Breaking Bad News: Learning Through Experience

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Breaking Bad News: Learning Through ExperienceStephanie J. Arnold and Bogda KoczwaraINTRODUCTIONShe sits in bed, propped up by two pillows, wearing awhite hospital gown, staring out of the window. Herfingers pick at somethingis it a tissue? listlessly,distractedly. Ive been told to see her and get ahistory. Im nervousshe doesnt look well andcertainly is in no cheerful mood to talk. But I do asIm told, and approach her with a smile: Hello, Ima medical student; do you mind chatting to meabout why youre in the hospital?She turns and wearily looks me up and downwas my cheerfulness too forced? Oh, I suppose so, ifyou must. Not much else for me to do, is there? SoI pull up a chair and we get started. Dianne tells methat she noticed a lump on her neck some weeks ago,and dismissed it at first, thinking, must haveknocked myself on something, but when it didntgo away, she visited her local doctor. Before sheknew it, he ordered some tests, and had her admittedto the hospital overnight for a lymph node biopsy.And here she wasit was midmorninganxiouslyawaiting her test results. They said it could be lym-phoma, she told me, which is a death sentence, isntit? My friends mother had a blood cancer a couple ofyears ago, and it was horribleall her hair fell out, shewas so sick. Those last few months. . .she was in somuch pain.And then she burst into tears. Im going to dieof cancer, Dianne sobbed, Im so young, I havetwo children. What is my husband going to do? Andwhat about workI cant afford to take time off!Desperately, I offered up the box of tissues by herbed wanting to get out of the room and feelingcompletely helpless.Time out! Lets leave it there for a minute. Tellme, Dianne, how are you feeling? Our moderatorcut in. And you, Stephanie, what do you thinkabout the way you approached this patient? I was ina simulation. Dianne no longer had a lump and hadwiped away her tears, revealing the actor beneath. Ifelt blocked, said the actor. Your offering me atissue was an indication that you didnt want tolisten to my problems, you just wanted me to stopcrying! I agreed, but for different reasonsI had noidea how to help a very distressed patient deal withterribly bad news and was actually very upset myself.WHY IS BREAKING BAD NEWS SO DIFFICULT?Breaking bad news and communicating with dis-tressed patients are some of the most important yetchallenging tasks required of the medical profession.The benefits of good communication skills are wellknown. Evidence shows that patients who ratehighly their doctors communication style have in-creased cancer-related self-efficacy and reducedemotional distress.1 Aside from patient satisfaction,the quality of doctor-patient communication caninfluence compliance and reduce the risk of a mal-practice claim.2 Accounts of patients distressed bythe insensitive delivery of bad news are regrettably alltoo familiar.3Communicating with distressed patients canbe difficult. Doctors suffer significant stress whenfaced with the task of breaking bad news.4 Theyoften react emotionally to the patients distress andmay feel guilt and a sense of failure for not fulfillingthe patients expectations.5 Increasing advances oftechnology and modern medicine can create an er-roneous perception of infallibility of the medicalprofession leading to unrealistic expectations bysociety and within the profession itself.6 Suchunrealistic expectations, compounded by poorcommunication skills, can lead to physicianburnout and stress.7Even in the setting of realistic expectations,breaking bad news is never easy. Perhaps, one of thereasons is in the nameit is bad news that cliniciansdeal with and dealing with human tragedy is nevereasy, irrespective of how skilled one may be. Thenatural response to human tragedy is sadness andcompassion. As the connection between the doctorand a patient grows stronger, so does the emotionalconnection. Perhaps, breaking bad news can neverbe easyperhaps it shouldnt be easy.IS BREAKING BAD NEWS ANACQUIRED SKILL?Traditionally, communication skills for doctorswere taught in an informal way, on ward rounds andthrough observation of more experienced clinicians.In a survey from 1998, the American Society ofFrom the Orange Base Hospital, NewSouth Wales; and the Flinders MedicalCentre, Adelaide, Australia.Submitted August 7, 2006; acceptedAugust 25, 2006.Presented in part at the Cancer Councilof Australia Medical Student Competi-tion on Cancer Education for the 21stCentury Opportunities and Challenges.April 2005, Sydney, Australia.Authors disclosures of potential con-flicts of interest are found at the end ofthis article.Address reprint requests to BogdaKoczwara, MD, Department of MedicalOncology, Flinders Medical Centre,Flinders Dr, Bedford Park, SA, Australia5042; e-mail: 2006 by American Society of ClinicalOncology0732-183X/06/2431-5098/$20.00DOI: 10.1200/JCO.2006.08.6355JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y:When