Rosenbaum, Marcy E. PhD; Ferguson, Kristi J. PhD; Lobas, Jeffrey G. MD
Delivering bad news, a task that occurs in any medical practice, can be daunting for the clinician. Although it is most often thought of as communicating about life-threatening illness, the imminence of death, or communicating about the death of a loved one to a family member, Bor et al.1 provide a useful and more inclusive definition of bad news: “… situations where there is either a feeling of no hope, a threat to a person's mental or physical well-being, a risk of upsetting an established lifestyle, or where a message is given which conveys to an individual fewer choices in his or her life.” Given this definition, delivering bad news is something that occurs daily for most practicing clinicians.
How bad news is delivered can have a significant impact on patients’ perspective of illness, their long-term relationships with clinicians, and both patient and provider satisfaction.2–5 Several authors have reported that patients had significantly more distressing feelings toward clinicians they felt delivered the news in an inappropriate manner.2–5
Practicing physicians and residents have been shown to lack both confidence and skill in performing this basic clinical task.6–9 A number of factors can contribute to this discomfort, such as feeling responsible for patients’ misfortune, perceptions of failure, unresolved feelings about death and dying, concerns about patients’ responses to the news, and clinicians’ concerns about their own emotional responses to the circumstances.7
Another contribution to low confidence and discomfort in this task is that the majority of practicing physicians have reported having received no formal training in effectively communicating bad news.6,10,11 Thus, until recently, most practitioners learned to give patients bad news through trial and error and perhaps by observing role models during their training. Because negative role models for giving bad news are common,6 relying on experience and role-modeling may result in communication patterns that do not meet patient needs rather than in effective approaches to this task. Therefore, teaching the skills for delivering bad news increases the likelihood that physicians will learn how to deliver bad news effectively.
Much has been written about the skills necessary for effective delivery of difficult news, including extensive reviews of the literature and creation of consensus guidelines for this practice.2,3,7,12,13 In the literature specifically focusing on educational interventions, several useful content models have been developed and implemented in both undergraduate and graduate settings. For example, the SPIKES model (setting, perception, invitation, knowledge, empathy, summary and strategy) developed by Buckman7 for delivering difficult news is used in many medical schools (see Table 1).
In this article, we review published reports (based on Medline searches) of strategies that have been used to teach effective delivery of bad news to medical students and residents.* We describe available models and offer our opinions based on our experiences and on our review of the broader medical education literature on the advantages and disadvantages of each strategy (see Table 2). We also discuss findings from evaluations of these models. This article provides a guide to medical educators who are initiating or refining curriculum for medical students and residents to learn this essential and important communication task.
Based on our review of the literature, we conclude that, optimally, any curriculum should include a model for effective delivery of bad news (e.g., SPIKES), and opportunities for learners to discuss relevant issues, and practice and receive feedback on their skills. Potential strategies for providing education in bad-news delivery include lectures, small-group discussions, role-playing with peers and standardized patients (SPs), and teaching in the context of patient care.
Strategies for Teaching Skills for Delivering Bad News
In a comprehensive review published in 1997, Billings and Block found that lectures were the most widely used strategy for teaching end-of-life content in the medical curriculum, under which bad-news delivery is often addressed.14
In a lecture on delivering bad news described in one report, residents learned death notification skills as part of an advanced cardiac life support course.15 This lecture focused on methods of notification, understanding grief and after-notification issues. We found no other published reports of a sole reliance on lectures to teach learners about delivering difficult news. Several studies have discussed using interactive lecture formats to convey basic information and as a catalyst for discussion and skills practice in subsequent small-group sessions.16–19 In one example, two faculty provided an interactive lecture on delivering difficult news.16 They involved the audience and role-played both poor and effective encounters, using elements of the model described by Buckman.7 Trigger videotapes, showing dramatized bad-news encounters, can also be used in this process.19 After each demonstration, the audience was asked to identify effective and noneffective behaviors on the part of the clinician, based on the patient's communication needs. Then steps in effective delivery of bad news (see Table 1) were presented in detail while referring to both case examples.
