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Journal of Cancer Education, 23:260–263, 2008Copyright © AACE and EACEISSN: 0885-8195 print / 1543-0154 onlineDOI: 10.1080/08858190802235379

HJCE

Educating Doctors About Breaking Bad News: An Iranian Perspective

Iranian Perspective on Doctors Breaking Bad News MOHSEN TAVAKOL, PHD, ROGER MURPHY, PHD, SIMA TORABI, PHD

Abstract—Background. The breaking of bad news is a frequent and well recognized task that is per-formed by a variety of health professionals including medical doctors. In this article, we explore bothhow this topic is dealt with in medical education in Iran and also consider how this aspect of the cur-riculum might be enriched in the future. Methods. This article is based on research, which was under-taken using a purposively selected sample of medical course planners in Iran. Semistructuredinterviews were conducted with each of 10 carefully selected participants. Their interview responseswere analyzed in such a way as to provide an in-depth exploration and interpretation of both theirperceptions and experiences in relation to this sensitive and highly important topic. Results. Fourmajor themes emerged from the analysis of the interview transcripts: medical paternalism, religion,training issues, and professional barriers. Conclusions. On the basis of this analysis, there appears to bean urgent need for integrating more emphasis on techniques for breaking bad news into the Iranianmedical education curriculum. This curriculum could in the future place more emphasis on address-ing specific religious issues, which are unique to the local culture. A number of other specific recom-mendations are formulated and discussed. J Cancer Educ. 2008; 23:260-263.

reaking bad news is an integral component of thework of many health professionals and can some-times be an extremely challenging experience for

them as well as for their patients and their families.1 A dis-closure of something like a malignant cancer may result inpatients changing their view of the future in a fundamentalway.2 However, the individual circumstances of patients,such as previous life experiences, personality characteris-tics, and religious and spiritual beliefs, can greatly influencethe emotional impact and isolation experienced by therecipient of bad news.3,4 Communicating bad news in thiscontext is an essential skill for all health professionals, espe-cially medical practitioners to whom the prime responsibil-ity often falls. In Western cultures, a large number ofauthors have indicated that not only do most patients andtheir relatives typically want to hear bad news, but alsomodern physicians are generally eager to explain promptly,

sensitively, and frankly when such situations arise.5-7 However,the cultural and religious context in Iran is substantially dif-ferent from Western countries where most of the previousresearch studies about breaking bad news have occurred. It istherefore important to consider the extent to which princi-ples, which have been developed to inform approaches toconveying potentially distressing information to patientswithin Western culture, may or may not be applicable in Iran.

In Iran, despite the attention paid to improving communi-cation when giving bad news to patients and the availability ofagreed guidelines for disclosing unfavorable information,4,8 itis generally recognized that Iranian doctors may not have ade-quate skills in this area. It is notable in this context how littleis formally known about the state of affairs regarding commu-nicating bad news in Iran. In addition, little is known aboutthe methods Iranian doctors currently employ to disclose badnews to their patients, and there have been no publishedresearch reports that have focused on recipients’ perspectiveson the breaking of bad news in medical situations.

The purpose of this study was to explore the state ofpreparation for breaking bad news within medical educa-tion in Iran. We also sought explanations, where appropri-ate, as to why breaking bad news training might notgenerally be adequately covered.

Received from Medical Sciences, University of Tehran, Iran (MT);University of Nottingham, United Kingdom (RM); and Institute forResearch and Planning in Higher Education, Tehran, Iran (ST).

Address correspondence and reprint requests to: Dr Mohsen Tavakol,Medical Sciences, University of Tehran, Educational Development Centre,Tehran, Iran; Phone: 98 21 669 21 144; e-mail: <tavakolm@tums.ac.ir>.

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METHODS

In this study, we used a qualitative interview approachbased on purposive sampling.9,10 The 10 medical courseplanners interviewed were from a range of Iranian institu-tions, and they were all interviewed using an in-depthinterview schedule. Participants were all full-time membersof academic staff from these 3 highly influential universitymedical schools, and they ranged in seniority from associateprofessors to full professors. All participants were assuredanonymity in that none would be identified personally insubsequent reports.

Two interviews were scheduled with each participant.The first interviews lasted between 30 to 40 minutes. Theparticipants were asked broad questions and encouraged torespond in narrative form. For instance, “Can you tell meabout approaches to teaching medical students skills aboutdelivering bad news in medical schools, especially after theIslamic revolution?”; and “What is the impact of religion onthe approach doctors take to breaking bad news topatients?” Subsequent questions were derived from the par-ticipants’ responses.

In the second part of this study, 5 months later, secondinterviews were conducted with the same participants. Thepurpose of the second interviews was to address any gaps ofinformation that had been identified within the first inter-views. Responses from both sets of interviews were audio-taped and transcribed. The data obtained during the studywere interpreted and analyzed using specific data codingtechniques.11

RESULTS

Four themes were identified (Table 1). Examples fromthe transcripts have been selected to illustrate the type ofdata classified under each theme.

Medical Paternalism

In this study, doctors had different approaches withrespect to the delivery of bad news. Mostly these could beclassified as paternalistic. Some participants believed thatpatients have different capacities to receive bad news andthat patients are very sensitive, thus requiring the need forthat bad news to be given carefully(Table 1, Example 1).This illustrates that some Iranian doctors do not directlydisclose the disease to their patients. Nearly all the partici-pants believed that the disclosure of bad news, particularlywith respect to malignancies, evokes fear and anxiety andcan affect the quality of life of the patient who is gravely ill.Most of them stated that the doctor decides how much andwhich information is provided to the patient. The partici-pants also valued the importance of keeping hope for thepatient who is severely ill (Table 1, Example 2). Severalrespondents also commented that some Iranian doctorsdirectly disclose the disease to the patient’s family ratherthan patients and view this as a more empathic response bydoctors. However, another respondent stated that somefamilies are not aware of the general condition of theirpatients, especially patients with serious illness, until thelast minutes of his or her life.

