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Patient Education and Counseling 89 (2012) 267–273
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Patient Education and Counseling
jo urnal homepage: www.elsevier.com/locate/pateducou
Communication Study
How the doc should (not) talk: When breaking bad news with negations
§
influences patients’ immediate responses and medical adherence intentions
a, a b,c
Christian Burgers *, Camiel J. Beukeboom , Lisa Sparks
a
Department of Communication Studies, VU University Amsterdam, The Netherlands
b
Health and Risk Communication, Schmid College of Science, Chapman University, Orange, CA, USA
c
Chao Family Comprehensive Cancer Center/NCI Designated, Public Health/Medicine, University of California, Irvine, USA
A R T I C L E I N F O A B S T R A C T
Article history: Objective: We investigate the role of specific formulations in a doctor’s bad news delivery. We focus on
Received 3 April 2012
the effects of negations and message framing on patients’ immediate responses to the message and the
Received in revised form 16 July 2012
doctor, and long-term consequences including quality of life and medical adherence intentions.
Accepted 9 August 2012
Methods: Two lab experiments with 2 (language use: negations vs. affirmations) 2 (framing: positive
vs. negative) between-subjects designs. After reading a transcription (experiment 1) or seeing a film clip
Keywords:
(experiment 2), participants rated their evaluation of the message and the doctor, expected quality of
Breaking bad news
life, and medical adherence intentions.
Negations
Results: Positively framed bad news with negations score more negative on these dependent variables
Framing
than positively framed affirmations (both experiments). For negatively framed negations, these results
Doctor–patient interactions
Medical adherence are reversed (experiment 2). Furthermore, the evaluations of the message (experiment 1) and the doctor
(both experiments) mediate the interaction of framing and language use on medical adherence
intentions.
Conclusions: Small linguistic variations (i.e., negations vs. affirmations) in breaking bad news can have a
significant impact on the health message, doctor evaluation and medical adherence intentions.
Practice implications: Doctors should refrain from using negations to break positively framed news, and
employ negations when breaking negatively framed news.
ß 2012 Elsevier Ireland Ltd. Open access under the Elsevier OA license.
1. Introduction provider training as effective as possible, it is important to
understand the factors that determine patients’ positive or negative
Next to being excellent health experts, doctors need to be good psychosocial responses.
communicators. Doctors deliver bad news to patients thousands of Yet, little is known about which specific elements make doctor–
times during their professional careers [1]. For patients, receiving patient communication effective. Most studies on the required
bad news is stressful in itself [2], but when doctors deliver the news formulation and style of doctor–patient interaction are descriptive,
poorly, additional stress may be induced with negative effects on which means that they describe current practices in breaking bad
patients’ health [2]. Furthermore, good doctor–patient communica- news (for overviews, see [11,12]). In fact, less than 2% of studies
tion can predict medical adherence [3–6]. Thus, breaking bad news focusing on doctor–patient interaction explicitly address how
to patients in an appropriate and effective way is a crucial task that doctors should formulate the information in such a way as to
bears important consequences [7]. Fortunately, many studies increase patient satisfaction [12]. The rare studies that did address
demonstrate that alerting and training doctors in these sensitive this issue adopted a general perspective, and showed that doctors’
communication issues greatly improves doctor–patient interaction general communication styles (e.g., comforting or empowering
[8–10] and subsequent patient satisfaction [7]. In order to make styles) influence the effectiveness of doctor–patient conversations
[7,13–15].
In the present study, we take a micro perspective by focusing on
§
The authors would like to thank Anouk van Berkel, Misha Naumovski, Nikki the actual words chosen by the doctor. Based on prior research, we
Ouborg, Bram Schothorst and Sanne van der Velde for their help with the data argue that – next to the general communication styles employed
collection for experiment 2.
(e.g., direct/indirect, comforting, empowering [7]) – specific words
* Corresponding author at: VU University Amsterdam, Department of Commu-
may also be important predictors of the effectiveness of doctor–
nication Studies, De Boelelaan 1081, 1081 HV Amsterdam, The Netherlands. Tel.:
patient interaction. Breaking bad news to patients and their family
+31 20 5987889.