In an alternate approach, an audience member was asked to volunteer to give bad news to a SP. For a student audience, a scenario that required little medical knowledge was provided. For a more advanced audience (residents and practicing clinicians), volunteers were asked to identify a typical situation. As this example shows, a spontaneous demonstration has the advantage of being perceived as more genuine.20 In addition, learners in the audience can more easily imagine themselves in the volunteer's position and ponder what they would do in a similar circumstance. The disadvantage is that some common ineffective or effective behaviors will be left out if they are not scripted.
Several education programs have used speaker panels to present information about delivering bad news.10,17,21 In one example, parents of children in whom cancer had been diagnosed described their responses and needs in relation to bad news, and they fielded questions from the audience.17 In another example, a panel of clinicians discussed their approaches to delivering bad news and described the challenges they had faced.10
The main advantage of lectures is that they take minimal time and faculty resources to deliver content to a wide audience. However, they allow for only limited assessment of learner needs, limited discussion of issues, and no chance for practice and refinement of the skills discussed.
Reported interventions using small-group discussion sessions for teaching delivery of difficult news have included trigger tapes, demonstrations, case descriptions, or presession readings to generate discussion (see Table 3). 20–24 These tools are used in a manner similar to didactic approaches but include opportunity for learners to discuss the issues raised. For example, during a one-hour case conference in internal medicine, a student or faculty member was invited to give bad news to a SP in front of the group as a catalyst for discussion during the session.20 In another intervention, during two-hour sessions with groups of 16–18 second-year medical students, group members discussed their perceptions of bad-news tasks and challenges, watched two videotapes on delivering bad news, and then interacted with a handicapped child and his or her parents, or a patient with cancer. This approach is particularly innovative in including actual patients as part of the small group discussion.22
Although small-group discussions give learners an opportunity to discuss their concerns more deeply and explore their reactions, these discussions can require more faculty time than do lectures to reach the same number of learners, and there is no opportunity for skills practice and feedback.
Small Groups with Peer Role-Playing
Some small-group interventions include giving learners an opportunity to practice and receive feedback on their skills through peer role-play exercises following discussion of basic bad-news delivery issues.2,10,17,25,26 Some interventions have used preprepared cases in which one learner portrayed the patient and the other acted as the clinician delivering the news.25,26 Preprepared cases can be especially appropriate for learners who have little actual experience to draw on. In one example, second-year medical students were introduced to issues about delivering bad news through clinicians’ describing their experiences and then the students critiqued trigger videotapes. Students then role-played detailed, written bad-news encounters, and answered a series of questions.25,26
Some interventions for higher-level learners use learner-generated cases. These cases can be elicited either before or during the actual session. For example, one intervention based a seminar on cases written by the institution's own residents.17 Using cases generated during sessions, group members identified a clinical experience they would like to “reenact” (often one they felt did not go as well as they would have liked).11,26 This approach allows participants to address concerns they feel they need to work on, making it especially relevant for them.
In one approach to learner-generated cases, the learner provides medical information, patient circumstance, patient reaction, and clinician's approach to the encounter. Then, a group member portrays the patient, and the clinician–learner delivers the news in a different way than he or she did in the actual encounter, applying some of the concepts already discussed in the group. The group provides feedback about ineffective and effective behaviors demonstrated in the encounter and alternative ways to approach the situation. Alternatively, the clinician whose “case” is being role-played takes on the role of the patient, and another group member takes on the role of the clinician. In this configuration, the person who generated the case gains insight into both a different way to approach the case and what the patient may have been experiencing in this encounter. In both situations, if groups of three are formed then one person can observe and provide feedback.
In summary, role-playing allows learners to practice their skills, receive feedback, and gain insight into the patient's perspective; it also generates discussion. Peer role-playing is less demanding of resources and organizational needs than role-playing with SPs. Disadvantages to role-playing are variation in learners’ abilities to portray patients in a realistic manner, familiarity among peers, and more faculty time required than less interactive sessions.
