3 Delivering Bad News

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S P E C I A L T H E M E A R T I C L E

Teaching Medical Students and Residents Skills forDelivering Bad News: A Review of Strategies

Marcy E. Rosenbaum, PhD, Kristi J. Ferguson, PhD, and Jeffrey G. Lobas, MD

ABSTRACT

Although delivering bad news is something that occursdaily in most medical practices, the majority of clinicians

have not received formal training in this essential and

important communication task. A variety of models arecurrently being used in medical education to teach skillsfor delivering bad news. The goals of this article are (1) to

describe these available models, including their advan-tages and disadvantages and evaluations of their effective-

ness; and (2) to serve as a guide to medical educators whoare initiating or refining curriculum for medical students

and residents. Based on a review of the literature and the

authors’ own experiences, they conclude that curricularefforts to teach these skills should include multiple ses-sions and opportunities for demonstration, reflection, dis-

cussion, practice, and feedback. Acad Med. 2004;79:107–117.

D

elivering bad news, a task that occurs in any

medical practice, can be daunting for the clini-cian. Although it is most often thought of as

communicating about life-threatening illness, the

imminence of death, or communicating about the death of aloved one to a family member, Bor et al.1 provide a useful andmore inclusive definition of bad news: “. . . situations where

there is either a feeling of no hope, a threat to a person’smental or physical well-being, a risk of upsetting an estab-

lished lifestyle, or where a message is given which conveys toan individual fewer choices in his or her life.” Given this

definition, delivering bad news is something that occurs dailyfor most practicing clinicians.

How bad news is delivered can have a significant impacton patients’ perspective of illness, their long-term relation-

ships with clinicians, and both patient and provider satisfac-

tion.2–5

Several authors have reported that patients hadsignificantly 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’ misfor-

tune, perceptions of failure, unresolved feelings about deathand 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 patientneeds rather than in effective approaches to this task. There-

fore, 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 re-

views of the literature and creation of consensus guidelines

for this practice.2,3,7,12,13 In the literature specifically focus-

ing on educational interventions, several useful content

models have been developed and implemented in both un-

Dr. Rosenbaum is assistant professor of family medicine and Dr. Lobas is

professor of pediatrics, Roy J. and Lucille A. Carver College of Medicine; Dr.

Ferguson is associate professor of community and behavioral health, College

of Public Health. All are at the University of Iowa, Iowa City.

Correspondence should be addressed to Dr. Rosenbaum, 1204 MEB, Uni-versity of Iowa College of Medicine, Iowa City, IA 52245; e-mail:[email protected].

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dergraduate and graduate settings. For example, the SPIKESmodel (setting, perception, invitation, knowledge, empathy,

summary and strategy) developed by Buckman7 for deliveringdif ficult news is used in many medical schools (see Table 1).

In this article, we review published reports (based onMedline searches) of strategies that have been used to teach

effective delivery of bad news to medical students and resi-dents.* We describe available models and offer our opinions

based on our experiences and on our review of the broadermedical education literature on the advantages and disad-

vantages of each strategy (see Table 2). We also discussfindings from evaluations of these models. This article pro-

vides a guide to medical educators who are initiating orrefining 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 effec-tive 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 pro-

viding education in bad-news delivery include lectures,small-group discussions, role-playing with peers and stan-

dardized patients (SPs), and teaching in the context of

patient care.

STRATEGIES FOR TEACHING SKILLS FOR DELIVERING

BAD NEWS

Didactic Approaches

In a comprehensive review published in 1997, Billings and

Block found that lectures were the most widely used strategyfor 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 onereport, residents learned death notification skills as part of anadvanced 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 deliveringdif ficult news. Several studies have discussed using interac-

tive lecture formats to convey basic information and as acatalyst for discussion and skills practice in subsequent small-

group sessions.16–19 In one example, two faculty provided aninteractive lecture on delivering dif ficult news.16 They in-

volved the audience and role-played both poor and effective

encounters, using elements of the model described by Buck-man.7 Trigger videotapes, showing dramatized bad-news en-

counters, can also be used in this process.19 After eachdemonstration, the audience was asked to identify effective

and noneffective behaviors on the part of the clinician, basedon the patient’s communication needs. Then steps in effec-

tive delivery of bad news (see Table 1) were presented indetail while referring to both case examples.

