Dr. Warner Huh: Hello everyone, this is Dr. Warner Huh, the Chair of Obstetrics and Gynecology here at the University of Alabama at Birmingham. And I want to welcome you all to this monthly episode of Women's Health with Dr. Huh. Excited about summer kicking off this year. So today, we got a great topic. It's a little bit different.

I think our listeners are going to enjoy this one. We're going to talk about how to deliver difficult or unexpected news to patients. And I think it's important for our listeners to know that, you know, although we work traditionally in a medical profession that's often associated with excitement and happiness of introducing new lives into this world and starting and growing families; there are moments in our work where we have to deliver difficult and challenging and unexpected news to our patients and our families, and this is a hard part of our job. So with me today to talk about this is Dr. Brian Brocato, who is an Assistant Professor in the Division of Maternal Fetal Medicine, in the Department of OBGYN here at UAB.

 Just a couple things about Dr. Brocato. He, has a specific interest in working with women, particularly pregnant women with substance abuse disorders, and is one of our two lead physicians who works at our renowned UAB Comprehensive Addiction and Pregnancy Program, also known as CAPP, and he also serves as the obstetrical lead for the Alabama Perinatal Quality Collaborative, also known as the ALPQC and works with a team that is very much dedicated to the quality and the safety of perinatal care across the state of Alabama. And I just want to highlight that this committee is really important because right now one of the most important topics in women's health, particularly here at UAB, is how do we impact the concerning rate of maternal morbidity and mortality in the state of Alabama?

So Dr. Brocato, I'm super excited that you're here, that we're talking about this. This is going to be a fun podcast because this is not something that I think our listeners often hear. So welcome.

Brian Brocato, MD: Thank you. Excited to be here today.

Dr. Warner Huh: So clearly you and I both recognize that this is an important topic. You as an obstetrician have to sometimes deliver unexpected news. Myself, as an oncologist also have to deliver unexpected news. Why did you want to talk about this? Why, why is this important to you?

Brian Brocato, MD: Yeah, it's a great question. When I was first thinking about topics that we could discuss, you probably get this as well. A lot of people who know me personally or outside of a work setting, this is a question they often ask me, how does that go when you have to deliver unexpected or bad news? People are interested in that part of our job, and as you said, that's not what we're doing all the time, but it actually is, it does come up in our job on at least a weekly basis where we may be delivering some difficult news. The other reason why this is important is because difficult or unexpected pregnancies is actually not that uncommon of an experience for women. The birth defect rate is approximately three to 5% of all births. Miscarriage is fairly common in pregnancy, and a lot of times those losses may occur without the general public even knowing. A mom may be pregnant, she hasn't shared that with her friends and family. She may experience a pregnancy loss before the public even knows it.

Host: So, I think our listeners would be interested in knowing, like, are we as doctors formally trained to deliver bad news? You know, what was your experience and memory of that kind of training and, you know, how does it relate to your job now?

Brian Brocato, MD: The training for delivering bad news is, it's formal and informal, but to answer your question, yes, there, there is formal training. It starts in medical school. I actually remember very clearly the scenario that I was put in as a medical student, it was, I was to go in and, and tell a pretend patient that they needed to go on dialysis.

And as you can imagine, you know, as a I hadn't even completed medical training. It's a little bit awkward because people are watching you give this, you know, presentation. And then you get some sort of feedback. You get it from the patient who is going through this pretend scenario, and then you get feedback through your teachers and mentors about how you delivered news.

And that's all done in, in a setting of what I would say are here are the best practices of how to deliver difficult news. But as you're aware too, real life is very different in these situations, than some sort of, uh, simulated patient. And so that's why I would say the informal training comes and medicine is a, is ultimately still an apprentice style teaching. We don't just go in blind, into cases that we've never dealt with. We typically are with an attending physician or who our teacher physician is. We're going to watch how they do this. Hopefully we have some conversation about that. And, you get to sort of see this happen where you're not ultimately delivering that news.