E-mail address: [email protected] (C. Burgers). members entails a highly sensitive communicative exchange in
0738-3991 ß 2012 Elsevier Ireland Ltd. Open access under the Elsevier OA license. http://dx.doi.org/10.1016/j.pec.2012.08.008
268 C. Burgers et al. / Patient Education and Counseling 89 (2012) 267–273
which small differences in word choices can make a big difference We expect that a positively framed message yield more positive
[7,16–18]. After all, doctors need to balance their words carefully. responses than a negatively framed message, but that these effects
They need to be truthful, but at the same time, they want to are moderated by the language used in the message (negations vs.
preserve the hopes of the patient and mitigate the information. In affirmations). When negations are used to break news that is
this balancing act, subtle differences in word choice may influence framed as relatively good (e.g., ‘‘not bad’’), patients are expected to
a patient’s evaluation of the conversation and the doctor, which in more negatively evaluate the message (H1a), the doctor (H2a) and
turn have potential long-term effects on medical adherence [19]. their expected quality of life (H3a) and to have lower medical
A first aspect in message formulation is the framing used to adherence intentions (H4a), compared to when affirmations are
deliver the diagnosis, which can be framed to emphasize either the used (e.g., ‘‘good’’). In contrast, when breaking news that is framed
positive or the negative outcomes of a diagnosis. The relative as relatively bad and more mitigated language is thus appropriate,
strengths of positive and negative framing of factually equivalent we expect these effects to be reversed (H1-4b). We expect the
information has been studied with regard to the communication strongest effects of language use in positively framed messages,
involved in health-related decisions, which has its conceptual because in these cases negations (e.g., ‘‘you will not die’’) imply the
roots grounded in prospect theory (see [20–22]). These studies negative inference that the doctor has a more negative expectation
show that individuals react differentially to information presented than the actual message conveys.
in different frames. In the health domain, various studies show Furthermore, we expect the immediate responses to the
occurrences of framing of health-related information [23–25] and message to be related to the more long-term outcomes. That is,
their effects on patient perceptions [26–31]. With respect to given the link between patients’ impressions of the doctor–patient
breaking bad news, a framing differences may refer to emphasizing relationship and medical adherence [19], we expect that the long-
either the positive or negative aspects of a given diagnosis: given term effects of framing and language use on medical adherence
the range of possible diagnoses, is the particular diagnosis intentions are mediated by the immediate evaluation of the
presented as relatively good (positive frame) or relatively bad message (H5a) and the doctor (H5b).
(negative frame)?
An aspect that may moderate a framing effect [32] in the
2. Methods
balancing act of breaking bad news is the actual words that doctors
choose to formulate their message. Empirical evidence suggests
2.1. Design and sample for experiment 1
that doctors tend to mitigate their words when they have to deliver
relatively bad news compared to relatively good news [13]. One
A total of 100 US respondents participated in experiment 1,
verbal strategy that doctors can use to mitigate information and to
which had a 2 (framing of diagnosis: good vs. bad) 2 (language
be polite is using negations (e.g., ‘‘this news is not good’’) rather
use: negations vs. affirmations) between-subjects experimental
than affirmations (e.g., ‘‘this news is bad’’; [33,34]). Indeed, 1
design. Participants were healthy volunteers and recruited in
empirical evidence suggests that doctors frequently use negations
forums on social network sites, such as Facebook, and participated
when making diagnoses [35–38].
in an online experiment by clicking on a link. The average age was
Using negations, however, may come at a cost, because
41.88 years (SD = 12.43). A large majority of participants (78.0%)
negations may provide implicit cues about the expectancies of
was female.
