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Teaching and training in breaking bad news at the Dutch medical schools: A comparison
Medical Teacher
Abstract and Figures
Physicians consider breaking bad news (BBN) a difficult task, and training is therefore necessary. There is much variety in what schools consider to be best practice and best timing for such training. This article discusses BBN-programmes at the Dutch medical schools. We studied how students value their training and offer recommendations.
We developed two questionnaires to obtain programme information from course co-ordinators and student opinions about BBN-training. We compared student opinions right after BBN-training (T1) and towards the end of the medical curriculum (T2).
BBN-programmes in Dutch medical schools vary in timing, models used and training methods. Overall, students are satisfied with the timing. They appreciate feedback by physicians and simulated patients most. At T2, some groups of students reported that BBN-training had given them slightly less guidance than was reported by T1-students at the same institution.
T2-students perhaps realised they had not received the amount of support they needed and may have shifted from being unconsciously incompetent to being consciously incompetent.
We recommend: (a) longitudinal programmes with experiential skills-training sessions and clinical practice, (b) to involve simulated patients, physicians and psychologists in training programmes as well as practising physicians who supervise students during clinical work and (c) to ensure ongoing support and feedback in the clinical phase.
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... Diversos estudios del Reino Unido y Estados Unidos han enfatizado en la necesidad de una formación estructurada de los estudiantes de medicina para comunicar las malas noticias. Esto es similar a estudios realizados en escuelas de medicina holandesas, los cuales demostraron que la mayoría de los médicos y residentes recomiendan incluir programas que ayuden a perfeccionar esta habilidad 4,15 . ...
... En la literatura se han descrito diversos métodos para potenciar estas habilidades de comunicación tales como conferencias, discusiones en grupos pequeños, juegos de roles y/o pacientes simulados, médicos y psicólogos en programas de capacitación, videos instructivos, exámenes clínicos con objetivos estructurados (OSCEs), médicos en ejercicio que pueden supervisar a los estudiantes durante el trabajo clínico y el estudio de la ética médica 2,4,5,8,15 . ...
Introducción: El término “malas noticias” se define como cualquier información que se entregue a los pacientes y a sus familiares, que directa o indirectamente evidencie algún trastorno negativo o grave que pueda cambiar sus perspectivas sobre el futuro y su visión de la vida. Objetivo: Establecer la importancia de que estudiantes de medicina reciban durante su formación académica una adecuada preparación para la entrega de malas noticias. Metodología: Búsqueda bibliográfica en la base de datos Pubmed publicadas entre los años 2010 y 2020. Resultado: El uso de protocolos e intervenciones para mejorar la entrega de malas noticias se asoció con mejoras importantes y significativas en las habilidades comunicativas de los médicos. Además, éstas reducen el estrés y aumentan la confianza de los médicos al momento de entregar malas noticias. Discusión: A pesar de la importancia de esta habilidad en la práctica clínica, los médicos durante su formación en las facultades de medicina no reciben las herramientas necesarias para comunicar adecuadamente malas noticias. En consecuencia, esta habilidad de comunicación generalmente se aprende a través de prueba y error u observación de colegas superiores. Conclusión: Una entrega hábil de malas noticias puede brindar consuelo al paciente y a su familia, además de disminuir el estrés que esta situación le provoca al médico. Por consiguiente, es fundamental incluir intervenciones sobre cómo entregar malas noticias en la formación académica de los estudiantes de medicina.
... Studies have recommended that medical schools invest in the teachinglearning process of communication skills (CS) [1][2][3][4][5]., in order to guarantee the formation of professionals capable of exercising their role in society [6]. ...
... Results of studies have indicated that physician-patient communication should begin very early with medical students [4,9,17], considering that, as communication is a skill, it includes complex delicate, emotional and cognitive aspects. Thus, it has been increasingly evident that the development of this skill requires training and, due to its complexity, requires time and repetition [1]. ...
Objective
To analyze the medical students’ perception about simulated consultations before and after training using the SPIKES protocol.
Methods
Quasi-experimental study, with a qualitative approach. It counted with the participation of 20 students as Simulated Physicians (SF), and 20 students as Simulated Patients (SP), all belonging to a medical course. Data were obtained from the responses given to a reflective question, applied before and after training with the SPIKES. The treatment and the analysis of the data were guided by the stages of thematic analysis.
