Medical Education 1989, 23,25%261

Breaking bad news: medical undergraduate communication skills teaching and learning

J. D. E. K N O X t & G. M . T H O M S O N S

tDepartrnent of General Practice, University o f Dundee and $Development OfficerParent to Parent Tayside Coordinator, Scottish Child and Family Alliance

Summary. Teaching on the theme of ‘breaking bad news’ was selected for special development as part of an introductory course on communi- cation skills for preclinical medical students in 1987. Eight parents of handicapped children and three patients terminally ill with neoplastic diseases cooperated in a series o f semi-structured group discussions in which students were en- couraged to interact with patients and children. The patients/parents readily assumed the role of teachers and where it was possible, they partici- pated in similar sessions the following year.

Analysis of questionnaires indicated that the plan had proved acceptable to patients, relatives and students. Follow-up of student opinion one year later indicated that students felt they had derived benefit from these opportunities to learn first-hand from patients and parents of handi- capped children.

Key words: *communications; *education, medical, undergraduate; physician-patient rela- tions; parents; teachingimethods; Scotland; atti- tude of health personnel; students, medical

Introduction

The theme of educating medical students, doctors and other health professionals in general communication skills has attracted increasing attention during the past decade. Experience gained in this relatively new development has enabled teachers to become more specific in the

Correspondence: Professor J. D. E. Knox, Depart- ment of General Practice, Wesrgate Health Centre, Charleston Drive, Dundee DD2 4AD, UK.

content and methods appropriate to the needs of learners. Among several topics relevant to undergraduate medical students, the theme ‘breaking bad news’ is one of special importance, because of its relevance to the everyday work of most clinicians, and because there is evidence that patients and their relatives feel that there is scope for improving doctors’ abilities (Lichter 1987).

This paper describes a recent development in the Dundee Medical School communication skills course which attempts to tackle this diffi- cult theme.

The setting

The course, more fully described elsewhere (Knox 81 Bouchier 1985), is an introductory one aimed to orient second-year preclinical medical students towards a more patient-centred approach before being taught clinical methods in the third year of the course. The course uses both hospital and general practice settings: it relies especially on supervised one-to-one encounters between student and patient selected from gen- eral practice. The theme ‘breaking bad news’ was introduced into the course during the second term, after students had experience of routine consultations during the first term.

Aims

This part of the course had the following aims: (1) to assist medical students to consider

psychological adjustments which patients and their families make in coping with such major life

258

Breaking bad news: teaching and learning with patients 259

events as the diagnosis of a handicapping condi- tion like Down’s syndrome, and cancer;

(2) to experience some of the emotions and professional .behaviour involved in caring for people in such situations; and

(3) to learn from direct contact with patients/ parents how to improve abilities in coping with sensitive issues.

For the patientdparents, the sessions also afforded opportunities for them to comment on their experiences. Although the original intention was for teaching purposes, the sessions appeared to be therapeutic for the patients.

Methods

Previous experience had shown that students tend to retain impressions and information obtained directly from patients and relatives often in a more vivid form than in theoretical classroom teaching (Kent et al . 1981). It was therefore decided to explore the potential role of patients/relatives as teachers by enlisting their cooperation. Encouragement to proceed along these lines came from several sources, including the proceedings of a conference organized by Scottish Child and Family Alliance (SCAFA) involving parents of handicapped children. In addition, it was considered that cancer sufferers had a potential contribution to make to the theme, and that their contribution might help to draw out more clearly basic principles which apply widely in doctors’ dealings with patients.

It proved possible, after preliminary dis- cussions with them and with their families, to enlist the help of such patient/parents willing to talk about their feelings and reactions. The structure of the course allowed all 110 students to attend one of six seminars. Groups of 16-18 students met for a session lasting about 2 hours; each session followed roughly the same pattern.

Background material

After introducing the theme, but before the patientdparents arrived, the leader canvassed the group for their perceptions of tasks facing a doctor breaking bad news to a relative and/or patient. Identification of what might constitute ‘bad news’, problems inherent in conveying the

information, professional techniques and poss- ible reactions of patients, relatives and others were eagerly taken up by the students (average age 20 years): they were encouraged to draw on their own experiences as far as possible. These themes were then brought together and illustrated by playing parts of the video teaching series entitled ‘Why won’t they talk to me?’ produced by Buckman & Maguire (1985) (avail- able through Linkward Production Ltd, Shep- perton Studio Centre, Middlesex TW17 OQD, UK) and the video ‘Shared concern: breaking the news to parents that their newborn child has a disability’ (available from Society of Parents Helping in Education, King’s Fund, London).

T h e patiendparent teaching role

At this point the patient or parent(s) of a handicapped child (and the child) joined the group. The group leader introduced the patients and/or relative, who were invited to narrate their experiences. Thereafter, the seminar took one of two forms, each designed to involve the students more actively.