the Tumor Is Not the TargetVOLUME 24 NUMBER 31 NOVEMBER 1 20065098Downloaded from on November 8, 2014. For personal use only. No other uses without permission.Copyright 2006 American Society of Clinical Oncology. All rights reserved.Clinical Oncology attendees showed that only 6% of physicians havereceived any formal training in delivering bad news.8 More impor-tantly, the majority ranked their ability to discuss bad news with theirpatients as poor to fair.8 Data show that communication skills do notnecessarily improve with years of medical practice alone.9 In recentyears a variety of resources have emerged highlighting the importanceof communication skills training for cancer professionals, but theevidence for the efficacy of various strategies remains limited. Thestrongest evidence comes from randomized clinical trials of commu-nication skills training that offered face-to-face learning involvingcommunication with the patient or simulated patient, coupled withopportunities to practice skills and receive feedback in a learner fo-cused environment.10-12Research shows that communication is a skill that can belearned.13 Like anatomy and physiology, the principles of communi-cation skills can be delivered through didactic means such as tutorialsand lectures, textbooks, and other aides, like CD-ROMS and web sites.However, unlike basic clinical science, communication skills may re-quire learning on another, more cognitive and behavioral, level (Table1). The skills of good communication need refining and practicingthrough experience. Practicing communication skills in a structuredsetting allows for feedback from the object of the communication thatcannot be achieved through a didactic session. This is especially sowhen it comes to highly emotive areas of communication, wherenuances of verbal and nonverbal communication are important; insuch areas, feedback can only be obtained through practice with a livehuman being. Few, if any, books, videos, or CD-ROMS have theemotional impact required to teach students how to communicateappropriately with distressed patients. While observing a senior clini-cian communicating with a distressed patient may be feasible forsome, such encounters, aside from intruding on the intimacy of thedistressing experience for the patient, cannot be directly experiencedor repeated for further improvement. In a simulation, a scenario canbe repeated as necessary, interrupted, or modified to provide an op-portunity to practice different techniques in a nonconfrontationalsetting.14 The student receives real-time feedback on her performancefrom her peers, the facilitator, and, most importantly, the patient.Actors can assume a variety of roles to suit the teaching session, such asbeing angry, tearful, or in denial. This broadens the experience forparticipants, who can then adjust their communication techniques tosuit different circumstances.Many doctors can easily recall the sense of terror when asked toparticipate in a role play; they find the scrutiny of the rest of the groupconfronting, and performing in front of their peers frightening andembarrassing.15 They also feel nervous about how they will reactemotionally to an upset patient. Clinicians are often not used toreceiving feedback in front of their peersan experience often morestressful for those who have been in clinical practice for a long time.And, finally, because breaking bad news is intrinsically distressing,being watched by others can aggravate a sense of vulnerability for theclinician who is already upset by the difficult conversation.Despite these anxieties and the initial skepticism, feedback fromparticipants in role play education is usually positive.16 The challengeis to overcome the initial reluctance of participants.IS IT TIME TO FOLLOW MEDICAL SCHOOLS?Given the reluctance of more senior clinicians to engage in role play,training medical students in developing appropriate communicationskills may be the answer. Many medical schools have embraced prin-ciples of experiential learning and are introducing communicationskills training to the curriculum of their students and juniordoctors.17-19 Starting early makes sensestudents are taught an im-portant skill at the time when they are most receptive to knowledgeand when they are least embarrassed by the trials of role play. Butleaving communication skills training to medical students alone leavesunaddressed the issue of a large number of practicing clinicians todaywho have never received training in communication skills and whomay never develop such skills now that their medical training is over.20Is it time to follow medical schools and offer comprehensive commu-nication training programs for fellows and practicing clinicians?In the US, communication skills workshops are now available atselected programs.16 In Australia, attendance at a communicationskills workshop is now mandatory for all advanced trainees in medicaloncology, and a regular workshop