Results
In the category “Simulated Medical Student’s Self-Perception”, the subcategories “Nervousness and Insecurity” were predominant after the first consultation, while “Tranquility and Security” after the second consultation after training. In the category “Simulated Medical Student’s Perception about the Educational Process”, the subcategory “Reflective Learning” emerged in the students’ speeches, especially after the second consultation. In the speeches of SP, it was evidenced the improvement of the care provided by SF after training.
Conclusion
The strategy used for the development of communication skills showed evidence of short-term effectiveness.
Innovation
The research resulted in a teaching protocol for students in pre-clinical stages that involves four stages: simulation, self-assessment, feedback and new simulations.
... Successfully teaching professional communication requires different modalities. Previous studies assessing communication skills training have found that training may be most effective if provided often and early on, as in longitudinal programs [27][28][29]. Further, medical curricula are encouraged to include a multitude of possibilities of practicing communication strategies for effective BBN with different learning opportunities, such as lectures, role-playing, and teachable moments in clinical settings [27,29]. Learning professional behavior -as opposed to acquiring factual knowledge -depends mostly on the observation of others, such as peers or seniors who serve as role models [30][31][32][33]. ...
... Previous studies assessing communication skills training have found that training may be most effective if provided often and early on, as in longitudinal programs [27][28][29]. Further, medical curricula are encouraged to include a multitude of possibilities of practicing communication strategies for effective BBN with different learning opportunities, such as lectures, role-playing, and teachable moments in clinical settings [27,29]. Learning professional behavior -as opposed to acquiring factual knowledge -depends mostly on the observation of others, such as peers or seniors who serve as role models [30][31][32][33]. ...
Objective
Breaking bad news (BBN) is challenging for physicians and patients and specific communication strategies aim to improve these situations. This study evaluates whether an E-learning assignment could improve medical students' accurate recognition of BBN communication techniques.
Methods
This randomized controlled trial was conducted at the University of Basel. After a lecture on BBN, 4th year medical students were randomized to an intervention receiving an E-learning assignment on BBN or to a control group. Both groups then worked on an examination video and identified previously taught BBN elements shown in a physician-patient interaction. The number of correctly, misclassified and incorrectly identified BBN communication elements as well as missed opportunities were assessed in the examination video.
Results
We included 160 medical students (55% female). The number of correctly identified BBN elements did not differ between control and intervention group (mean [SD] 3.51 [2.50] versus 3.72 [2.34], p=0.58). However, the mean number of inappropriate BBN elements was significantly lower in the intervention than in the control group (2.33 [2.57] versus 3.33 [3.39], p = 0.037).
Conclusions
Use of an E-learning tool reduced inappropriate annotations regarding BBN communication techniques.
Practice Implications
This E-learning might help to further advance communication skills in medical students.
... This is a process of information exchange between patient and physician. Proper exploitation of patient's fundamental insight is vital as much as is the knowledge of what not to do and what to expect, because the patient is the one who knows what is hurting him most and he is the one who knows how to move forward [10]. Truthful disclosure of psychologically painful information not only hurts the patient and their relatives but also embarrasses the doctor [11]. ...
... Entretanto, no grupo Strategy and Summary não foi identificado essa evolução.Esse fato pode ter ocorrido tanto por uma falha do método, visto que o discente pode ter acreditado que já havia finalizado a estação não dando importância para essas etapas; quanto por uma dificuldade para estabelecer, identificar e comunicar as próximas etapas a serem realizadas após a comunicação da má notícia. Um ponto importante a ser destacado é que em todos os grupos de questões do protocolo SPIKES, o terceiro semestre apresentou um melhor desempenho, reforçando a importância do treinamento para o desenvolvimento da habilidade de comunicar notícias difíceis.Além disso, um ponto importante a enfatizar é a eficácia no uso de protocolos de comunicação de más notícias, como demonstram três estudos(van Weel-Baumgarten et al., 2012;Ramaswamy et al., 2014;Coutinho & Ramessur, 2016) usando o SPIKES, no qual o desempenho dos alunos não pode ser comparado àqueles que não receberam nenhum treinamento e o impacto do uso do protocolo não pode ser estabelecido. ...