Small Groups Using Standardized Patients
The majority of published educational interventions that focus on delivering bad news used SPs who can be trained to portray patient responses to bad news in a realistic and standardized manner.16,18,27–32 These interventions included portrayal of multiple scenarios, giving most (if not all) participants a chance to practice delivering difficult news. Using multiple scenarios in bad-news role-playing sessions can provide insight into the common and contrasting patient responses and skills needed in different situations and also allows for exposure to different learners’ approaches to the task.16 For example, two reported interventions with medical students used a combination of preprepared cases and student-generated cases in role-plays with SPs during small-group sessions (four to ten students each).18,27 Each student role-played with the SP, and then the group proceeded with feedback and discussion. Some interventions have used closed-circuit television with small groups, allowing learners to watch as individual group members deliver bad news to a SP in a separate room.16,28 Closed-circuit observation systems can provide a more realistic context than can performing directly in front of the group and the setting allows the observers to comment as the encounter proceeds. In one example, each student in a small group of students delivered difficult news to a different SP while being observed by others over closed circuit television.16 In another example, four to six students observed over closed circuit television as three other students each took a turn delivering difficult news in a variety of situations. Each scenario was followed by feedback and discussion with a faculty facilitator, the students and the SP. In this configuration, not all participants may practice delivering the news but they are exposed to multiple approaches and varying scenarios.
Use of SPs in role-play situations gives learners an opportunity to practice their skills with skilled and nonfamiliar “patients” and receive feedback from peers, SPs, and faculty. This role-playing, however, requires intense use of both faculty and SP time and audiovisual support resources if closed-circuit television is used. In addition, having to perform in front of one's peers can be intimidating for some and creates a less realistic situation than a one-to-one encounter with SPs.
One-to-One Learning with Standardized Patients
Several schools have reported using one-to-one encounters between learners and SPs as their primary approach to teaching delivery of difficult news.33–39 This approach has most often been used with learners who have already had patient care experiences. In some approaches, the SP was the main teacher during this intervention. In one example, in two SP encounters students learned about delivering bad news during surgery and obstetrics/gynecology rotations.33 After reviewing written materials on techniques for delivering difficult news, each student delivered difficult news (rectal cancer diagnosis or pregnancy loss) to the SP, who afterward provided feedback to the learner on strengths and suggestions for improvement. Using this approach minimizes demand on faculty time but requires more intensive use of SP time for training and teaching sessions.
Other examples reported using faculty observers and feedback in one-to-one simulated sessions. One approach used two SP encounters of providing a cancer diagnosis to train residents and fourth-year students during a family practice rotation.35 After the second encounter with a SP, faculty members reviewed the videotape with learners and provided feedback on skills improvement. One advantage of this approach is that it provides an opportunity for faculty to observe learners actually delivering news to a patient, albeit a standardized one, which is often difficult for faculty during clinical rotations.
One-to-one SP encounters eliminate the discomfort that can accompany role-playing in front of groups and can provide a more clinically realistic encounter. In addition, the time commitment for both learners and faculty is minimized. Disadvantages of this approach are that learners do not have an opportunity to benefit from observing multiple approaches and multiple patient responses to bad news.
Teachable Moments in Delivering Bad News
Although rarely described in the literature, faculty have ample opportunities to teach and reinforce skills for delivering bad news in the direct context of clinical care. These teachable moments can be identified and used in inpatient ward round and outpatient staffing settings.6,8,19,40–42 Before a bad-news encounter, faculty members can discuss concerns and possible approaches to bad-news delivery. They can ask the learner(s) about their experiences and concerns regarding delivering bad news, and thus assess their learning needs and levels of comfort with the task. This also encourages approaching the encounter with a set plan in mind for delivering the news.18 In addition, learners can ask questions and be queried regarding their perceptions of the patient's reactions and needs, as well as the effectiveness of approaches. Providing self-study resources such as articles and videotapes can also be useful for enhancing learning and skill development in these venues.18
Role modeling and demonstration are important ways trainees can learn and refine their bad-news delivery skills. In a curriculum at our institution, we told third-year medical students that if they found themselves in a position of giving bad news that they were uncomfortable with at their level of training, the students could ask a supervisor to deliver the news while they observed.16 One of the challenges to bedside teaching of this skill is to maintain patients’ privacy during this emotionally charged encounter while still being able to teach learners these important skills. Setting aside time outside of rounds with one or two learners is advised, in order to deal with the interaction sensitively and effectively while maximizing the experience for the learners. The patient should be informed of the reason for the learner's(s') presence in this type of encounter. If bad news must be delivered during rounds we suggest that the encounter be saved until the end of rounds to avoid time pressure and also allow the attending physician to limit the number of learners that participate. In addition to giving enough time to the patient, this also can allow time immediately after the encounter to process with the learner(s).