is run at the annual meeting of theMedical Oncology Group of Australia. The workshop also provides anopportunity for refresher training for practicing oncologists. Incen-tives from medical indemnity programs may further motivate practic-ing clinicians to refresh their skills. After all, dealing with a simulatedpatient is a better opportunity to practice, rehearse, and refine onesskills than when dealing with a real person struggling to cope withdevastating news.Like any other skill, breaking bad news can be practiced to makeeasier an experience that is never easy.EPILOGUEI step outside for a moment, take some deep breaths and composemyself. Once again I approach Dianne and once again she is upset,teary, inconsolable. However, things go better this time: she cries, Ihold her hand, we talk about her kids and her husband, her expecta-tions, and her hopes. As I thank Dianne, she gives me a tearful smile,but this time the tears do not feel as frightening.REFERENCES1. Zachariae R, Pedersen CG, Jensen AB, et al: Association of perceivedphysician communication style with patient satisfaction, cancer-related self-efficacy, and perceived control over the disease. Br J Cancer 88:658-665,2003Table 1. Suggested Elements of Effective Communication Skills TrainingElement ActionLearner centered Learning objectives are shaped by thelearning needs of participantsExperiential Drawing on and relevant to theprevious experience of participantsSkill focused Designed to practice and refine a skillrather than knowledge aloneParticipatory Involving participation and face-to-facecontactPractice based Allowing repetition of a skill andmodification of approach involvingfeedbackThe Art of Oncology: When the Tumor Is Not the 5099Downloaded from on November 8, 2014. For personal use only. No other uses without permission.Copyright 2006 American Society of Clinical Oncology. All rights reserved.2. Levinson W, Roter DL, Mullooly JP, et al: Physician-patient communica-tion: The relationship with malpractice claims among primary care physicians andsurgeons. JAMA 277:553-559, 19973. Dias L, Chabner BA, Lynch TJ, et al: Breaking bad news: A patientsperspective. Oncologist 8:587-596, 20034. Faulkner A: Communication with patients, families and other profession-als. BMJ 316:130-132, 19985. Baile WF, Kudelka AP, Beale EA, et al: Communication skills training inoncology. Cancer 86:887-897, 19996. Quill TE, Suchman AL: Uncertainty and control: Learning to live withmedicines limitations. Humane Medicine 9:109-120, 19937. Armstrong J, Holland J: Surviving the stresses of clinical oncology byimproving communication. Oncology 18:363-368, 20048. Kramer P: Doctors discuss how to break bad news. ASCO Daily News1:8-9, 19989. Cantwell BM, Ramirez AJ: Doctor patient communication: A study ofjunior house officers. Med Educ 31:17-21, 199710. Fallowfield L, Jenkins V, Farewell V, et al: Efficacy of Cancer Res UKcommunication skills training model for oncologists: A randomized controlledstudy. Lancet 359:650-656, 200211. Razavi D, Delvaux N, Marchal S, et al: The effects of a 24-h psychologicaltraining program on attitudes, communication skills and occupational stressingoncology: A randomized study. Eur J Cancer 29A:1858-1863, 199312. Razavi D, Delvaux N, Marchal S, et al: Does training increase the use ofmore emotionally laden words by nurses when talking with cancer patients? Arandomized study. Br J Cancer 87:1-7, 200213. Fellowes D, Wilkinson S, Moore P: Communication skills training for healthcare professionals working with cancer patients, their families and/or careers.The Cochrane Library, Issue 3, Indianapolis, IN, John Wiley & Sons Ltd, 200614. Wakefield A, Cooke S, Boggis C: Learning together: Use of simulatedpatients with nursing and medical students for breaking bad news. Int J PalliatNurs 9:32-38, 200315. Joyner B, Young L: Teaching medical students using role play: Twelve tipsfor successful role plays. Med Teach 28:225-229, 200616. Back AL, Arnold RM, Tulsky JA, et al: Teaching communication skills tomedical oncology fellows. J Clin Oncol 21:2433-2436, 200317. Kalet A, Pugnaire MP, Cole-Kelly K, et al: Teaching communication inclinical clerkships: Models from the Macy initiative in health communications.Acad Med 79:511-520, 200418. Wagner PJ, Lentz L, Heslop SD: Teaching communication skills: A skills-based approach. Acad Med 77:1164, 200219. Scalliet P, Etienne AM: Teaching communication and stress managementskills to junior physicians dealing with cancer patients: A Belgian InteruniversityCurriculum. Supp Care Cancer 14:454-461, 200620. Walker LG: Communication skills: When, not if to teach. Eur J Ca32A:1457-1459, 1996Authors Disclosures of Potential Conflicts of InterestThe authors indicated no potential conflicts of interest.Arnold and Koczwara5100 JOURNAL OF CLINICAL ONCOLOGYDownloaded from on November 8, 2014. For personal use only. No other uses without permission.Copyright 2006 American Society of Clinical Oncology. All rights reserved.