Delivering bad news (DBN) to a patient or patient’s family is one of the most difficult tasks for physicians. As a complicated task, DBN requires better than average communication skills. This study investigated trainee’s attitude and awareness of DBN based on a self-assessment of their experiences and performance in practice. Survey subjects were also asked to assess their perception and the need for education in conducting DBN.
A survey was carried out on their experiences with DBN, how they currently deal such situations, how they perceive such situations and the need for education and training programs. A SPIKES protocol was used to assess how they currently deal with DBN.
One hundred one residents and fellows being trained in a teaching hospital participated in the survey. Around 30% had bad experiences due to improperly delivered bad news to a patient. In terms of self-assessment of how to do DBN, over 80% of trainees assessed that they were doing DBN properly to patients, using a SPIKE protocol. As for how they perceived DBN, 90% of trainees felt more than the average level of stress when they do DBN. About 80% of trainees believed that education and training is much needed during their residency program for adequate skill development regarding DBN.
We suggest that education and training on DBN may be needed for trainees during the residency program, so that they could avoid unnecessary conflict with patients and reduce stress from DBN.
Delivering bad news (DBN) is used as the term to describe the situation when unfavorable information must be disclosed to patients about their illness [
Since Baile et al. [
Therefore, the aim of our study was to investigate residents’ and fellows’ attitude and awareness of DBN,through a self-assessment of their experiences, and performance in DBN situations. Furthermore, we wanted to find out whether trainees would like the opportunity for education to improve communication skills for DBN.
A survey was conducted on residents and fellows in one teaching hospital located in an urban area of Korea between April and May 2013. All trainees except interns were asked to participate in the survey and the participation was voluntary without use of enforcement. Interns were excluded in this study because they have little to no experience with DBN. Consisting of six sections, the survey asked questions on the participants’ general characteristics,their experiences with DBN, how they are aware of DBN how they currently deal with DBN, how they perceive such situations and the need for education and training programs. The six-step protocol (SPIKES protocol) was used to evaluate how residents and fellows assess their own performance of DBN. Delivery style of DBN was assessed by providing them with medical scenarios that would occur.Blunt style was defined as DBN without preamble,forecasting style as preparing the patient for DBN, and stalling style as avoiding DBN [
One hundred one out of a total of 128 trainees (79%)in the hospital participated (
Participants were asked about their education and experiences in DBN (
Eighty–eight percent of trainees preferred to talk to the patient’s family, instead of talking to the patient directly.Fifty-eight percent of trainees believed that bad news should be delivered directly to a patient; however, the remaining 42% believed that it should not be delivered directly to the patient (
In order to evaluate how trainees assess their own performance on DBN, self-assessment was performed according to a SPIKES protocol (
Questions were asked about how trainees perceive DBN (
Eight-one percent of trainees believed that a training program is needed to develop adequate skills for DBN during their residency program. Sixty-eight percent of them were willing to receive education and training if they have an opportunity (
A six-step protocol (SPIKES protocol) was developed for the clinician to fulfill the four most important aims of an interview breaking bad news: collecting information from the patient, giving medical information,supporting the patient’s emotion, and deriving the patient’s cooperation in a future management plan [
As experienced oncologists, DBN has been a difficult and stressful task. When cancer is diagnosed, relapsed,and progressed despite treatment, patients and their families are advised to prepare the next steps. Whenever we face these circumstances, we always feel stressed and think about ways to deliver the news properly to somehow make the experience less traumatic for the patient. Similarly, many trainees like residents and fellows are also challenged and stressed out about performing DBN. The reason for this may be that the clinician feels a sense of failure for not providing the patient’s expectations or is troubled by not knowing how to give hope in the circumstance of a poor prognosis [
Needless to say, DBN can be improved by education and training. Two workshops were held at the MD Anderson Cancer Center to teach about how to deliver bad news and how to handle difficult patients. Participants achieved positive results regarding “feeling morecompetent” about negotiating these encounters [
Our study has clear limitations. Based on a questionnaire in which trainees assessed their own performance,this study may not be appropriate to consider an objective assessment of DBN. In the future, we may need more objective analysis to assess trainees’ attitude and skills for DBN, using video observation or standardized patients or actual patients in practice, and perhaps have a third party observer’s assessment. And it may not be enough to say that trainees need to be educated with this survey as this represents the results of a survey at a single hospital. Therefore, a cohort study with more trainees may be needed to assess whether education or training for DBN is needed in the residency program and furthermore to develop the effective educational program for communication skills.
