similar to the integrated circuits found in everyday electronic devices such as computers and smartphones. The brain is an intricate network of wires and connections that never rests, not even during sleep ²⁷.

Like any machine in full operation, the brain requires energy. Its consumption is remarkable: it uses around 20% of the body’s oxygen and between 15% and 20% of its glucose. During intense mental activity—such as deep study or complex debate—the brain may consume up to 50% of the body’s oxygen. In high-pressure situations, stress or difficult decision-making, the brain works at an even faster pace. However, keeping it in continuous high gear is akin to running a motor at constant full speed, which may lead to overloads or breakdowns in its functioning ²⁷.

This biological supercomputer—made up of 80 to 100 billion nerve cells in a vast network of connections—is in constant development until around the age of 25, and has unique energy demands. The brain is more than a physical organ; it is an adaptable, dynamic machine capable of forging new connections, although it typically follows established patterns to conserve energy. Its neural structures directly influence our perceptions and responses, shaping our thoughts and behaviors ²⁶.

Each brain is unique, equipped with specific pathways to solve problems, and its complexity enables the continuous creation of new connections. However, overload caused by bad news delivered without due care can be harmful. Excessive worry is one of the challenges faced by humans, particularly because of the negative impact it can have on the brain and mental health, leading to high levels of stress and anxiety that directly affect the body’s overall functioning ¹,⁷,²⁶.

Chronic stress triggers the excessive production of hormones such as cortisol, which in excess can harm memory, decision-making capacity and concentration. Elevated cortisol levels can also suppress the immune system, disrupt sleep, lead to weight gain, cause digestive problems, raise blood pressure, impair cognitive functions, increase cardiovascular risks, affect mental health and reduce bone density, which indicates the importance of hormonal balance for overall health ¹,²⁸.

In addition, excessive worry tends to keep the brain in a constant state of alert, preventing it from resting properly. Rest and recovery are essential for brain health, as they allow the brain to consolidate memories, process information and regenerate. When the mind is overloaded with constant worry, this restorative ability can be compromised, negatively affecting cognitive and emotional health ¹.

Negative events tend to leave deeper marks on our minds than positive ones. Daniel Kahneman, Nobel Prize winner in Economics, showed that people work harder to avoid losses than to achieve gains. In long-term relationships, approximately five positive interactions are needed to offset a single negative one. Harmony is achieved when positive experiences outnumber negative ones by a ratio of at least three to one. Negative events tend to contaminate more than positive events purify—for instance, a single misdeed tarnishes a hero’s reputation more than a good deed enhances a villain’s ²⁹.

According to Rick Hanson ²⁸, the extraordinary power of negative events over the human mind is linked to the brain’s intense response to unpleasant stimuli compared to equally intense pleasant stimuli. The main neural circuit behind this disproportionate reaction involves the amygdala, hypothalamus and hippocampus. Although the amygdala also responds to positive experiences and feelings, in most people it is more frequently activated by negative events and sensations ²⁸.

Imagine a situation where a doctor speaks harshly to a patient, triggering the latter’s anger. That anger activates the amygdala. The amygdala then sends alarm signals to the hypothalamus and the control centers of the sympathetic nervous system, located at the base of the brain. The hypothalamus triggers the release of adrenaline, cortisol, norepinephrine and other stress hormones. The heart rate increases, thoughts race and a feeling of agitation or disorientation sets in. The hippocampus records the experience—what was said, by whom, and how it made the person feel—consolidating this memory in the cortical networks for future reference. The amygdala prioritizes the storage of this stressful experience, to the point of influencing the formation of new neural connections to reinforce fear. Over time, negative experiences can heighten the amygdala’s sensitivity to negative stimuli. This feedback loop occurs because cortisol, a hormone signaled by the amygdala and requested by the hypothalamus, is released into the bloodstream, reaching the brain and strengthening the amygdala’s activity. The result is a faster and more intense response to aversive events. In addition, even after the perceived danger passes or turns out to be false, cortisol remains in the body for several minutes before it is metabolized and eliminated, keeping the person on high alert. For example, someone who narrowly avoids a car accident may still feel nervous and shaken even 20 minutes after the incident ²⁸.