TABLE 1. Textual Examples for Themes*

Themes Examples

Medical paternalism

1. Initially, we give an introduction for our patients. We describe to them how a disease can develop and we tell them the solutions to the disease. Indeed, we create a mental preparation; we never directly tell them about the disease, since people have different capacities to deal with such information.

2. If we say to the patient, you have got cancer or a serious illness, he or she will think everything is over; there is no hope in the world. It seems that the world has been smashed on their head.

Religion 3. There are very good guidelines in Islam in order to reduce the anxiety of families after the death of a relative. My experience shows that using verses such as “We belong to Allah,” and” We return to him” are very useful in order to calm the families.

Training issues

4. Students only act based on their personal experiences. This can lead to a series of acute problems, both for the student and the patient.

5. After the graduation, we see that the students are easily prone to causing agitation amongst their patients and their family members due to the lack of familiarity that they have with the issues of breaking bad news.

6. Well, we need to be culturally sensitive in breaking bad news to our patients. Whether we are embedding such a module within the curriculum or not, we must understand the actual influence of culture on the patient’s value system, particularly with regards to religious issues.

Professional barriers

7. We have no actual role in updating the medical curriculum. The contents of university curriculum have been identified by the High Council Cultural Revolution, and we have no right to change them. However, clinical teachers can somewhat identify the educational strategies for their subjects although some departments never ask for a lesson plan.

8. There is no systematic method that all medical teachers are involved in that aims to develop the curriculum.

*The themes and the quotes were translated into English for this article.

262 TAVAKOL et al. ■ Iranian Perspective on Doctors Breaking Bad News

Religion

Religious factors present further issues to be consideredin breaking bad news, particularly in the Iranian context.Perhaps it is for this reason that some doctors in Iran com-municate bad news based on Islamic principles, especiallyin conveying the difficult news about a patient’s impendingor actual death (Table 1, Example 3).

Training Issues

Almost all participants stated that undergraduate medi-cal teaching does not prepare students for discussion ofincurable illness with patients or their relatives. Most of theparticipants stated that they did not complete a specificmodule about how to break bad news effectively when theywere medical students. Some were explicit about the cur-rent lack of teaching for breaking bad news (See Table 1,Examples 4 and 5).

They all had ample opportunity to teach and reinforceskills for delivering bad news in the direct context ofclinical care, particularly with emphasis on role modelingmethods, without having formally received the trainingthemselves.

Most participants had positive attitudes toward commu-nication skills and recognized that educational modules,which dealt with breaking bad news, are notably absentwithin the Iranian medical curriculum. However, 1 respon-dent had a straightforward antagonistic attitude toward anyapproach to teaching skills for delivering bad news (Table 1,Example 6).

Professional Barriers

A number of participants drew attention to the fact thatmedical teachers have low incomes, and this can act as abarrier to their involvement in developing innovations inmedical education. They argued that such challenges leadmedical teachers to pay more attention to their privatemedical practices rather than to improve educational issues.

Moreover, participants indicated that clinical teachershad some concerns about the lack of their professionalidentity. One of the most strongly articulated features, frommost of the participants, was the sense that the clinicalteachers play a fairly passive role in improving universitiesmedical education curricula (See Table 1, Examples 7 and 8).

DISCUSSION

In general, the results point to a deep concern about thecurrent lack of preparation of medical students in relationto breaking bad news within the Iranian curriculum. Ourresults illustrated that Iranian doctors do not break badnews very directly when they are required to do so. Thisapproach contrasts with research in Western countries indi-cating that “gone is the paternalistic impulse to spare

patients from horrible truth.”12 Our results indicated thatreligion can have a big impact on the context within whichbreaking bad news often occurs in Iran. Further researchshould, however, examine how it might affect patienthealth care outcomes. This study also illustrated that doc-tors have very little confidence in their ability to ade-quately communicate bad news to patients and theirrelatives. This is consistent with other studies that haveindicated that doctors felt poorly prepared for and did notreceive enough training in the general communicationskills required for delivering bad news.13–17 In Iran, this maybe attributed to the fact that doctors have never beentrained to consult in general practice settings. Perhaps forthis reason, Western countries have initiated improve-ments in developing the skills of doctors to convey badnews to patients effectively.1,17 Furthermore, the effect oflow income on staff willingness has lead doctors to pay lessattention to improving medical education curricula.

Given these issues, it is suggested that new medical edu-cational programs are necessary to improve breaking badnews skills. Such courses in Iran also urgently need to findways to address multicultural and religious issues.

Further research is now needed to determine what breakingbad news skills are most important to include in interventionsand how best to teach medical students. More knowledge isalso needed about how continuing medical education educa-tors can take leadership roles in defining, designing and imple-menting new learning programs for practicing doctors.

Limitations

In this study, we attempted to develop an account of thepractices and training of medical practitioners in Iran fromthe interview responses of 10 highly knowledgeable infor-mants. We cannot, however, be sure that these individualscan accurately portray all aspects of the current situation inIran. Nevertheless, the findings certainly point to areas forboth future research and development.

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