Parent and handicapped child

In the case of parents of handicapped children, when it was possible to involve two (or more) families at the one session, the students divided up into subgroups with the task of exploring in greater depth the broad issues identified in the preliminary session. They were also encouraged to play with the children and see for themselves the abilities and disabilities in Down’s syndrome, blindness, deafness and mental subnormality, for example. In the final half hour, the group compared findings and parents were quick to underline the salient issues as they saw them, and express their opinions on different approaches which might have been used. The presence of a professional staff member (Development Officer) of the Scottish Child and Family Alli- ance (a non-medical organization) allowed medical, lay and other opinions to be examined in an objective fashion. Roles of the Develop- ment Officer included supporting parents and providing for students a model for listening behaviour.

260 /. D . E. Knox G G. M . Thomson

Cancer sufferers

With a cancer patient, the seminar took a slightly different form. After the introduction, a student was invited by the course leader to take over as ‘interviewer’, with promptings from the student group as might be required. The course leader was prepared to intervene if he sensed that the situation was in danger of going beyond the students’ capabilities. In fact such action did not have to be taken, even although the patients who made their contributions were approaching what proved to be the terminal phases of their disease.

Evaluation

Assessment of this part of the course included parents’ views (collated by the Development Officer) of the sessions involving handicapped children. The doctors responsible for the ter- minal care of the cancer patients, and the students provided additional feedback of information.

Results

Parents’ responses indicate strongly positive feel- ings for this teaching.

All three cancer patients felt that they had put their experiences to good use. Suggestions as to how the sessions might be improved included the following:

(1) smaller groups (than 12-15) to encourage more student participation;

(2) groups consisting of parents and students only;

(3) longer sessions (than the 2 hours allowed), with less direction and more informal seating arrangements;

(4) better provision for the children prior to the session; and

(5) more sessions to allow parents and students to become more comfortable in each other’s presence.

Acceptance by students

In addition to the pro forma routinely used to obtain student opinion at the end of the com- munication skills course (Knox & Bouchier 1985), students’ views of the ‘Breaking Bad News’ component were also evaluated by the Development Officer, 3 months and 18 months later.

At the initial assessment, 63% ofthe class rated the component as useful, 30% as extremely useful and 7% as oflimited value. The follow-up surveys suggested similar proportions in the categories of acceptability. Even after 18 months, during the stimulating period of introduction to clinical work in the wards, some students expressed such positive views as the following:

‘This, for me, helped to bring across just how important it is to consider people close to the patients (i.e. friends, relatives) as well as the patiendclient as an individual.’

Table 1. Responses of eight parents

Number responding

Item positively

(1) (2) (3) (4)

(5)

Were you comfortable in the surroundings? Did you feel able to express your feelings freely? Did you feel there was genuine interest? Did you feel the students understood your situation? Did you think the students have a better understanding of the implications of handicap for a family? Do you think the students have gained insight which will help to develop counselling skills? Would you be prepared to participate again?

(6)

(7)

8 7 8

6

8

7 8

Breaking bad news: teachitig arid learning with patients 26 1

‘It was very good not only to see the doctor’s point of view on breaking bad news but also the parent’s, who has actually experienced such an ordeal.’

‘Even after approximately a year and a half, the one session with the parents and children is still vivid. This hands-on experience of parents’ grief of not only the immediate circumstances of their child’s handicap but the problems with the medical fraternity was enlightening.’

The students’ suggestions for improvement included:

(1) smaller groups; (2) two compulsory sessions with additional

(3) increasing the frequency of such visits; and (4) more than one session with the same

optional ones;

patient.

Comment

In the absence of more objective testing, it would go beyond the evidence to claim that the students’ learning and, perhaps more impor- tantly, their professional behaviour, has been influenced to a major degree by the course described here. At least, however, a sensitive area of professional activity has been brought before students in ways which are acceptable to them and to patientdparents. The patientdparents appeared ready to assume the role of teacher as the following comments illustrate:

‘The birth of a handicapped child is a very traumatic time for all involved, i.e. parents, medical staff, nursing staff, etc. To hear first- hand experiences can only help to stop blunders being made. Also the importance of the truth which should be told to the parents as soon as possible.’

‘By hearing mistakes made by medical staff due to their lack of counselling techniques these sessions will hopefully help the students to avoid similar problems arising later on in their careers.’

‘If the sessions were held more often the communication barriers would be removed, as students and parents alike would be more com- fortable in each other’s presence.’

‘Sessions well worth continuing - consumer input to the National Health Service is all too rare. ’

By voicing their concern parents are helped to feel they have some control over how future doctors cope with breaking bad news. By hear- ing some of the problems voiced by the students some parents expressed a deeper understanding of the situation facing the medical profession.

Acknowlegements

The authors are indebted to the patientdparents and to Dr W. F. Morrison Dorward, Director of Roxburghe House Hospice, Dundee, for their help and cooperation.

References

Buckman R. & Maguire P. (1985) Video series ‘Why won’t they talk to me?’ University of Manchester.

Kent G.G., Clarke P. & Dalrymple-Smith D. (1981) The patient is the expert: a technique for teaching interviewing skills. Medical Education 15, 38-42.

Knox J.D.E. & Bouchier I.A.D. (1985) Communi- cation skills teaching, learning and assessment. Medical Education 19, 285-9.

Licther I. (1987) Communication in Cancer Care, p. 1. Churchill Livingstone, Edinburgh.

Received 17 December 1987; editorial comments to authors 8 February 1988; accepted for publication 5 September 1988