the speaker [39–41]. For example, negations like ‘‘you will not die’’
may implicitly communicate that the doctor expected, or at least
2.2. Design and sample for experiment 2
considered, that the patient would die. Such inferences are not
likely when the doctor says ‘‘you will live’’, because, in contrast to
Experiment 2 was a conceptual replication of experiment 1 in a
the former statement, the latter statement does not implicitly
Dutch sample. A total of 115 Dutch respondents completed the
activate the concept of dying [34,40]. Moreover, from negations
questionnaire. Where a written scenario was employed in
(e.g., not bad), recipients infer that the speaker had an opposite
experiment 1 to present a doctor’s bad news delivery to
prior expectancy [39,40]. Consequently, using negations may
participants, experiment 2 used a film clip. 26 participants
implicitly give the impression that the doctor is insincere and hides
reported that they had experienced technical problems and could
the real message.
not properly see the film clip and were removed from the dataset,
Given that patients are eager to understand the doctor’s real
leaving a total of 89 participants. Their average age was 26.03 years
expectancies about their conditions [42], implicit messages can
(SD = 11.86). A large majority of participants (71.9%) was female.
have a strong impact on psychosocial responses. We expect that in
a positive frame, negations (e.g., ‘‘you will not die’’) yield more
2.3. Stimulus materials for experiment 1
dissatisfied participants, compared to affirmations (e.g., ‘‘you will
live’’). That is, in a positive frame, negations mitigate the good
Participants were presented with a written excerpt of a bad
news, and imply that the doctor may actually have an opposite
news conversation in which a patient was diagnosed with a
negative expectancy. In a negative frame, in contrast, negations
disease. The conversation was about the relatively unknown
(e.g., ‘‘you will not live’’) may yield more positive responses, as
Bekhterev’s disease to prevent previous knowledge about the
compared to affirmations (e.g., ‘‘you will die’’), because in these
disease from influencing results. Indeed, 99% of participants
messages, negations functionally mitigate the negative message
reported they had never heard of this disease prior to their
and implicitly activate positive inferences.
participation (one participant did not complete this question).
Following recent calls for more research using experimental
The excerpt consisted of seventeen sentences divided over four
methods to demonstrate causal relations in the field of doctor–
paragraphs. The total number of words differed between 186 and
patient interaction [13,43], we conducted two lab experiments,
192 in the four conditions. The first paragraph introduced the topic
using a US and a Dutch sample. In our experiments, we
of the conversation. In the second paragraph, the diagnosis was
investigated the inferences that potential patients draw in cases
given to the patient. The third paragraph dealt with the patient’s
in which a doctor uses negations rather than affirmations when
breaking bad news, using either a positive or negative frame. We 1
One participant did not complete the questionnaire seriously, as this person
measure evaluation of the message and the doctor, expected
paraphrased the conversation in an improper way. This person was removed from
quality of life with the disease and medical adherence intentions. the data.
C. Burgers et al. / Patient Education and Counseling 89 (2012) 267–273 269
Table 1
Examples of experimental manipulation.
Negative framing Positive framing
I know that you probably have many questions right now. For now, it is important I know that you probably have many questions right now. For now,
to know that Bekhterev’s disease is a genetic disease. Most patients find it difficult/do it is important to know that Bekhterev’s disease is a genetic disease.
not find it easy to live with this disease. But I would like to prescribe you with a specific Most patients find it easy/do not find it difficult to live with this
drug. Still . . . with these drugs, your quality of life is likely to deteriorate/not likely to disease. But I would like to prescribe you with a specific drug. With
improve over the next few weeks. these drugs, your quality of life is likely to improve/not likely to
deteriorate over the next few weeks.
Manipulation of language use (affirmations vs. negations) in bold.
prognosis and the doctor’s advice to take specific medications. In considerate, compassionate, and respectful (a = .93). Next, parti-
the fourth paragraph, the doctor gave the patient the option of cipants rated their expected quality of life living with the disease,
obtaining further advice about the condition and ended the and the quality of life they thought the doctor expected (two items,
conversation. a = .93). Finally, medical adherence intentions were tapped by three
In the first to third paragraphs, we manipulated the framing of items asking whether following the doctor’s advice was wise, a
the diagnosis (negative vs. positive) and language use (affirmations good idea, and if participants would actually try to follow the
vs. negations). The diagnosis was either framed as relatively recommendations (a = .95). Since all variables proved reliable, we
positive (giving the range of possible diagnoses, the particular calculated a mean overall score for each variable.