Este estudo objetiva avaliar as habilidades de estudantes de medicina na comunicação de más notícias. Estudo transversal, analítico e observacional por meio de checklist da avaliação prática em estilo Objective Structured Clinical Examination (OSCE), de graduandos de medicina, baseado no protocolo SPIKES, contendo 12 itens distintos. Foram avaliados 172 checklist, sendo 61 (35,5%) do 1° semestre do internato, 59 (34,3%) do 2° semestre e 52 (30.2%) do 3º semestre. Do total, 56,97% eram do sexo feminino. Não houve diferença estatística entre o sexo e os períodos avaliado (p>0,05). A média de acertos do 1° semestre do internato foi de 8,21 ±2,60, a do 2° semestre foi de 7,13 ±2,51 e a do 3° semestre foi de 9,98 ±1,72. Houve um bom desempenho dos internos quanto as habilidades de comunicação de notícias difíceis, porém, o semestre de avaliação mostrou-se um fator de melhora no desempenho, evidenciando a importância do treinamento dessa habilidade.
... Debriefing was performed by the same teachers, practitioners with experience in oncology, to ensure appropriate students' supervision, support, and feedbacks. Those elements are considered of great importance [18]. Comparing the two peer role-play training methods, i.e. "in-class'' vs. VPRP, bring some interesting observations in terms of students' knowledge gain. ...
Background
We report two different peer role-play training courses for breaking bad news (BBN) in Oncology, the classic “in-class” model and the “virtual” peer role-play (VPRP) model developed during the SARS-CoV-2 pandemic.
Methods
Each session included 20–25 4th year medical students supervised by two practitioners experienced in oncology. After an ice breaking activity to exchange with students on means to promote hope to patients when BBN, peer role-plays started. Pre-and post-session questionnaires were submitted to evaluate students’ satisfaction, attitudes, and perceptions. Pre-and post-session knowledge test were realized. Each student has participated to only one peer-role play either “in-class” (2018) or VPRP (2020).
Results
In 2018, a total of 222 students received the “in-class” training. In 2020, a total 431 students received the VPRP training. For almost all students it was the first peer role-play training session. Before training, reported level of confidence in BBN was low. After training, students of the VPRP group were highly satisfied regarding quality (realism, organization). Students also reported great interest and perceived benefits. Students who underwent “in-class” training course showed a significantly higher improvement (+1.9 points) of their knowledge scores compared to those who underwent the VPRP training course (+0.7 points) (P-value = 2e–16).
Conclusion
The two methods seem beneficial to improve knowledge skills in BBN although “in-class” training class seem to be more efficient. To our knowledge, this is the first comparison between virtual and in-class peer-role play training for BBN in oncology.
... In their international study, A. Alshami et al. showed that only 26.6% of medical students received formal DBN training during their education [10]. The deficit of this type of instruction causes students to still report the need for in-depth training in this area [11,12]. Although competency development courses in delivering bad news appear to be relatively effective, they may not meet all expectations. ...
Background:
Numerous reports indicate the educational deficiencies of medical students in delivering bad-news-related skills. Evaluation of the performance of training programs in this area should be one of the key components of the educational process. The purpose of this study was to analyze medical students' preferences and educational needs regarding DBN (delivering bad news). The effect of clinical experience on the self-assessment of skills was analyzed.
Methods:
The quantitative survey was conducted using the CAWI technique. The study involved 321 fifth- and sixth-year medical students from 14 medical universities in Poland. Pearson's χ2 test was used for statistical analysis. The profile of respondents for categorical variables was determined by KMeans analysis.
Results:
As many as 75.1% of students revealed that they did not feel sufficiently prepared for DBN. Only 18.7% reported having adequate competence in this area. More than half of the inquired students (63.6%) witnessed a situation during their clinical practice in which a physician provided a patient with information about an unfavorable diagnosis. These students were less likely to declare that they could not deliver BN (43.4%) than students who had no such experience (58.2%). As many as 86.3% of the respondents reported the need for more time in DBN skills training. Students mostly preferred active teaching methods.
Conclusions:
Understanding students' learning needs and preferences can help medical schools optimize their education programs to develop DBN-related competencies.
