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Teaching Doctors to Break Bad News (Part 2 of 2)

In part one of this blog post, I examined the reasons patients might feel dissatisfied after a doctor presents them with bad news and also how poor communication by clinicians can negatively influence patients’ view of their care.

Improved techniques for breaking bad news could mean less stress for patients and doctors

But delivering bad news poses risks for medical providers, too. There are tremendous costs that can result from poorly handled communication.

What many patients don’t know is that for many doctors the stress caused by the discussion of a negative outcome far outweighs the stress of the actual medical care during the event. In fact, over time, breaking bad news has been shown to contribute significantly to physician burnout, and ultimately, on a regional level, provider shortages—a problem especially true for obstetrics.

It turns out, then, that breaking bad news badly is a problem with personal but also public health ramifications. What can we do? My research project, “Breaking Bad News in Obstetrics: A Trial of Simulation-Based Education,” looked at whether we can teach skills that make delivering difficult news easier and more effective, and if so, what is the best method for doing so.

In the design of this project, we had our OB/GYN residents undergo a simulation of a difficult patient-care situation while being observed; during this simulation, we had actors playing the roles of the patients.

Each resident then underwent one of two forms of education. The resident was either randomly selected to review (that is, debrief) his or her simulation of the bad news situation or randomly allotted to attend a standard PowerPoint lecture about communication techniques. This study design means that this was a blind, randomized trial, because we wanted to fulfill the highest standards of research—a rare achievement in the field of communications research.

After this intervention, our residents were placed in another tough “breaking bad news” simulation and observed again. After each simulation, the communication experience was evaluated—by the residents as well as by “expert observers” (in this case, members of the Maternal-Fetal Medicine faculty at Montefiore Medical Center), and finally, by the actors.

What did we find? We found that our actors did not experience much improvement. However, our “expert observers” who watched our interactions felt that either a lecture or simulation/debriefing curriculum provided improvement, and about the same amount. Significantly, our physicians, although they showed improvement after a lecture, showed significantly more improvement in their skill development and confidence after simulation/debriefing.

Even more powerfully, our six-month follow-up evaluations by the medical providers themselves showed scores that improved over their baseline, but also significantly above their second evaluation. That is, with the framework provided to them by the communications curriculum they received, they were able to retain or improve their skills even half a year after the workshop was done.

So what does this mean? This means that we think we can help both our doctors and our patients a lot by using a formal curriculum to help our new (and not-so-new) providers learn basic techniques to make breaking-bad-news discussions more beneficial for patients and less stressful for clinicians. Using simulation and debriefing to help our physicians work through these kinds of situations may have advantages over conventional teaching techniques, such as lectures, in giving providers the confidence and comfort they need to improve their communications skills.

We have already started implementing a mixed curriculum—simulation/debriefing plus a lecture—as part of our OB/GYN resident educational program. Other departments have expressed interest, and we hope that we can help them determine what works best for them as well.

Bad news shouldn’t be seen as a conversation ender, either at a cocktail party or in a hospital room.

When delivered compassionately and with honesty, it can be an opportunity for doctors to provide patients and their families with what they need: the opening of an important dialogue at one of the most difficult times of their lives. This painful conversation can give patients and doctors the tools required to take an informed and appropriate next step in medical care. Because of this research, we have proven that breaking-bad-news skills can be taught, effectively and with lasting results.

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Chavi Eve Karkowsky, M.D.

Chavi Eve Karkowsky, M.D.

Dr. Karkowsky is assistant professor of obstetrics & gynecology and women’s health at Albert Einstein College of Medicine and medical director, obstetrics & gynecology and women's health at Montefiore Medical Group-Comprehensive Family Care Center.

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Comments on this entry are closed.

  • Melinda Thomas July 30, 2012, 6:02 PM

    This is very interesting and very important work. I look forward to hearing more about it.