diagnosis was relatively good) or negative (the particular diagnosis
was relatively bad). In these frames either negations (e.g., not bad, 2.6. Instrumentation for experiment 2
not good) or affirmations (good and bad) were used. Table 1 shows
our manipulations in the third paragraph of the conversation. In The questions used in experiment 1 were translated into
total, the manipulation was applied to four of the seventeen Dutch. Reliability for the measures evaluation of the message
sentences. The fourth paragraph was equal across conditions. (a = .69), evaluation of the doctor (a = .89), expected quality of life
(a = .69) and medical adherence intentions (a = .89) was again
2.4. Stimulus materials for experiment 2 satisfactory and we calculated a mean overall score for each
variable.
For experiment 2, the materials from experiment 1 were
translated into Dutch. In translation, the total number of words 3. Results
differed between 167 and 173 between the four conditions.
Furthermore, in order to simulate a more realistic doctor–patient Next to a main effect of framing, we expected an interaction
interaction, we created film clips in which a male actor posed as a effect of framing and language use on the evaluation of the
doctor and read the text directly to camera. To participants message, the evaluation of the doctor, the expected quality of life
watching the film clip, this made it seem as if the doctor directly and medical adherence intentions (H1-4). For both experiments,
addressed them. More participants (15.7%) indicated that they we conducted 2 (framing: positive vs. negative) 2 (language use:
were familiar with Bekhterev’s disease and were able to correctly affirmations vs. negations) multivariate analyses of variance
identify at least one major symptom associated with the disease. (MANOVA) with evaluation of the message and the doctor,
expected quality of life and medical adherence intentions as
2.5. Instrumentation for experiment 1 dependent variables. Tables 2 and 3 show the means and standard
deviations of these variables per condition for the two experi-
We measured all dependent variables with multiple-item, 7- ments.
point Likert scales, ranging from 1 = completely disagree to
7 = completely agree. First, participants were asked to evaluate 3.1. Experiment 1: main effects
the message and the doctor. To measure the evaluation of the
message, participants indicated how much they agreed that the The MANOVA showed a main effect of framing on psychosocial
message was informative, clear, understandable and took away responses to the breaking of bad news (Wilks’ l = .26, F(4,
2
hope (reverse-coded; a = .70). For evaluation of the doctor, 93) = 64.86, p < .001, h p ¼ :74). Subsequent univariate analyses
participants indicated their overall impression of the doctor and revealed that framing had a significant effects on the evaluation of
2
the degree to which they thought the doctor was nice, polite, the doctor (F(1, 96) = 12.30, p < .01, h p ¼ :11) and the expected
Table 2
Experiment 1 (USA): mean scores (and standard deviations) of the evaluation of the message and the doctor, the expected quality of life, and medical adherence intentions, in
the framing of the diagnosis (negative vs. positive) and language use (affirmations vs. negations) conditions.
Negative framing Positive framing
Affirmations Negations Affirmations Negations
(e.g., bad) (e.g., not good) (e.g., good) (e.g., not bad)
a a x y
Evaluation of the message 3.28 (1.46) 3.78 (1.14) 4.29 (1.27) 3.44 (1.42)
a a x y
Evaluation of the doctor 2.95 (1.24) 3.34 (1.13) 4.44 (1.12) 3.65 (1.52)
a a x y
Expected quality of life 1.65 (.56) 2.07 (.76) 5.35 (1.02) 4.78 (1.40)
a a x x
Medical adherence intentions 4.26 (1.70) 4.52 (1.48) 5.17 (1.43) 4.59 (1.58)
Note: 7-point Likert scales: higher numbers indicate more positive evaluations, higher expected quality of life and higher intention to follow the doctor’s advice. Means of
variables with different subscript within negative (a, b) and positive (x, y) framing conditions are significantly different according to pairwise comparisons with a certainty of p < .05.