So that's how I would say most of us were trained.

Host: Yeah, I, I mean, I personally want to expand on that because, unfortunately I'm a little bit older than you, but, when I went to medical school back in the nineties, we got zero training on this and I actually got zero training on this when I was a resident in OBGYN. So much of what I've learned has been very much on the job learning. The one thing I will tell you, and I think this is, I think you probably would agree with this, is that, you know, as you get older, there's a certain level of maturity and empathy that you develop that uniquely changes as you sort of better understand your patients, you under you, you're more comfortable in the material.

And so the way I deliver this type of difficult news is very different than the way I delivered it when I was younger. I think it's purely a function of maturity. Right? And I think for the listeners, I think one practical thing just to think about, and much of this is actually really well articulated, in a book by Atul Gawande, who is a surgeon.

He works through Harvard Medical School in the Brigham. The book is called Being Mortal. In the book is a chapter, that he actually initially published in the New Yorker Magazine just about death and dying. And the one thing that I really took away from that chapter is that your doctor really should be listening more and not talking so much.

So, you know, if you have your provider and they're over talking you, if that's not such a good thing. Right? And I think some of the best empathetic physicians and providers I've ever met, they just sit in a room, sit down, look eye to eye, and just listen. And that's part I think of half of what we do is to lend an empathetic ear and just listen to our patients. And I think that's, I just want our audience to understand how important that is. And so, just something to, to kind of park in the back of your mind. So let me ask you this, Dr. Brocato. So what do you say to someone who has experienced a difficult pregnancy where they experience receiving bad news? And, they are or want to be pregnant in the future. How do you reconcile that? Because I can imagine that it's traumatic to have potentially a unexpected outcome, maybe a pregnancy loss or something related, and they're talking about getting pregnant again. Talk to me a little bit how you approach that.

Brian Brocato, MD: Sure. Actually this scenario is fairly common that I may be seeing someone for their pregnancy when a lot of what we are there to talk about is what happened in a prior pregnancy. So maybe they experienced a pregnancy loss, or have a child that has a birth defect or a genetic syndrome and they're pregnant again.

And here they are sitting in front of me. We also sometimes will see patients before pregnancy discuss Hey, what, what is the chances of something like this happening again? So we may see them in anticipating pregnancy. And first I would say, I love it when this person, mom is wanting to be pregnant again.

I think that's a healthy sign. That she may have experienced this, but she's willing to take that risk again, and it points to the resiliency of women. It points to bravery and so many aspects that when I see someone desiring pregnancy again, who have been through something difficult, I think that's wonderful when they come to us and say, Hey, I'm, I want to be pregnant again. But for those who have experienced a difficult pregnancy, and especially if they've received news in a way that, you know, it was almost traumatic experience, I would say. And even receiving the news, the, the most important thing is to talk to someone. So, I will often ask a question like this. What was it like when you learned that your baby or developing baby had X, Y, and Z? You can learn a lot from that question, but it allows me to gauge a little bit where are they in that grieving process. And if they're still, I would say in, in that process that, maybe they haven't talked through the whole scenario, that's when I really encourage them, we need to start talking about it. It's important that you told me. It's important that your providers know where you are. I always tell people, please don't try to grin and bear it. Emotional weight, it doesn't work if we just try to power our way through. A lot of times we'll see moms, they present with more like anxiety or depression, and what we come to find out is they, they may just be dealing with still severe grief from a prior pregnancy, and so talking to someone is important.

And if you could tell your provider that if they talk to me, I may even recommend they talk to someone professionally. There may be folks that, there's tons of resources as you're aware, but it may be that they need to speak to someone professionally. Someone said to me once that sadness is an honoring emotion, and I think a lot of folks are afraid to feel the sadness because they think if I'm sad, I'll get stuck in it. It means I'm not ready to move forward. But, I always encourage moms, it's okay to feel the sadness. It's normal to feel the sadness. If I'm pregnant now and I had a difficult pregnancy last time, it's okay to feel that sadness.