In an alternate approach, an audience member was askedto volunteer to give bad news to a SP. For a student audience,

a scenario that required little medical knowledge was pro-vided. For a more advanced audience (residents and practic-

ing clinicians), volunteers were asked to identify a typicalsituation. As this example shows, a spontaneous demonstra-

tion 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 theywould do in a similar circumstance. The disadvantage is that

some common ineffective or effective behaviors will be leftout if they are not scripted.

Several education programs have used speaker panels topresent information about delivering bad news.10,17,21 In one

example, parents of children in whom cancer had beendiagnosed described their responses and needs in relation to

* We limited this review to models of bad news education described in

published articles indexed in Medline. Attention should be drawn to the

availability of descriptions of other models for bad news education in the

End of Life/Palliative Education Resource Center (EPERC) Online Data-

base, managed by the Medical College of Wisconsin. This database (www.

eperc.org) provides peer-reviewed descriptions of curricula focused on

delivering bad news and other end-of-life communication skills, and is a

useful resource for persons interested in developing or enhancing education

in these areas.

Table 1

The SPIKES Protocol for Delivering Bad News to Patients*

Step Description of Task

Setting Establish patient rapport by creating an appropriate setting

that provides for privacy, patient comfort, uninterrupted

time, setting at eye level, and inviting significant other(s)

(if desired).

Perception Elicit the patient’s perception of his or her problem.

Invitation Obtain the patient’s invitation to disclose the details of the

medical condition.

K nowledge Provide knowledge and information to the patient. Give

information in small chunks, check for understanding,

and frequently avoid medical jargon.

Empathize Empathize and explore emotions expressed by the patient.

Summary and

strategy

Provide a summary of what you said and negotiate a

strategy for treatment or follow-up.*From Baile WF, Kudelka AP, Beale EA, et al. Communication skills training in oncology:

description and preliminary outcomes of workshops on breaking bad news and managing

patient reactions to illness. Cancer. 1999;86:887–97. Baile et al.’s protocol was adapted from

Buckman R. How to Break Bad News: A Guide For Healthcare Professionals. Baltimore: Johns

Hopkins University Press, 1992.

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bad news, and they fielded questions from the audience.17 In

another example, a panel of clinicians discussed their ap-proaches 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 wideaudience. However, they allow for only limited assessment of

learner needs, limited discussion of issues, and no chance forpractice and refinement of the skills discussed.

Small-Group Discussions

Reported interventions using small-group discussion sessionsfor teaching delivery of dif ficult news have included trigger

tapes, demonstrations, case descriptions, or presession read-ings to generate discussion (see Table 3).20–24 These tools are

used in a manner similar to didactic approaches but includeopportunity for learners to discuss the issues raised. For

example, during a one-hour case conference in internalmedicine, 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 perceptionsof bad-news tasks and challenges, watched two videotapes on

delivering bad news, and then interacted with a handicappedchild and his or her parents, or a patient with cancer. This

approach is particularly innovative in including actual pa-tients as part of the small group discussion.22

Although small-group discussions give learners an oppor-tunity to discuss their concerns more deeply and explore

their reactions, these discussions can require more facultytime 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 anopportunity to practice and receive feedback on their skills

through peer role-play exercises following discussion of basicbad-news delivery issues.2,10,17,25,26 Some interventions have

Table 2

Advantages and Disadvantages of Strategies for Teaching Medical Students and Residents Skills for Delivering Bad News

Strategy Advantages Disadvantages

Didactic approaches Presents core concepts to large numbers of learners efficiently Little opportunity for discussion

Minimal faculty time and resources No opportunity for practice and feedback

Learners are anonymous

Opportunity for efficient use of skills demonstration and use of

speaker panels can be done efficiently

Small-group discussion Opportunity to discuss issues, ski lls, and concerns No opportuni ty for practice and feedback