270 C. Burgers et al. / Patient Education and Counseling 89 (2012) 267–273
Table 3
Experiment 2 (Netherlands): mean scores (and standard deviations) of the evaluation of the message and the doctor, the expected quality of life, and medical adherence
intentions, in the framing of the diagnosis (negative vs. positive) and language use (affirmations vs. negations) conditions.
Negative framing Positive framing
Affirmations Negations Affirmations Negations
(e.g., bad) (e.g., not good) (e.g., good) (e.g., not bad)
a a x1 y1
Evaluation of the message 4.30 (1.18) 4.28 (1.29) 3.73 (1.19) 2.97 (1.20)
a b x y
Evaluation of the doctor 3.08 (1.22) 3.77 (1.01) 4.21 (1.33) 3.31 (1.19)
a a x x
Expected quality of life 3.33 (1.32) 2.67 (1.26) 4.58 (1.46) 3.89 (1.73)
a b x y
Medical adherence intentions 4.93 (1.57) 5.79 (1.08) 5.55 (1.23) 4.70 (1.59)
Note: 7-point Likert scales: higher numbers indicate more positive evaluations, higher expected quality of life and higher intention to follow the doctor’s advice. Means of
variables with different subscript within negative (a, b) and positive (x, y) framing conditions are significantly different according to pairwise comparisons with a certainty of
p < .05. x1,y1: this specific pairwise comparison reached significance at p < .05, even though the interaction term was non-significant.
2
quality of life (F(1, 96) = 261.01, p < .001, h p ¼ :73), but not on the 3.3. Experiment 1: interaction effects
evaluation of the message (F(1, 96) = 1.60, p = .21) or medical
adherence intentions (F(1, 96) = 2.47, p = .12). Participants receiv- In line with hypotheses 1–4, we observed an interaction
ing a positively framed message were more positive about the between framing and language use on psychosocial outcomes
2
doctor (M = 4.04, SD = 1.38) and the expected quality of life (Wilks’ l = .90, F(4, 93) = 2.67, p < .05, h p ¼ :10). Subsequent
(M = 5.07, SD = 1.24) than participants receiving a negatively univariate analyses revealed that the interaction was significant
framed message (evaluation of the doctor: M = 3.20, SD = 1.17; for the evaluation of the message (F(1, 96) = 6.56, p < .05,
2
expected quality of life: M = 1.92, SD = .72). No main effect of h p ¼ :06), the evaluation of the doctor (F(1, 96) = 5.39, p < .05,
2
language use was observed (Wilks’ l = .99, F(4, 93) < 1). h p ¼ :05) and the expected quality of life (F(1, 96) = 6.22, p < .05,
2
h p ¼ :06). The interaction for medical adherence intentions was
3.2. Experiment 2: main effects non-significant (F(1, 96) = 1.82, p = .18).
Because our hypotheses predict distinctive effects within frames,
Similar to experiment 1, the MANOVA showed a main effect of we conducted pairwise comparisons for the significant interaction
framing on the psychosocial responses to the breaking of bad news effects. These revealed that, for negatively framed messages, no
2
(Wilks’ l = .69, F(4, 82) = 9.30, p < .001, h p ¼ :31). Subsequent effects of language use were observed on the evaluation of the
univariate analyses revealed that framing had significant effects on message (p = .12) and the doctor (p = .27). The expected quality of
2
evaluation of the message (F(1, 85) = 12.84, p < .01, h p ¼ :13) and life was marginally higher (p = .081) when negations were used
2
expected quality of life (F(1, 85) = 16.14, p < .001, h p ¼ :16), but compared to affirmations. For positively framed messages, however,
not on the evaluation of the doctor (F(1, 85) = 1.72, p = .19) or the evaluation of the message (p < .05) and the doctor (p < .05) and
medical adherence intentions (F < 1). Participants in the condition the expected quality of life (p = .052) were all more negative when
with positive framing were more positive about the expected negations were used compared to affirmations (see Table 2).