You're not going to harm your current pregnancy, you're not going to make, you know, something happen bad just by being sad, but it may be a sign that there's more sort of work to do or to talk through or to deal with, maybe a counselor or something.

Host: No, I think that's great. I like that. I like that comment about sadness being a nurturing emotion. That's a great way to put it. And I think that, you know, we all grieve at some point of our lives and sadness is something that you can't just bottle up, but I feel like you mentioned that different people have different mechanisms of sadness and how to express that.

And, uh, but I think the mistake is not to let it come out because I think it, I think people harbor a lot of anxiety, trauma, and I think that the best way to get that out is literally just to get it out. So let me, I know this is a question that, I'm very curious to hear what you have to say. And one that I think is important is, uh, you know, what is the role of the family or loved one of a person experiencing a difficult pregnancy? And before you answer, you know, on the oncology side, you know, as a provider or a physician, I really feel like I'm not just caring for the patient, I'm actually caring for the entire family.

And in many circumstances I find I actually talk more to the family than I do to the patient. And that's important because, you know, we all have to be on the same page and supportive of the patient. But I'm curious about what you think the role of the family or a loved one is.

Brian Brocato, MD: This question, it makes me think of a story to, to illustrate that how the family can play a role. I had a patient who unfortunately, experienced a pregnancy loss and I saw her maybe six or eight weeks after wards the event. And, she looked really good to me, you know, and, and I said, you know, how are you doing? How are things going? And she said, you know, actually I'm doing okay. Some days are better than others, but I'm having a problem that my mother-in-law texts me every day, to tell me, you know, how sad she is, you know, this kind of thing. And then my dad is calling me every day because he's worried that my grief is going to move into depression. And he is constantly checking on me, to make sure I'm not depressed. She said to me, she goes, you know, actually I think I'm doing pretty good. It's just that, one side of my family is making me constantly talk about it, and then the other side is not letting me talk about it at all. That's kind of, I hope that's somewhat of, you know, kind of a humorous story.

But the point and what, and what I told her is as I reiterated, you are doing well, you are going through it in your own way and, and really encouraged her to trust her herself and her path. And then also to encourage her a little bit, that she's not necessarily responsible for the grief of her family, but also to acknowledge that the family has some grief in here too.

So, my job too, I feel the same way that like, like you just said about a lot of times you're caring for the family. You know, in my, in our job, of course, you know, there's a partner and grandparents involved and so absolutely feel like we're caring for the family. But, I try to speak to the family and my recommendation is this, talk with the patient. You guys need to process this together. And then you need somebody that's not so directly impacted. You know, hopefully there's a friend, someone, church member, pastor, you know, someone else, an aunt or an uncle who may not be so, uh, directly related. And then similarly as patients, there are resources and support groups for family specifically. And so that's why it's important that if these issues are there, that it's brought up to the provider, that hopefully we can point you in the right direction.

Host: No, I think that's great and I love that anecdote as well, cause I see that all the time on the cancer side as well. It's the patient inadvertently is getting squeezed by both sides. But, just some closing thoughts and I just would welcome your, you know, your thoughts on this is what I've learned since becoming the Chair of the Department of OBGYN is that, uh, you know, I really do think that we need to do a better job at supporting women that have a first trimester pregnancy loss. They have some bleeding. They pass a pregnancy and you know, I think sometimes we just instinctually say okay you're like, okay, you're fine, you can get back to work and what, what you're doing and there is as much of a grieving process as it is for someone later in pregnancy who has a pregnancy loss. So, you know, one of the things I'm very committed to with my leadership team is understanding that how do we provide those psychosocial counseling services that I think are much needed.