Observing learners giving difficult news can also allow faculty to provide feedback to improve skills. However, roles of the learner(s) and the attending physician need to be clearly defined before a bad-news encounter. For example, with a resident–physician who has his or her own patient pool, the attending can offer to accompany the resident as a resource if he or she cannot answer patient questions. The resident can inform the patient of the attending's role as an observer. The challenge in observing learners with patients is for the attending physician to resist the temptation to dominate the encounter and have the patient focus on the attending physician. However, with observation, feedback on actual performance can be even more effective than giving feedback regarding SP encounters.
Teaching about bad-news delivery in the context of actual patient care can open the door to identify ways for learners to improve and acknowledge the emotional challenges that accompany being the bearer of bad news. In addition, faculty can relay both negative and positive outcomes from different approaches they have tried. Finally this approach allows for application of skills in the context in which they will be used. Potential disadvantages include time constraints for teaching in the clinical setting and concerns about patients’ privacy.
Evaluation of Teaching Strategies
The number of published reports evaluating different strategies for teaching skills for delivering bad news are limited and the majority limit their assessment of the impact of educational interventions to learner satisfaction and confidence rather than assessing change in learners’ actual behavior (see Table 3). However, the following evidence points to the advantage of using some strategies over others.
We found only one report specifically that evaluated a lecture for teaching bad-news delivery.15 In a prospective, randomized study, 18 of 36 residents received a lecture on death notification. Members in the lecture group performed significantly better in a death-notification encounter with a standardized survivor. Although this report indicates a lecture can have some immediate impact on learners’ skills for delivering bad news, the literature on teaching communication skills in general and delivering bad news in particular argues against sole reliance on lectures to teach these behavioral skills.13,19,41–43 Learners must have an opportunity to practice the skills before they can internalize them. In combination with other methods, however, didactic presentation of the principles of delivering bad news can provide important baseline information for discussion and practice. When using lectures, we encourage teachers to employ more interactive techniques, such as incorporating demonstrations, role-plays, panels, and audience feedback, as a way to engage the audience and help with retention of information.
The majority of reports on small-group activities to teach skills for delivering bad news relied on learner self-assessments of confidence before and after the intervention, and learner evaluation of the usefulness of the educational activity (see Table 3).16–18,21,24-27,30 Almost all interventions using these assessments reported significant changes in learner self-confidence and high ratings of the usefulness of the training. One study found no significant differences in confidence in delivering bad news after a small-group discussion session with residents.24 The authors postulated that this was due to lack of opportunity for feedback and practice of these skills within the session. The majority of small-group studies indicate that learners desire more training opportunities and the opportunity to practice with SPs.16,22,25,27 Some studies have evaluated the impact of small-group activities on learners’ knowledge and attitudes. For example, in a pre/post study, learners were able to describe the six steps in Buckman's model for delivering bad news and were more likely to have a plan for giving bad news following a small-group intervention in which learners applied the model to trigger videos.23 In another pre/post comparison study, learners could provide longer, more comprehensive lists of steps in effective bad-news delivery after small-group, SP sessions than they could before the intervention. We found one study evaluating the impact of small-group training on learners’ behaviors.10 Objective structured clinical examination scores of students who had participated in small-group training and those who had not were compared and the comparison demonstrated significantly better humanistic behavior scores (e.g., communication and empathy skills) among those students who had participated in the training sessions.
One-to-one learning with SPs allows for simultaneous assessment of actual bad-news delivery behaviors during and after educational interventions. In most of these interventions faculty and/or SPs use checklists to identify learners’ strengths and weaknesses. In two reports, residents participated in encounters with SPs and were provided once with feedback.35,36 In addition to demonstrating skills in certain areas of bad-news delivery (learners’ concern for patients, honesty, and appropriate follow-up plans), faculty observers of these encounters identified areas for improvement, such as providing too much data and scientific information during the encounter.35 Studies suggest the limitation of only providing one opportunity for learners to practice their skills and receive feedback without having the chance to practice applying behaviors recommended in the feedback. For example, one study36 found that residents’ ratings of their own abilities were actually lower after a one-time encounter with feedback than they were before the encounter. In contrast, reports by others33,34 demonstrate improvement of learner skills when compared across two simulated encounters. For example, one of these studies33 found significant differences in content and communication skills between students who had received training and feedback through previous simulated encounters for delivering bad news and those who had not received training and feedback.