During this time interval, in a cumulative sequence, cortisol acts excessively on the brain, resulting in overstimulation, weakening and, occasionally, the elimination of cells in the hippocampus, thereby diminishing its capacity over time. This is a problem because the hippocampus plays an important role in contextualizing events, soothing the amygdala and modulating the hypothalamus to stop the release of stress hormones. Consequently, it becomes more challenging to place a single negative event in context among numerous positive ones, making it harder to control an overactive amygdala and hypothalamus ²⁸. As a result of this process, feelings of stress, worry, irritation or hurt experienced today increase vulnerability to these same emotions the next day, creating a persistent cycle of negativity and a vicious feedback loop ²⁸.

Regarding the treatment and healing process, what is the physician’s role? According to Covas ³⁰, the notion of healing goes beyond the mere remission of physical symptoms; it is a holistic process aiming at the full restoration of the individual as a whole. Rooted in humanistic medicine, this journey seeks not only to treat diseases but also to alleviate suffering, promote well-being and counteract the effects of chronic illnesses. The idea of healing transcends medical boundaries, involving various therapeutic philosophies—from allopathy to homeopathy and oriental medicine—all of which converge to place human beings, with all their biopsychosocial complexity, at the center of medical care.

This systematization of healing is not limited to the individual level, as it also takes social and environmental influences into account. Within this framework, the physician’s role goes beyond the direct treatment of the disease to include initiatives that optimize not only individual aspects but also the social and environmental factors that affect the patient’s health. Developing the ability to engage in sensitive and transparent dialogue is essential to this approach, enhancing understanding of medical conditions while providing emotional support and clear information about prognoses and treatments. Knowing how to communicate difficult issues compassionately and empathetically is key to fostering trust and partnership between physician and patient, significantly contributing to the shared pursuit of healing and well-being ³⁰.

Numerous studies show that the quality of the physician-patient relationship is vital to determining a positive treatment outcome for both the patient and the healthcare professional. As a result, the concept of patient-centered care—which emphasizes the physician-patient relationship—has gained prominence by promoting genuine collaboration between both parties. This model represents a substantial shift from the old paradigm where the physician held the power and played a paternalistic role in healthcare, centered on the professional. Patient-centered care encourages the patient to actively participate in the healing process, sharing responsibility with the physician ³⁰.

Improving communication skills

Strategies and methods

Communication is a fundamental component of healthcare. Patients, clients and families have the right to be informed about their clinical conditions, and it is the duty of healthcare professionals to convey such information clearly and understandably ⁴. Establishing effective communication in this context means guaranteeing a high-quality dialogue and making sure that what is expressed is truly understood by the receiver ². Managing this communication is a constant challenge for healthcare teams ³¹. This interaction goes beyond the mere transmission and reception of information; it involves building an interpersonal relationship around the shared content and the way it impacts the person receiving the news. Especially when delivering difficult news, as highlighted in this study, it is not enough to convey the information: the professional must be equipped with the appropriate elements and care to handle content that often triggers anxiety, pain and reflections on various aspects of life, the processes of health and illness, and the experience of death and dying ⁵,⁶,¹².

We are now aware that communication between physician and patient is key to ensuring clear comprehension and the establishment of an effective treatment plan, especially in complex and difficult situations for patients. To this end, it is extremely important to provide information progressively and understandably, which involves eliciting the patient’s previous knowledge about the subject, breaking down information into manageable steps and checking understanding after each step. It is also relevant to ask patients what additional information they would like to receive, allowing them to be agents of their own learning process ¹².

Making it easier for patients to understand and retain information is essential in these challenging circumstances. Organizing information logically, dividing it into clear and sequential parts, and using strategies such as listing and repetition help assimilation. It is crucial to use simple language and, after conveying the information, to verify whether patients have understood the proposed plan by encouraging them to repeat in their own words what was explained ³⁰.