Good communication is necessary for good clinical care, but defining good communication has been surprisingly difficult and controversial. Many current ideas that identify good communication with certain communication behaviours, or 'skills', were ethically inspired to help doctors see beyond disease to the whole patient. However, promoting specific behaviours is problematic because communication is contextually dependent. In recent decades, observational research into practitioner-patient relationships has begun to provide a scientific basis for the field, identifying patients' vulnerability and practitioners' authority as defining features of fundamentally asymmetric clinical relationships. Future educators can learn from research that explores the judgments that experienced practitioners make when they manage communication dilemmas arising from this asymmetry. In future, instead of the current emphasis on teaching communication behaviours, educators could provide practitioners with knowledge about relationships to inform those judgments, while addressing the attitudes and values that motivate and guide their communication.
Background
Delivering bad news to patients is one of the most challenging tasks in medical practice. Despite its great relevance to patients, relatives, and medical staff, there is a paucity of data pertaining to training, experience, expectations, and preferences of physicians and medical students on breaking bad news.
Methods
We conducted an international survey in Germany, Switzerland, and Austria using an online questionnaire among physicians and medical students.
Results
A total of 786 physicians and 303 medical students completed the survey. Physicians stated that 32.7% deliver bad news several times a week and 45.2% several times a month. Difficulties controlling their emotions (35.1%) and remaining professional (43.4%) were the greatest challenges for physicians. Delivering bad news is associated with feelings of anxiety, both among experienced physicians (median of 3.8 out of 10.0) and medical students (median of 5.3). Conveying bad news is a burden to physicians and consequently has a substantial impact on their job satisfaction. All participants reported the need for more communication training concerning this subject. Only 49.5% of medical students and 67.3% of physicians mentioned having learned adequate communication skills. Our data demonstrate that communication training decreases the level of anxiety and increases the feeling of self-confidence towards breaking bad news. Preferred educational tools were seminars with simulation (students: 71.4%, physicians: 49.5%), observing more senior faculty (students: 57.4%, physicians: 55.1%), and supervision and feedback sessions (students: 36.3%, physicians: 45.7%). The largest barriers regarding education on communication were limited time (students: 77.0%, physicians: 74.9%) and missing awareness of supervisors (students: 60.6%, physicians: 41.1%).
Conclusions
Our study showed a great need for systematic training and education in breaking bad news among physicians and medical students. Hospitals, medical schools, and postgraduate training programs are strongly encouraged to fill this gap, and improve sustainable doctor–patient communication to overcome the psychological burden for physicians.
Background
Simulated patients (SPs) are widely used, but the most effective way of utilising them in undergraduate breaking bad news (BBN) medical education is unknown.
Objectives
To conduct a systematic review into SP’s use in developing BBN skills in medical students.
Methods
14 databases searched with the terms “Medical education”, “Patient simulation”, “Bad news”. Data was systematically extracted, and thematic analysis undertaken.
Results
Of 2117 articles screened, 29 publications met the inclusion criteria. These demonstrated a variety of SP models, including actors as patients (65.5%), peers (7.0%), and cancer survivors (3.5%). with delivery at varying times in the curricula. SPs are uniformly reported as having positive impact, but there is a lack of high-quality evidence comparing the use of differing forms of training. There was some evidence that virtual SPs were as useful as in-person SPs.
Conclusions
SPs allow students to practise vital BBN communication skills without risking detriment to patient care. Despite the heterogeneity of ways in which SPs have been used, the benefits of different approaches and when and how these should be delivered remains unclear.
Practice implications
Further educational development and research is needed about the use of SPs to support undergraduate BBN communication skills development.
This study explored the interacting effects of personal dispositions and situational conditions on the stress response. Forty gynecologic patients about to undergo a diagnostic procedure (colposcopy) were divided into information seekers (monitors) and information avoiders (blunters). Half in each group were exposed to voluminous preparatory information, and half to the usual low level of information. Subjective, physiological, and behavioral measures of arousal and discomfort were obtained before, during, and after the procedure. Overall, low-information patients expressed less subjective arousal than high-information patients, and blunters showed less subjective and behavioral arousal than monitors. In addition, patients' level of psychophysiological arousal was lower when the level of preparatory information was consistent with their coping style; that is, blunters were less aroused with low information and monitors were less aroused with high information. Further evidence was gained for the utility and validity of a new scale for identifying monitors and blunters.