Faculty time intensive

Small-group, peer role-play Opportunity to discuss issues, ski lls and concerns Variable abil ity of learners to portray patients

Skills practice with feedback Faculty time intensive

Insight into patient perspective

Small-group standardized patient role-play Multiple scenarios show range of approaches and patient

responses

Peer performance anxiety

Standardized patients and faculty time intensive

Skills practice with feedback from faculty, peers, and

standardized patients

Less realistic than one-to-one standardized

patient encounter

More realistic than peer role-play

One-to-one standardized patient encounters Skills practice with feedback from standardized patients or

faculty

More realistic than group encounters

No group discussion

No exposure to different approaches and patient

responses

Faculty or standardized patient intensive

Teachable moments in clinical settings Actual context of patient care Clinical time restraints

Observation, demonstration, and feedback Patient privacy





Table 3

Summary of Literature on Strategies for Teaching Medical Students and Residents Skills for Delivering Bad News to Patients*

Format Authors Level of Learner Strategies Assessment Measures/Results†

Lecture Pollack 199915 PGY One-hour lecture on death notification Design: Random assignment to lecture or nonlecture

group and all participated in SP death-notification

encounter

Measures: SP global rating

Results: Lecture group did significantly better than

nonlecture group

Small-group

discussion

Edinger et al. 199920 MS3 Demonstration SP role-play Not available

Romm 200221 Obstetrics/

Gynecology

PGY

Panel of parents

Group discussion

Learner satisfaction

Knox et al. 198922

MS2 Trigger videosDiscussion with family of disabled child

Demonstration cancer diagnosis role-play

Learner satisfaction three months and 18 months after theseminar

McNeilly et al.

200123MS3 Presentation of Buckman model

Trigger videos

Application of model to videos

Design: Pre/post knowledge and attitude

Measures: Students asked to name six steps in Buckman

model and if they had a plan for breaking bad news

Results: Significant improvement in bad news knowledge

and attitude after the seminar

Angelos et al.

199924Surgery PGY Small-group discussion

Limited role-play with prepared cases

Video review

Design: Pre/post confidence questionnaire and learner

satisfaction

Measure: Self-assessed confidence in “explaining bad

news”

Results: No significant difference before and after the

seminar

Small-group

peer role-

play

Vetto et al. 199910 MS1–2 Self-study readings

Clinician panel

Group discussion

Written case-based peer role-play

Design: Comparison of objective structured clinical

examination scores from intervention and

nonintervention groups

Measures: SP-rated knowledge and humanistic skills and

faculty-rated humanistic skills

Results: Intervention group did significantly better on

humanistic skills with no significant difference on

knowledge

Morgan et al.

199617Pediatrics PGY1 Didactic

Panel of parents


Peer role-play with resident-generated

cases

Magnani et al.

200225MS2 Clinical incidents

Trigger videos


Written case based peer role-play, three

cases

Reflection questions

Ungar et al. 200226 PGY2 14 sessions, 90 minutes each Learner satisfaction

Group discussion

Written case-based peer role-play

Video review





Table 3 (Continued)


Small-group Rosenbaum et al. MS3 Lecture/demonstration Design: Pre/post questionnaire

SP role-play 200216 SP role-play with others watching, fivecases

Measures: Self-assessed comfort in delivering bad news indifferent situations

Results: Significant increase in comfort after the session

Garg et al. 199718 MS3 Video critique Design: Pre/post questionnaire

Small-group exercises

Peer role-play

SP role-play

(Four cases chosen out of 12 possible)

Measures: Self-assessment of whether students had a plan

for approaching delivering bad news and if felt competent

to do so

Results: Significant increases posttest on both measures

Cushing et al. 199527 MS4–5 Discussion Design: Pre/post questionnaire

Video critique

Peer role-play

SP role-play

Measures: Students were asked to give level of confidence

in specific bad-news situations and list as many things a

clinician can do to help recipients when giving bad news

Results: Significant increases in confidence level and longer,

more comprehensive list of steps in effective bad news

Van Winkle et al. 199828 MS4 Discussion Learner satisfaction

SP role-play with others watching, three

cases

Tolle et al. 198929 PGY1 SP role-play with learners consulting as

team


Group feedback

Kahn et al. 200130 MS3 SP role-play wi th four learners taking

turns on same case

Group feedback

Discussion

Design: Pre/post self-efficacy questionnaire

Measure: Self-assessment of “ I am comfortable giving bad

news to patients”