It's a very vulnerable time for a woman. And I think as a group we could do much better. I think we do good, but I think we can do much better. So I think that's one thing that I've noticed. The other thing I, I just want to share with the audience, and I know that you agree with this, we've been doing these podcasts for about two years now. We've been sharing a lot of sort of factual medical information, some medical input and advice in terms of how to manage certain problems. But this is the part of what we call the art of medicine that is really hard to teach. I think we talked about that. For me it's so aspirational because, you know, when I can sit down and talk about a really hard subject or topic and click with the patient and their family, for me it's something just so magical and so rewarding and kind of reinforces why I made that decision to go to medical school, you know, almost 30 years ago.

But it's hard. And it takes a lot of time to hone those skills. And so, I would just love to know your, just your general thoughts on those two topics. So.

Brian Brocato, MD: Yeah. Those are great thoughts, topics. The first question about first trimester pregnancy loss, you said earlier about the importance of listening and my patients who experience a first trimester pregnancy loss, that's where it is important to gauge, have that relationship. Because I, over the years, I've come to realize that the way that may impact someone can be vastly different. Some women may be able to move through that process very quickly. Why that is. I, you know, I have some theories, but I don't know, where others that may be life altering, devastating. The amount of grief may be similar to someone who loses a pregnancy much later. And it's important. That's where that relationship is so important, right? Is to know, gauge, check up on your patient. And then, I think that's where our system helps too, that it's not just me and the patient, but it's our whole team taking care of them to kind of gauge and, and I can't tell you how many times I've had a situation where to me, I didn't think this patient was, was necessarily having difficulty with, with the loss, but maybe our nurse said, Hey, she said something to me that we need to check in on her.

Or this patient called and something call her back. Let's engage her again. And, and I love, that sort of team aspect of caring for women who have gone through this difficulty. I love that you brought up the art of medicine because I think that delivering difficult news really is where that science and art meets. To do a good job in delivering difficult news, you have to know your stuff.

You have to be comfortable discussing the situation, and I think as you said, you know, over the years, you, you do this in a different way than when you first started. That, that's true of myself. And I think a lot of it is because I've seen it several times, right? I've, I've sort of gone through a process, but understanding and knowing what's going on and having a sense that you are fairly confident of where we're heading and then that art piece is communicating that to a patient, that the scenario or situation may be unique here. And if I go back to one of the first things we said is, it's a common question that people ask me about my job. And a lot of times they say something like, I don't know how you do that, but the reality is, and I, and I can see this look on your face as you know what I'm about to say; the reality is, is not that I ever enjoy delivering that kind of news, but the truth is sharing such an intimate space with a patient and the connection that often is made with families and the patient, it's the most rewarding aspect of my job.

I consider those spaces, I'll use the word sacred. It's sacred ground. When you are allowed to, come into that scenario, space with a patient, you're able to connect with them. It is definitely the most rewarding part or aspect of a patient physician relationship. So that's where the art really comes into play.

Host: That's beautifully stated, Dr. Brocato. I, um, I have a certain valence to these types of discussions, not because, you know, I like delivering bad news, but just what you said; these conversations bring out the most fundamental aspects of our humanity, what makes us unique and how we identify with other individuals.

And, again, it's hard, but I think that for the listeners, it's important for you to hear that for your providers, that there is really some, that's something that we hold sacred and it's important to us. And when we deliver the bad news and we do it empathetically and well, it really feels like we're doing our job well, in turn. So well, again, I'd like to thank you Dr. Brocato. This is awesome. I think it was a fantastic discussion about how to deliver unexpected or difficult news. And in fact, just listening to you right now, I'm actually thinking about creating sort of a tangential podcast that talks about some of these sort of subjective issues in medicine.

 And things I think we, that we need to relay to our listeners and the general public and our patients about what's going through our minds, right? And how to extract more value out of your relationship with your physician or provider. So this to me was really kind of thought provoking.

But anyway, as always, please rate this podcast and as you all know, I welcome any comments, particularly on topics that you are all interested in. And for more information on our obstetrical care and the clinical services that UAB provides, please check out uabmedicine.org. And until next time, thank you, have a great day.

Enjoy the beginning of summer. Take care. Peace out. Bye-bye.