In conclusion, our study suggests that education and training may be needed for trainees during their residency programs to improve skills for DBN, and to help reduce their stress from DBN. However, further research is needed for a more objective assessment of the current situation in practice, and also in finding ways to provide trainees with education.
(A) Question C1, (B) Question C2, (C) Question C3, (D) Question C4, (E) Question C5, (F) Question C6, (G) Question C7.
(A) Question D1, (B) Question D2, (C) Question D3, (D) Question D4.
Participants’ Characteristics
Characteristic | No. (%) |
---|---|
Sex | |
Male | 59 (58.2) |
Female | 42 (41.8) |
Median age (range) (yr) | |
25-30 | 39 (38.6) |
30-35 | 62 (61.4) |
Medical educations | |
College of Medicine | 92 (91.1) |
Graduate School of Medicine | 9 (7.9) |
Training department | |
Dermatology | 4 (3.9) |
Emergency Medicine | 5 (4.9) |
Family Medicine | 9 (8.9) |
General Surgery | 6 (5.9) |
Gynecology/Obstetrics | 2 (1.9) |
Internal Medicine | 27 (26.7) |
Neurology | 4 (3.9) |
Neuropsychiatry | 8 (7.9) |
Neurosurgery | 4 (3.9) |
Ophthalmology | 7 (7.8) |
Orthopedic Surgery | 9 (8.9) |
Otolaryngology | 4 (3.9) |
Pediatrics | 7 (7.8) |
Rehabilitation Medicine | 5 (4.9) |
Level of training | |
The first year | 26 (25.7) |
The second year | 24 (23.8) |
The third year | 24 (23.8) |
The fourth year | 19 (18.8) |
The fellowship | 8 (7.9) |
Education and Experience of Delivering Bad News
A. Questions | No. (%) |
---|---|
1. Have you ever received any education for “delivering bad news”? | |
Yes | 64 (63.4) |
No | 37 (36.6) |
2. Where did you receive education for “delivering bad news”? | |
1) In medical school, while learning about medical ethics | 60 (95) |
2) During seminars or education programs for residents | 1 (0.015) |
3) On the internet or through mass media | |
4) By senior residents or staff | |
5) Other | 2 (0.03) |
3. Have you ever delivered bad news to patients or patients’ family? | |
Yes | 94 (93.1) |
No | 7 (6.9) |
4. Do you have any bad experiences due to improperly delivered bad news? | |
Yes | 30 (29.7) |
No | 71 (70.3) |
How Are Trainees Aware of Delivering Bad News?
B. Questions | No. (%) |
---|---|
1. Do you prefer to talk with a patient or the family members when you deliver bad news? | |
Patients | 11 (10.9) |
Patients’ family | 89 (88.1) |
2. Do you believe that bad news should be delivered directly to the patient? | |
Yes | 59 (58.4) |
No | 42 (41.6) |
Survey Contents
1. Do you set up the interview for the patient to feel comfortable and keep privacy? |
2. Do you assess the patient’s perception of his or her medical condition? |
3. Do you obtain the patient’s invitation? |
4. Do you assess the patient’s emotions with empathic responses? |
5. Do you give knowledge and information to the patient? |
6. Do you explain future strategy including treatment options and prognosis? |
7. What do you think of your delivery style? |
1. Do you feel stressful when you deliver bad news to the patient or the patients’ family? |
2. Do you believe that you can do better if you have more experience of delivering bad news? |
3. Do you believe that you can do better delivering bad news when you become a senior resident? |
4. Do you believe that you may be less stressed if you have more experience of delivering bad news? |
1. Do you feel that training is needed for adequate skill development in “delivering bad news” during your residency program? |
2. Are you willing to attend the training or education if you have the opportunity? |