Results: Significant increase in self-efficacy

Fortin et al. 200231 MS2 Mini-lecture Learner satisfaction

SP role-play with others watchingFeedback

Serwint et al. 200232 PGY2 All day seminar Learner satisfaction, use of techniques

Video triggers Self-assessed 18 months after the seminar

SP role-play with others watching, two cases

Lectures

One-on-one

SP

encounters

Coletti et al. 200133 MS3 Reading packet

SP with feedback

Design: Comparison between SP encounter and non-SP

encounter groups on end-of-rotation clinical practice

examination bad-news SP station

Measures: SP ratings on numbered item evaluation form

addressing content and communication skills

Results: SP encounter group did significantly better on the

examination

Greenberg et al. 199934 Pediatrics

PGY2–3,

fellows

SP encounter with feedback

SP encounter without feedback

Design: Comparison across two SP encounters, before and

after feedback.

Measures: I. SP ratings on content checklist, Gibb trust

scale, and National Board of Medical Examiners Patient

Perception Questionnaire. II. Resident self-assessed

comfort level pre/post

Results: Significant improvement in content categories of

communication and follow-up. Significant differences in

counseling skills. No significant differences in Patient

Perception Questionnaire

continued on next page





used preprepared cases in which one learner portrayed the

patient and the other acted as the clinician delivering thenews.25,26 Preprepared cases can be especially appropriate for

learners who have little actual experience to draw on. In oneexample, second-year medical students were introduced to

issues about delivering bad news through clinicians’ describ-ing 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 interventionbased a seminar on cases written by the institution’s own

residents.17 Using cases generated during sessions, groupmembers identified a clinical experience they would like to

“reenact” (often one they felt did not go as well as they wouldhave 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, patientreaction, and clinician’s approach to the encounter. Then, a

group member portrays the patient, and the clinician–learnerdelivers the news in a different way than he or she did in the

actual encounter, applying some of the concepts alreadydiscussed in the group. The group provides feedback about

ineffective and effective behaviors demonstrated in the en-counter and alternative ways to approach the situation.

Alternatively, the clinician whose “case” is being role-playedtakes on the role of the patient, and another group member

takes on the role of the clinician. In this configuration, theperson who generated the case gains insight into both a

different way to approach the case and what the patient mayhave been experiencing in this encounter. In both situations,

Table 3 (Continued)


Goldschmidt et al.

198735MS4, Family

medicinePGY1

SP encounter with feedback

SP encounter


Rosenbaum et al.

199636PGY1 SP encounter wi th faculty feedback Design: Pre/post questionnaire

Measure: Self-assessed rating of confidence in giving bad

news

Results: Significantly less confidence after one encounter

Jewett et al. 198237 Pediatrics

PGY2–3

One SP encounter with feedback at

beginning of rotation

Design: Posttest control group design, comparison of

performance before training and after

One SP encounter with feedback at end

of rotation

Measures: SP rating of critical information giving, clarity

of information, and interpersonal skills

Results: Significant improvement in critical information,

general improvement in clarity, and improvement in

interpersonal skills, especially listening and partnering

with patients

Roth et al. 200238 Medicine PGY1 SP encounter with feedback from SP and

observing faculty


Pan et al. 200239 MS3 Small-group session using role-play,

reflection, and discussion.


SP encounter with feedback from faculty

Clinical

teaching

Muir et al. 199940 MS4 Didactic

Rounds


Bedside modeling

Videotaped SP

*MS, medical student; PGY, postgraduate year (resident); SP, standardized patient.

†We did not report measure for studies that relied on learner satisfaction. All authors reported high ratings of interventions by learners. Assessment methods are explained only to the extent they wereclearly explained in the original article.