We found no published reports that systematically evaluated the effectiveness of learning about delivering bad news in the less formal settings of inpatient wards and outpatient clinics. A few studies have reported student and resident experiences in bad-news delivery in the context of patient care. Two recent reports42,44 found that many students and residents received little guidance from or opportunity to debrief with faculty around these bad-news encounters. They also reported that students and residents desired this guidance and found discussion, observation, and feedback beneficial when provided in these contexts.
There are a variety of approaches available for teaching skills in bad-news delivery. All of the interventions we describe here have been rated highly by learners and have demonstrated impact on learner self-confidence and, in some cases, learner knowledge and behaviors.
Adult learning is best facilitated through instruction that is interactive and learner-centered, draws on previous experience and knowledge, is relevant to the learner's practice, allows the learner to apply what is being learned in a timely manner, and includes the opportunity for feedback and reflection. Based on these adult learning principles and findings in the education literature on delivering bad news, we conclude that the most effective interventions present basic steps to effectively delivering bad news, and provide opportunities for learners to discuss concerns, practice, and receive feedback on their skills.
Our recommendation of best practices in teaching skills for delivering bad news echoes recommendations made by others.6,19 In addition, evaluations that include observation of actual behaviors point to the benefit of learners having more than one opportunity to practice and receive feedback so that they can try out new behaviors they may not have demonstrated in their first encounter. It is striking that in evaluation of many of the interventions, learners indicated a desire for more training and opportunities for practice. In addition, researchers need to examine the impact of educational interventions on learners’ actual behaviors and learners’ long-term retention of these skills. Measures have been developed specifically for assessing skills for delivering bad news that could be used for this purpose.9
This review demonstrates there are many models for teaching skills for delivering bad news; one's choice will depend on resources available in terms of faculty, SPs, and curricular time. In addition, deciding when to provide this training to learners will depend on available resources, but the training is likely to be most effective if it is provided early and often. As suggested by Kurtz et al.,43 following a helical model where communication skills are reiterated and reinforced throughout medical training is essential to maximum skill development. Thus, prior to or early in their direct patient care experiences, medical students can benefit from training by having an opportunity to practice giving bad news in a safe, simulated environment before having to deliver bad news with actual patients and families. Early training also gives students a framework in which to critically evaluate role models they may observe giving bad news on the wards and in the clinics. As students and residents have increased patient-care responsibilities, new and more complex aspects of bad-news delivery can arise. It has also been argued that students’ communication skills tend to degrade over the four years of medical school if the skills are not reinforced.43 Faculty who have the skill to recognize and capture these teachable moments in the context of clinical rotations can help learners discuss these issues and hone their skills. At the resident level, formal instruction and practice in delivering bad news guarantees that all residents, regardless of where they went to medical school, are equipped to adequately perform this task.
In recommending more faculty-intensive educational interventions to teach skills for delivering bad news (e.g., small groups, role-plays with feedback, clinical teaching), it follows that faculty also need and deserve training in providing this instruction. Several successful models have been implemented to train practicing physicians, some for the first time, to deliver bad news.11,45,46 Thus, training will help improve physicians’ own interactions with patients, as well as their ability to teach others in formal settings and to identify learning opportunities in the context of patient care.
Learning to deliver bad news effectively is an important part of providing good medical care, maintaining productive relationships with patients, and enhancing patient and physician satisfaction. Through educational interventions, the bad-news encounter can be made less distressing for both clinician and patient. To incorporate effective behaviors for delivering bad news into practice, we encourage medical education programs to commit the necessary resources to provide a comprehensive approach to teaching this task, one that includes multiple sessions and opportunities for demonstration, reflection, discussion, practice, and feedback.
We are grateful to Dr. Jerold Woodhead for supporting our implementation and refinements of the curriculum for bad-news delivery and assisting in thinking through the issues involved in this review. We are also grateful to Dr. John F. Wilson for inspiration and assistance in development and implementation the curriculum for bad-news delivery. In addition, we want to thank Dr. Paul Casella for his editorial assistance.
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