Objective.
—To review the literature on breaking bad news while highlighting its limitations and describing a theoretical model from which the bad news process can be understood and studied.Data Sources.
—Sources were obtained through the MEDLINE database, using "bad news" as the primary descriptor and limiting the sources to English-language articles published since 1985.Study Selection and Extraction.
—All articles dealing specifically with bad news were examined. These works included letters, opinions, reviews, and empirical studies. Recommendations from these articles were examined, sorted into discrete categories, and summarized.Data Synthesis.
—The 13 most consistently mentioned recommendations (eg, delivering the news at the patient's pace, conveying some hope, and giving the news with empathy) were examined.Conclusion.
—Although much has been written on the topic of breaking bad news, the literature is in need of empirical work. Research should begin with the simple question of whether how the news is conveyed accounts for variance in adjustment before moving to more specific questions about which aspects of conveying bad news are most beneficial. It is suggested that the bad news process can be understood from the transactional approach to stress and coping.
Communicating bad news to patients and their families is a difficult but routine responsibility for hospitalists. Most practitioners have little or no formal training for this task. Preparation for, delivery of, and follow-up to these conversations should be deliberately planned in order to meet patients' needs. In this article, we review the literature that guides this process and, with a case example, describe steps practitioners can take to effectively deliver bad news and pitfalls that should be avoided. As competency in this skill set is necessary for effective patient care, hands-on training should be part of the core curriculum for all health care practitioners. Hospitalists should be proficient in this area and may serve as role models and instructors for colleagues and trainees. Journal of Hospital Medicine 2007;2:415–421. © 2007 Society of Hospital Medicine
No studies have previously evaluated factors associated with high stress levels and poor communication performance in breaking bad news (BBN) consultations. This study determined factors that were most strongly related to doctors' stress responses and poor communication performance during a simulated BBN task.
In 2007, the authors recruited 24 doctors comprising 12 novices (i.e., interns/residents with 1-3 years' experience) and 12 experts (i.e., registrars, medical/radiation oncologists, or cancer surgeons, with more than 4 years' experience). Doctors participated in simulated BBN consultations and a number of control tasks. Five-minute-epoch heart rate (HR), HR variability, and communication performance were assessed in all participants. Subjects also completed a short questionnaire asking about their prior experience BBN, perceived stress, psychological distress (i.e., anxiety, depression), fatigue, and burnout.
High stress responses were related to inexperience with BBN, fatigue, and giving bad versus good news. Poor communication performance in the consultation was related to high burnout and fatigue scores.
These results suggest that BBN was a stressful experience for doctors even in a simulated encounter, especially for those who were inexperienced and/or fatigued. Poor communication performance was related to burnout and fatigue, but not inexperience with BBN. These results likely indicate that burnout and fatigue contributed to stress and poor work performance in some doctors during the simulated BBN task.
Our novel teaching approach involved having students actively participate in an unsuccessful resuscitation of a high fidelity human patient simulator with a gun shot wound to the chest, followed immediately by breaking bad news (BBN) to a standardized patient wife (SPW) portrayed by an actress.
Brief education interventions to include viewing a brief video on the SPIKES protocol on how to break bad news, a didactic lecture plus a demonstration, or both, was compared to no pretraining by dividing 553 students into four groups prior to their BBN to the SPW. The students then self-assessed their abilities, and were also evaluated by the SPW on 21 items related to appearance, communication skills, and emotional affect. All received cross-over training.
Groups were equal in prior training (2 h) and belief that this was an important skill to be learned. Students rated the experience highly, and demonstrated marked improvement of self-assessed skills over baseline, which was maintained for the duration of the 12-wk clerkship. Additionally, students who received any of the above training prior to BBN were rated superior to those who had no training on several communication skills, and the observation of the video seemed to offer the most efficient way of teaching this skill in a time delimited curriculum.
This novel approach was well received and resulted in improvement over baseline. Lessons learned from this study have enhanced our curricular approach to this vital component of medical education.