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 isless demanding of resources and organizational needs thanrole-playing with SPs. Disadvantages to role-playing are

variation in learners’ abilities to portray patients in a realisticmanner, 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 andstandardized manner.16,18,27–32 These interventions includedportrayal of multiple scenarios, giving most (if not all)

participants a chance to practice delivering dif ficult news.Using multiple scenarios in bad-news role-playing sessions

can provide insight into the common and contrasting patientresponses and skills needed in different situations and also

allows for exposure to different learners’ approaches to thetask.16 For example, two reported interventions with medical

students used a combination of preprepared cases and stu-dent-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 withfeedback and discussion. Some interventions have used

closed-circuit television with small groups, allowing learnersto watch as individual group members deliver bad news to a

SP in a separate room.16,28 Closed-circuit observation sys-tems can provide a more realistic context than can perform-

ing directly in front of the group and the setting allows theobservers to comment as the encounter proceeds. In one

example, each student in a small group of students delivereddif ficult news to a different SP while being observed by others

over closed circuit television.16 In another example, four tosix students observed over closed circuit television as three

other students each took a turn delivering dif ficult news in avariety of situations. Each scenario was followed by feedback

and discussion with a faculty facilitator, the students and theSP. In this configuration, not all participants may practice

delivering the news but they are exposed to multiple ap-proaches and varying scenarios.

Use of SPs in role-play situations gives learners an oppor-tunity 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 per-

form in front of one’s peers can be intimidating for some and

creates a less realistic situation than a one-to-one encounterwith 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 dif ficult news.33–39 This approach hasmost often been used with learners who have already had

patient care experiences. In some approaches, the SP was themain teacher during this intervention. In one example, in

two SP encounters students learned about delivering badnews during surgery and obstetrics/gynecology rotations.33

After reviewing written materials on techniques for deliver-ing dif ficult news, each student delivered dif ficult news (rec-

tal cancer diagnosis or pregnancy loss) to the SP, whoafterward provided feedback to the learner on strengths and

suggestions for improvement. Using this approach minimizesdemand on faculty time but requires more intensive use of SP

time for training and teaching sessions.Other examples reported using faculty observers and feed-

back in one-to-one simulated sessions. One approach usedtwo SP encounters of providing a cancer diagnosis to train

residents and fourth-year students during a family practicerotation.35 After the second encounter with a SP, faculty

members reviewed the videotape with learners and providedfeedback on skills improvement. One advantage of this

approach is that it provides an opportunity for faculty toobserve learners actually delivering news to a patient, albeit

a standardized one, which is often dif ficult for faculty duringclinical rotations.

One-to-one SP encounters eliminate the discomfort thatcan accompany role-playing in front of groups and can

provide a more clinically realistic encounter. In addition, thetime commitment for both learners and faculty is minimized.

Disadvantages of this approach are that learners do not havean 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 deliver-ing bad news in the direct context of clinical care. These

teachable moments can be identified and used in inpatientward round and outpatient staf fing settings.6,8,19,40–42 Before

a bad-news encounter, faculty members can discuss concernsand possible approaches to bad-news delivery. They can ask

the learner(s) about their experiences and concerns regard-ing delivering bad news, and thus assess their learning needs







evaluating the impact of small-group training on learners ’

behaviors.10 Objective structured clinical examination scoresof 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 stu-dents who had participated in the training sessions.

One-to-one learning with SPs allows for simultaneousassessment of actual bad-news delivery behaviors during and

after educational interventions. In most of these interven-tions faculty and/or SPs use checklists to identify learners ’

strengths and weaknesses. In two reports, residents partici-pated in encounters with SPs and were provided once with

feedback.35,36 In addition to demonstrating skills in certainareas of bad-news delivery (learners’ concern for patients,

honesty, and appropriate follow-up plans), faculty observers

of these encounters identified areas for improvement, such asproviding too much data and scientific information duringthe encounter.35 Studies suggest the limitation of only pro-

viding one opportunity for learners to practice their skills andreceive feedback without having the chance to practice

applying behaviors recommended in the feedback. For exam-ple, one study36 found that residents’ ratings of their own

abilities were actually lower after a one-time encounter withfeedback than they were before the encounter. In contrast,

reports by others33,34 demonstrate improvement of learnerskills when compared across two simulated encounters. For

example, one of these studies33 found significant differences

in content and communication skills between students whohad received training and feedback through previous simu-

lated encounters for delivering bad news and those who hadnot received training and feedback.

