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Interventions to Improve the Breaking of Bad or Difficult News by Physicians, Medical Students, and Interns/Residents: A Systematic Review and Meta-Analysis

Johnson, Judith, PhD, ClinPsyD; Panagioti, Maria, PhD

doi: 10.1097/ACM.0000000000002308

Purpose To assess the effectiveness of news delivery interventions to improve observer-rated skills, physician confidence, and patient-reported depression/anxiety.

Method MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Register of Controlled Trials databases were searched from inception to September 5, 2016 (updated February 2017). Eligible studies included randomized controlled trials (RCTs), non-RCTs, and controlled before–after studies of interventions to improve the communication of bad or difficult news by physicians, medical students, and residents/interns. The EPOC risk of bias tool was used to conduct a risk of bias assessment. Main and secondary meta-analyses examined the effectiveness of the identified interventions for improving observer-rated news delivery skills and improving physician confidence in delivering news and patient-reported depression/anxiety, respectively.

Results Seventeen studies were included in the systematic review and meta-analysis, including 19 independent comparisons on 1,322 participants and 9 independent comparisons on 985 participants for the main and secondary (physician confidence) analyses (mean [SD] age = 35 [7] years; 46% male), respectively. Interventions were associated with large, significant improvements in observer-rated news delivery skills (19 comparisons: standardized mean difference [SMD] = 0.74; 95% CI = 0.47–1.01) and moderate, significant improvements in physician confidence (9 comparisons: SMD = 0.60; 95% CI = 0.26–0.95). One study reported intervention effects on patient-reported depression/anxiety. The risk of bias findings did not influence the significance of the results.

Conclusions Interventions are effective for improving news delivery and physician confidence. Further research is needed to test the impact of interventions on patient outcomes and determine optimal components and length.

J. Johnson is joint lecturer, School of Psychology, University of Leeds, Leeds, United Kingdom, and Bradford Institute for Health Research, Bradford, United Kingdom; ORCID:

M. Panagioti is senior research fellow, National Institute for Health Research School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom; ORCID:

Funding/Support: This research was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Yorkshire and Humber (; reference: NIHR IS-CLA-0113-10020). In addition, the NIHR School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre (Greater Manchester PSTRC) supported the time and facilities of M.P. The research team members were independent from the funding agency.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimer: The views expressed in this report are those of the authors, and not necessarily those of the National Health Service, the NIHR, or the Department of Health and Social Care. The funders had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; and the preparation, review, or approval of the manuscript.

Supplemental digital content for this article is available at

Correspondence should be addressed to Judith Johnson, School of Psychology, University of Leeds, Lifton Place, Leeds LS29JT, UK; telephone: +44 (0) 1133435719; e-mail:; Twitter: @DrJTJohnson.

© 2018 by the Association of American Medical Colleges