“Although many health care clinicians have been fired by a patient or family, palliative care clinicians may be at increased risk for dismissal. We invite difficult conversations, confront people with news they prefer to avoid, and encourage otherwise taboo topics such as human frailty and death. Our focus on what may go wrong differs from other clinicians’ optimism and may be unwelcome to patients and health care teams alike. We acknowledge emotional vulnerability, explore uncertainty, uncover fears, and describe a future in which patients make difficult choices about how they live and how they die.
When we do our jobs well, we walk the line between security and vulnerability. We invite rather than push. We assess patients’, families’, and clinicians’ readiness for tough conversations and motivate them to prepare. We help patients identify what they can and cannot control in an uncertain, if not undesirable, future. We help them identify and prioritize what matters most. We talk about coping to foster resilience. We diversify hopes and articulate worries so that both become more realistic. The tightrope can be precarious. Sometimes we fall.
Getting fired is difficult for all clinicians. It feels shameful. For palliative clinicians, this emotion may be particularly strong when the reason for being fired stems from a patient’s experience with our communication. After all, communication skills are a key source of palliative care clinician training, identity, and pride. Worse is that the firing feels public, as happens when the primary team suggests the patient does not want to see us again, when a colleague sees a family’s discomfort as evidence that our work is misguided, or when a single encounter undermines subsequent clinical consultations and programmatic growth. We practice in the same perfectionistic health care system as our colleagues; being fired can feel like failure.
[..] In a randomized trial of 100 patients with advanced cancer, participants viewed videotaped encounters between standardized patients and optimistic vs realistic oncologists. Participants perceived the optimistic oncologists as more compassionate and trustworthy, even if the information they shared was misleading. In a cohort study of nearly 1200 patients with advanced cancer, patient-reported satisfaction with clinician communication was inversely associated with accurate prognostic understanding. The study found that efforts to improve patients’ understanding would come at the cost of their satisfaction. Taken together, these and other studies suggest patients like and trust clinicians who provide optimistic over realistic outlooks.
Such preferences make the work of palliative care daunting. Although patients fire clinicians for behaviors ranging from egregious (blatant disrespect, dismissiveness, and bias) to subtle (a sense that the clinician is not fully listening), the most common reasons for firing one’s physician involve unmet expectations for communication, treatment outcomes, and goals of care.5 In a survey of 314 patients being treated by physicians from 15 medical subspecialties, less than half of patients stayed with their physician after they delivered bad news about prognosis or refractoriness of treatment.6 Indeed, the words that follow “I don’t want to see that physician again” are often “I didn’t like what they had to say.”
[..] Getting fired does not necessarily mean the clinician did wrong. Sometimes it means the clinician did what was needed.
Our job in palliative care is not necessarily to be liked. Our job is to advance the conversation and corresponding care, which is inherently difficult and requires courage; it almost always risks a short-term cost. The long-term gain, however, is that patients and families not only hear the information necessary to make informed decisions and receive goal-concordant care but also tend ultimately to trust and appreciate the clinicians who introduced the scary concepts in the first place. Studies suggesting patients like more optimistic than pessimistic clinicians may be misleading because they focus on single conversations. Good communication (like good palliative care) is more of a process. It involves exploration of preferences, tolerance of tense moments, and a willingness to keep showing up.
If palliative care clinicians walk the line between security and vulnerability, then they must expect to misstep sometimes, which may mean they are fired. We must neither celebrate nor avoid such moments. (Being fired too often may mean we lean too heavily toward challenging our patients. Never being fired may suggest an opportunity to challenge our patients, our colleagues, and ourselves a bit more.) Palliative care leaders can normalize and destigmatize the moment without minimizing its importance. We must, as a group, reflect and learn from our experiences. We must be ready to get back to work for the next person under our care. We, too, must model both security and vulnerability.”
Full editorial, AR Rosenberg, E Rabinowitz and RM Arnold, JAMA 2025.4.14