At the end of the consultation, it is important to consolidate the future plan agreed upon with the patient, clarifying the next steps and their timeline, especially in delicate situations. Establishing a contingency plan for unforeseen events, encouraging a sense of collaboration between physician and patient, and checking for agreement and comfort with the proposed plan are essential final elements. Additionally, asking if corrections are needed or if there are any unclear aspects ensures the patient feels part of the process and that all concerns have been addressed. Such effective and compassionate dialogue helps build and maintain a healthy, collaborative relationship between physician and patient at challenging times ³⁰.

It is worth noting that the scientific community has protocols in place for communicating bad news in the medical environment that provide structured approaches to face this delicate task. The SPIKES protocol, introduced by Bachman in 1992, was designed to simplify the delivery of difficult news, especially to cancer patients. Comprising six steps, it covers everything from choosing the appropriate setting for the conversation to concluding with a summary of what was discussed. Similarly, the CLASS protocol, consisting of five steps, prioritizes physical context, active listening, recognition of feelings, strategy development and a final review of the dialogue ¹².

Another relevant protocol, P-A-C-I-E-N-T-E, adapted by Pereira ³¹ from SPIKES, is divided into seven steps. It emphasizes preparation; assessing the patient’s knowledge and willingness to know; inviting honesty in communication; presenting information in quantity, pace and quality that allow the patient to make informed decisions; managing the patient’s emotions and strategic planning for future care; not abandoning the patient, ensuring follow-up care until the end; and outlining a strategy, meaning planning the next steps and treatment options ³².

All these protocols share the idea of systematizing communication and providing support to the patient throughout the process. These methodologies emphasize the importance of the healthcare professional being assertive when communicating difficult news and the need to establish a trustworthy environment. It is necessary to explore authenticity, unconditional positive regard, and empathic understanding in relation to communicating bad news in healthcare ¹²,³³.

Final considerations

Effective communication undoubtedly plays a key role in healthcare, as it minimizes conflicts and misunderstandings between medical teams and patients and their families. The impact of ineffective communication directly affects the patient and their family, resulting in unsatisfactory care. The quality of this communication is a process developed over time, especially when the physician faces the challenge of sharing difficult news. The medical professional must believe in the patient’s potential and offer information clearly and truthfully, without omitting prognoses or possible paths. Simultaneously, it is crucial to inspire respect by recognizing each patient’s uniqueness and assuring them that all efforts made aim to preserve their life. In addition, it is vital to allow the expression of empathy, acknowledging and validating the patient’s pain.

It is noteworthy that the communication challenges faced by healthcare professionals are partly due to gaps in academic training. There must be an emphasis on developing these communication skills during education in order to promote a more humanized approach to care. Nowadays, medical efficiency is no longer measured solely by technical competence but also by how the doctor establishes empathic connections with patients and their families ¹².

To conclude, it is worth remembering that the physical environment and technological resources are undoubtedly relevant elements in healthcare settings. However, they are not more important than the human essence, which shapes thought and actions and enables the construction of a more humanized reality. This reality, less hostile and aggressive, offers a refuge for individuals who daily frequent healthcare institutions ³⁴.

Poor empathy in personal interactions may compromise the effectiveness and satisfaction of users of healthcare services, while perpetuating interpersonal conflicts among professionals. The lack of adequate investment in technical improvement, teamwork skills training and resilience development intensifies discomfort and demotivates healthcare professionals. This leads to a loss of connection between professionals and their mission and culminates in care delivery that is automated and devoid of humanization. We need to strive for humanized healthcare that builds strong bonds and fosters trust and well-being between professionals and patients.

References

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Edited by

• Responsible editor
  Dilza Teresinha Ambrós Ribeiro

Publication Dates

• Publication in this collection
  11 Aug 2025
• Date of issue
  2025

History

• Received
  20 Dec 2023
• Reviewed
  18 Feb 2025
• Accepted
  20 Feb 2025