Breaking bad news is 1 of cancer specialists' most common and difficult duties, yet hematology-oncology fellowship programs typically offer little formal preparation for this daunting task. We designed the Breaking Bad News Standardized Patient Intervention (BBNSPI) as a standardized patient educational intervention to improve the communication skills of hematology-oncology fellows (HOFs) and advanced practice nurses (APNs) in breaking bad news to cancer patients.
A total of 6 HOFs and 2 APNs participated in the preintervention test and an educational session designed to improve communication skills. A total of 5 HOFs and 1 APN participated in the postintervention test 1 week later.
The average test score of the participants improved from 56.6% in the preintervention test to 68.8% (P < .005) in the postintervention test. The preintervention perception survey showed that 2 of 6 subjects (33%) expected the intervention to improve their communication skills in breaking bad news compared to 5 of 6 subjects (83%) in the postintervention survey (P < .08). The long-term intervention perception survey showed that all 6 subjects (100%) thought the intervention improved their communication skills in breaking bad news to cancer patients (P < .048).
BBNSPI improved HOFs' and APNs' communication skills in breaking bad news to cancer patients. The perception of the subjects about BBNSPI was positive.
In curriculum documents for medicine in undergraduate, post-graduate and continuing professional development, there is now a focus on communication skills. The challenges are to place communication skills in the crowded curriculum and then to construct and sustain a programme that uses an evidence-based approach to the teaching and learning of communication skills. For 6 years, we have conducted a programme that involves simulated parents supporting junior medical staff to refine their skills in communication, particularly in giving parents bad news. The aim of our study was to obtain a better understanding of the trainees' experiences of the programme.
Nine junior residents individually worked through two scenarios and received feedback from the simulated parent. They gave bad news to a simulated parent/actor who then gave feedback. A recording of the simulation was provided for discussion with a designated colleague at an arranged time. The tapes were then separately appraised by two independent raters - another actor and a paediatrician. Brief written reports and conducted semi-structured interviews provided more insights into the trainees' experience of the simulation. Other participating medical/medical education staff were interviewed about the simulation programme.
Five themes emerged from the qualitative data: timeliness, emotional safety, the complexity of communication, practical usefulness and the challenge of effecting change. In addition, the ratings of the videos helped to clarify those 'parent-centred' communication skills that trainees may neglect in difficult conversations: 'ask about support', 'encourage the parent to ask questions' and 'repeat key messages'.
The evaluation highlighted the value of an early-career experiential programme to highlight the importance of communication skills in post-graduate paediatrics practice.
Interviews were conducted with 77 patients aged 19-84, admitted to a medical oncology ward for assessment and modification of treatment. Satisfaction with information provided about tests, symptoms and treatment was assessed, together with satisfaction with care in general, factual knowledge concerning cancer and other medical conditions, and anxiety. Habitual style of coping with stress by information-seeking vs avoidance was measured using the Miller Behavioral Style Scale. Satisfaction levels were generally high. Patients reporting the highest level of satisfaction with information were more avoidant in their coping style than the remainder, and were also less anxious. Factual knowledge about cancer was in contrast greater among patients who were less satisfied with communication. These patterns were not dependent on age or education. It is argued that satisfaction with communication in medical settings is not a simple function of communication skills and the provision of adequately structured information, but that patients' tendencies to cope with stress by seeking out or avoiding information need to be taken into account.
PURPOSE AND DESIGN: One of the more difficult tasks that clinicians must perform as part of their care of patients is that of conveying bad news, such as a severe diagnosis or death. However, there is a paucity of empirically founded information that relates to the specific steps for breaking bad news. We report on a set of guidelines for breaking bad news that was developed using a consensus process and incorporates the views of medical oncologists, general practitioners, surgeons, nurse consultants, social workers, clergy, human rights representatives, cancer patients, hospital interns, and clinical directors of medical schools in Australia. RESULTS AND CONCLUSION: It is recommended that further research be undertaken in a number of areas. First, there is a need to assess patients' versus providers' perceptions of the importance of each of the steps in breaking bad news, in order to define criteria for minimal levels of competence in this area. Second, controlled trials are needed to assess the effectiveness of the guidelines in changing clinical practice, and to identify the most effective strategies for breaking bad news to patients.