quality of life (M = 4.29, SD = 1.59) and more negative about the
message (M = 3.41, SD = 1.24) than participants in the condition 3.4. Experiment 2: interaction effects
with negative framing (evaluation of the message: M = 4.29,
SD = 1.23; expected quality of life: M = 2.96, SD = 1.32). Like in Again, we observed an interaction between framing and
experiment 1, no main effect of language use was observed (Wilks’ language use on psychosocial outcomes (Wilks’ l = .87, F(4,
2
l = .91, F(4, 82) = 1.93, p = .11). 82) = 3.13, p < .01, h p ¼ :13). Subsequent univariate analyses
Table 4
Mediation analysis with the evaluation of the message and the doctor as hypothesized mediators of the interaction of framing and language use on medical adherence
intentions. Main effects of framing and language use are included as covariates.
B SE Normal theory p Bootstrap 95% CI
Experiment 1
Covariate main effect of framing .08 .41 .84
Covariate main effect of language use .11 .35 .76
Interaction framing language use
Total effect (c path) .85 .63 .18
0
Direct effect (c path) .21 .53 .70
*
Total indirect effect (via mediators) 1.05 .43 1.99, .30
*
Evaluation of the message .64 .30 1.32, .13
*
Evaluation of the doctor .42 .22 1.00, .08
2
Model R (p) .39 (<.001)
Experiment 2
Covariate main effect of framing .35 .38 .36
Covariate main effect of language use .59 .35 .09
Interaction framing language use
Total effect (c path) 1.70 .58 <.01
Direct effect (c’path) .83 .52 .11
*
Total indirect effect (via mediators) .87 .38 1.76, .23
Evaluation of the message .24 .21 .81, .05
*
Evaluation of the doctor .63 .28 1.31, .21
2
Model R (p) .37 (<.001)
Note: Mediation with 5000 bootstrap samples.
*
Indirect effect is significant with a certainty of p < .05, because the confidence interval does not include zero.
C. Burgers et al. / Patient Education and Counseling 89 (2012) 267–273 271
revealed that the interaction was significant for the evaluation of negations rather than affirmations in a negatively framed message
2
the doctor (F(1, 85) = 9.56, p < .01, h p ¼ :10) and medical (H2b).
2
adherence intentions (F(1, 85) = 8.65, p < .01, h p ¼ :09). In contrast Expected quality of life: Only in experiment 1 did participants
to experiment 1, the interaction for the evaluation of the message rate their expected quality of life lower when the doctor used
(F(1, 85) = 1.98, p = .16) and the expected quality of life were non- negations rather than affirmations in a positively framed message
significant (F < 1). (H3a). In both experiments, we observed no differences between
Pairwise comparisons revealed that, for negatively framed negatively framed messages with affirmations or negations on this
messages, using negations increased the evaluation of the doctor dependent variable.
(p = .056) and medical adherence intentions (p < .05) compared to Medical adherence intentions: In both experiments, negations
affirmations. In contrast, for positively framed messages, using influenced medical adherence intentions [19]. We observed a direct
negations decreased the evaluation of the doctor (p < .05) and effect only in experiment 2: participants reported lower medical
medical adherence intentions (p < .05) compared to using adherence intentions when the doctor used negations rather than
affirmations. Although – in contrast to experiment 1 – the affirmations in a positively framed message (H4a), and this effect
interaction term was non-significant for evaluation of the message, was reversed in negatively framed messages (H4b). Furthermore, we
pairwise comparisons to test H1a replicated the expected found indirect effects of the interaction between framing lan-
significant difference (p < .05, see Table 3). language use on medical adherence intentions via the evaluation of
the message (experiment 1) and the doctor (both experiments, H5).
