Do you want the good news or the bad news first?
It’s the setup line to a well-worn genre of joke, but it’s no laughing matter, according to Angela Legg, a Ph.D. student in psychology at the University of California, Riverside.
Legg’s research—done with Kate Sweeney, also of UC Riverside, and published online in the Personality and Social Psychology Bulletin—put a scientific lens to the question.
The answer, Legg found, depends on whether you are the giver or receiver of the bad news, and if the information will be used to modify behavior.
If you are on the receiving end, Legg says, experiments showed that an overwhelming majority—more than 75 percent—wanted the bad news first. “If people know they are going to get bad news, they would rather get it over with,” she says. Then, if there is good news to follow, “you end on a high note.”
Conversely, news givers—between 65 and 70 percent—chose to give good news first, then the bad news. “When news givers go into a conversation, they are anxious. No one enjoys giving bad news. They don’t understand that having to wait for bad news makes the recipient more anxious.”
But good news first, then bad could be a useful strategy if the goal is to get someone to change a behavior—when, for example, Legg says, “you are giving feedback to a patient needing to lose weight, who has to take action. The recipient doesn’t feel good about the news, but may do something about it.”
The Sandwich Approach
Then there is what she calls the good news, bad news, good news sandwich—when the bad news comes between piece of good news on either side. Example: “Your cholesterol is down. By the way, your blood pressure is morbidly high. Your blood sugar levels are good.”
That’s fine if you want someone to feel good, she says. “But hiding the bad news in the sandwich is generally not a good strategy. It downplays the bad news, and the recipient gets confused.”
The person who delivers a bad news sandwich is engaging in what Legg calls conversational acrobatics. “They believe they are making the conversation easier, but the message gets garbled.”
There’s even an acronym in psychological jargon for people who delay giving out bad news or avoid it altogether—MUM (mum about undesirable messages).
“The best news-giving strategies take into account that sometimes we want to make people feel good and sometimes we need them to act,” she says.
Legg’s advice to doctors is that when relaying a diagnosis or prognosis, it’s better to give the bad news first, and then the positive information to help the patient accept it.
What If There’s No Good News?
But how do physicians deliver bad news when there is no good news to soften it?
“Many physicians prefer not to have to give bad news until it’s obvious,” says Thomas J. Smith, director of palliative medicine at the Johns Hopkins Institutions in Baltimore. Palliative care is a relatively new field that emphasizes open and honest communication with seriously ill patients.
According to one study, “If we look at the charts of people with lung cancer, only 22 percent of the charts have any notation that the doctor and patient talked about the fact that the patient is going to die,” he says. “Most of the time the conversation goes along the lines of ‘it’s incurable, but treatable.’ Many times it doesn’t get mentioned again.” In reality, 90 percent of people say they want truthful and honest information.
The “bad news” conversation, Smith stresses, needs to be more than one conversation. “When you give a bad diagnosis, they don’t hear anything [anyone says] for the next three weeks anyway. They are stunned. ”
The situation is improving. “Forty years ago when I started, palliative care wasn’t the norm,” he says. Now, at Johns Hopkins, medical students practice breaking bad news to a trained actor “patient.”
“Many [other] countries are changing, as well. Japan has shifted from no one being told to everyone being told” the truth, even if it’s bad news.
And sometimes, even when the news is bad, good news can follow unexpectedly. Recently, Smith met with a survivor group at the National Institutes of Health, where a woman shared her story: “My doctor told me I had eight months to live. He did say, ‘Some do better, some worse.’ So I took that to heart and told the kids and prepared them, and my husband and I went and picked out our burial plots. I thought at the time it would all be grim, but it turned out to be really important planning.
“That was three years ago,” she added.