We found no published reports that systematically evalu-ated the effectiveness of learning about delivering bad news

in the less formal settings of inpatient wards and outpatientclinics. A few studies have reported student and resident

experiences in bad-news delivery in the context of patientcare. Two recent reports42,44 found that many students and

residents received little guidance from or opportunity todebrief with faculty around these bad-news encounters. They

also reported that students and residents desired this guid-ance and found discussion, observation, and feedback bene-

ficial when provided in these contexts.

CONCLUSIONS

There are a variety of approaches available for teaching skills

in bad-news delivery. All of the interventions we describehere have been rated highly by learners and have demon-

strated 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 expe-

rience 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 andreflection. 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 havedemonstrated 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 educa-

tional interventions on learners’ actual behaviors and learn-

ers’ 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 thistraining 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 rein-

forced 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 onthe wards and in the clinics. As students and residents have

increased patient-care responsibilities, new and more com-

plex 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, regard-





less of where they went to medical school, are equipped to

adequately perform this task.In recommending more faculty-intensive educational in-

terventions to teach skills for delivering bad news (e.g., small

groups, role-plays with feedback, clinical teaching), it followsthat faculty also need and deserve training in providing thisinstruction. Several successful models have been imple-

mented 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 theirability 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 productiverelationships with patients, and enhancing patient and phy-

sician satisfaction. Through educational interventions, the

bad-news encounter can be made less distressing for bothclinician and patient. To incorporate effective behaviors fordelivering bad news into practice, we encourage medical

education programs to commit the necessary resources toprovide a comprehensive approach to teaching this task, one

that includes multiple sessions and opportunities for demon-stration, 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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Teaching and Learning Moments

NOT JUST A REGULAR CUSTOMER

As a third-year resident at University of Illinois at Chicago, “Mary” was a regular “customer.” She was a frail white

woman in her early 50s with grace in her features, but suffered from cirrhosis due to alcoholism. Mary requiredrepeated admissions for encephalopathy and variceal bleedings.

In one of her many admissions to the intensive care unit, I had to evaluate her. Seeing her repeatedly as an internand a resident, it seemed routine work. Her husband of more than 30 years recited her familiar medical history to me

and I thought she was in her usual encephalopathic state. As I proceeded to examine her, a small grin appeared onher face. As I was doing a routine head and neck examination, I heard her whisper weakly, “You have a nice smell

doctor.” I didn’t know what to say and was stunned by the comment. In that moment, I realized I had lost the

humanistic part of my patient during the years of seeing her repeatedly.In our routine work and dealings with patients with chronic diseases, physicians tend to develop a “not again”

approach to these patients and ignore the fact that these chronic cases appreciate life and its subtleties—just like

everyone else. A fresh smell of a person had made such an impact amongst the aroma of alcohol, Betadine, and otherchemicals in the hospital. Mary’s surprising comment changed my attitude towards patients with chronic diseases. I

learned to separate the disease and the human being in my patients more easily. This also reminded me of the quote:“Patients are evaluating you while you are evaluating the patients.”1 Over the next few months, Mary continued to

be admitted and I continued to treat her until she died of massive variceal bleeding. Not only did Mary change myperspective of managing patients with chronic illnesses, but her evaluation of me gave her comfort and a smile. I am

proud that I was able to give her that moment of comfort. I continue to try to bring comfort and smiles to all of mypatients, especially my regular customers.

NAUMAN TARIF, MD

Dr. Tarif is assistant professor of medicine and consultant nephrologist, Department of Medicine, College of Medicine,

King Saud University, Riyadh, Saudi Arabia.

REFERENCE

1. Orient JM, Sapira JD. Sapira’s Art and Science of Bedside Diagnosis. 1st ed. New York: Lippincott Williams & Wilkins, 1998:9.



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3 Delivering Bad News