3.5. Experiment 1: mediation analyses Given that the experiments differed in method (written scenario
vs. film clip), language of experimental materials and cultural
To test whether evaluation of the message and the doctor background of the sample (USA vs. Netherlands), the comparable
mediated the interaction effect of framing and language use on general pattern of results is striking. For both experiments, the
medical adherence intentions (H5), we conducted mediation choice of negations over affirmations is particularly influential in
analyses and estimated indirect effects with 5000 bootstrap positively framed messages. In these cases, negations yield more
samples [44,45]. These analyses revealed significant indirect negative responses compared to affirmations. These findings are
effects of the evaluation of the doctor and the message on medical aligned with the idea that negations (e.g., ‘‘not bad’’) activate
adherence intentions (see Table 4), indicating that the interaction negative associations, and imply that the doctor may actually have
of framing and language use indirectly influences medical an opposite negative expectancy [34,39,40].
adherence intentions, via the evaluation of the message and the In negatively framed messages, however, the effects of
doctor. linguistic formulation was less pronounced, although the Dutch
experiment revealed that negations yielded more positive
3.6. Experiment 2: mediation analyses responses compared to affirmations. This is in line with the idea
that negations mitigate bad news (e.g., not good rather than bad)
As in experiment 1, mediation analyses revealed a significant and imply a positive expectation. Why we find this effect for Dutch
indirect effect of the evaluation of the doctor on medical adherence participants only may be explained by cultural differences in
intentions. In contrast to experiment 1, however, we did not doctor–patient interaction [46]. In feminine cultures like the
observe mediation for the evaluation of the message (see Table 4). Netherlands, doctors use more instrumental (task-oriented)
communication, while in masculine cultures (like the USA),
doctors more often use affective communication in which
4. Discussion and conclusion information may be mitigated [46]. Because affective communi-
cation is less common in Dutch doctor–patient interactions,
4.1. Discussion mitigating with negations for negatively framed news may be
more unexpected and thus increase positive psychosocial
Two experiments support the claim that formulation differ- responses. For the American participants, in contrast, an affective
ences in breaking bad news have psychosocial effects on patients. style is more commonly used and thus patients’ default expecta-
Both experiments suggest that positively framed messages have tion of what effective breaking bad news should be. For these
positive effects on patients’ evaluations as compared to negatively participants, an affective style does not lead to more positive
framed messages. More importantly, within these frames, the use responses compared to a more direct approach.
of negations or affirmations makes a difference. Negations tend to It should be noted, however, that differences between experi-
have positive effects in negatively framed messages, presumably ments are not necessarily due to culture, given that the stimuli also
because they mitigate the message’s direct blow. These effects are differed: where participants in experiment 1 read a transcript of
reversed in positively framed messages, probably because they the conversation, participants in study 2 saw a film clip.
make the doctor seem insincere. Findings are generally compara- Participants in experiment 2 may have been more transported
ble across our experiments, but specific differences on separate into the scenario and thus more open to empathetic remarks (i.e.,
variables were observed between experiments. We now discuss negations in negatively framed news) made by the doctor than
results per specific dependent variable. those in experiment 1 [47,48]. Future research comparing and
Evaluation of the message: Participants in both experiments contrasting these factors may provide further insights.
evaluated the positively framed message more negatively when it Some limitations about our study should be noted. We used
contained negations (e.g., ‘‘the news is not bad’’) rather than healthy volunteers as subjects, whose responses may differ from
affirmations (‘‘the news is good’’), which supports H1a. No effects those of real patients, and a relatively unknown disease, which
of language use were observed in negatively framed messages, may lead to different responses than well-known diseases.
disconfirming H1b. Furthermore, even though intentions are one of the strongest
Evaluation of the doctor: Participants in both experiments predictors of behavior [49–51], patients can always act differently
evaluated the doctor more negatively when s/he used negations from their intentions. Future research may monitor the language of
rather than affirmations in a positively framed message, which real doctors while breaking bad news concerning various medical
supports H2a. In experiment 2 (but not in experiment 1), conditions. By connecting specific observations to real patients’
participants evaluated the doctor more positively when s/he used survey responses over multiple waves, more information can be
272 C. Burgers et al. / Patient Education and Counseling 89 (2012) 267–273
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Disclosure statement
framed messages for encouraging disease prevention behaviors: a meta-
analytic review. J Health Commun 2007;12:623–44.
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The authors confirm that all patient/personal identifiers have
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been removed or disguised so the patient/person(s) described are
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