Ability of-primary-care-physician’s-to-break-bad-news-amiel-ungar-alperin-baharier-cohen-reis

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Ability of-primary-care-physician’s-to-break-bad-news-amiel-ungar-alperin-baharier-cohen-reis

  1. 1. Patient Education and Counseling 60 (2006) 10–15 www.elsevier.com/locate/pateducou Ability of primary care physician’s to break bad news: A performance based assessment of an educational intervention Gilad E. Amiel a,c, Lea Ungar b,c, Mordechai Alperin b,c, Zvi Baharier b,c, Robert Cohen d, Shmuel Reis b,c,* a Bnai-Zion Medical Center, Department of Urology, Haifa, Israel Clalit Health Services, Haifa District, Department of Family Medicine, Haifa, Israel c The Technion-Isreal Institute of Technology, Ruth and Bruce Rappaport Faculty of Medicine, P.O. Box 9649, Bat-Galim, Haifa 31096, Israel d Center for Medical Education, Hebrew University, Faculty of Medicine, Jerusalem, Israel b Received 14 August 2004; received in revised form 15 April 2005; accepted 23 April 2005 Abstract Objective: We have previously described a breaking bad news (BBN) training program for primary care physicians [Ungar L, Alperin M, Amiel GE, Beharier Z, Reis S. Breaking bad news: structured training for family medicine residents. Patient Educ Couns 2002;48:63–68]. In this paper, we present the assessment of an educational intervention aimed at improving this important skill. Methods: The assessment tool was an eight station objective structured clinical examination (OSCE) utilizing standardized patients (SPs). Intervention and control groups of 17 general practitioners (GP) each were evaluated before and after an educational intervention, or a Balint group (control). Results: Intervention group GPs significantly increased their average grade on the post-test as compared to the pre-test (58.5, S.D. 12.7 versus 68.4, S.D. 9.2), effect size 0.94. Improvement in the control group was minimal (pre-test 57, S.D. 10.4 versus 58.1, S.D. 9.5 for the post-test), effect size 0.23. Reliability of the OSCE was a = 0.81. Conclusion: The performance assessment used in this study proved to be a reliable and valid tool to assess the ability of physicians to break bad news. It provided evidence of the effectiveness of the intervention. Practice implications: BBN training can and should be evaluated by valid and reliable measures. SPs can serve as reliable evaluators of BBN training. # 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Breaking bad news; OSCE; Continuing medical education; General practitioners 1. Introduction There was a time when it was an acceptable practice to break bad news to a patient who was suffering from a terminal illness by mail, often without even seeing the patient [1]. Fortunately, the medical profession has made tremendous strides in dealing with this area of practice [2,3]. Consensus guidelines on how to break bad news to patients * Corresponding author. Tel.: +972 4 8295402; fax: +972 4 8295249. E-mail address: reis@netvision.net.il (S. Reis). as outlined by Rosenbaum et al. [4] Buckman [5] and by Baile et al. [6] represent some of the many attempts to establish basic principles for breaking bad news (BBN). A number of studies have shown that physicians experience difficulty when required to deliver bad news [7]. Lack of skills and the reluctance to deal with the patient’s feelings have been reported as the main causes for physicians’ avoidance of this task [8,9]. To overcome these problems, courses for breaking bad news have been implemented [10]. Of crucial importance is the effectiveness and outcome of such interventions, i.e. do they improve the 0738-3991/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2005.04.013
  2. 2. G.E. Amiel et al. / Patient Education and Counseling 60 (2006) 10–15 ability of participating physicians to breaking bad news, and to what degree do participants retain these skills. Assessment of the impact of such courses on competence is rare [2]. We were unable to find studies that reported on the development of a reliable performance based assessment of the ability of physicians to deliver bad news to patients. The purpose of this study was to: (1) evaluate the reliability and validity of a competence based assessment, utilizing simulated patients as evaluators, to assess primary care physicians’ ability to deliver bad news; (2) evaluate the effectiveness of a training program in breaking bad news offered to a group of general practitioners (GPs) as part of a continuing medical education (CME) program. 2. Method 2.1. Course framework and teaching modalities In 1991, a mandatory course for second year family medicine trainees on how to break bad news was introduced into our residency training program. Since 1996, this course has also been offered as a CME course for practicing GPs. The guiding textbook for this course has been ’How to break bad news’ by Buckman [5]. A group of certified family physicians and a social worker identified common and important situations dealing with bad 11 news in primary care that served as the basis for developing the teaching program. Based on this list, a blueprint of 14 relevant encounters for teaching and discussion was constructed. Each of the fourteen 90-min small group sessions included four elements: (1) a theoretical component, dealing with methods of managing stress and crisis intervention; (2) clarifying personal attitudes and coping with providers’ emotions when breaking bad news; (3) communication skills; (4) practicing communication by interviewing simulated patients. A detailed description of the course has been published elsewhere [11]. 2.2. The examination A performance based assessment tool, an objective structured clinical examination (OSCE) was developed to evaluate primary care physicians’ ability to deliver bad news to patients. The OSCE format was chosen, since it provided an opportunity to simulate multiple doctor–patient encounters in a standardized setting. This method has been shown to be reliable and valid, and has been widely used to assess the performance of medical students, residents and practicing physicians [12]. Eight 15-min stations representing breaking bad news scenarios commonly encountered by primary care physicians were developed (Table 1). Based on the course curriculum, a list of the skills required for providing bad news and coping with patients’ feelings was Table 1 Topic, description and communication challenge of the eight OSCE stations in breaking bad news Station No. Topic Description Communication challenge 1 Anger due to missed diagnosis Coping with a patient’s anger 2 Reactive depression 3 Perceiving that death is imminent 4 Fear of illness and disability 5 Difficulty in accepting the role of a patient 6 Coping with uncertainty before definite diagnosis Breaking unexpected bad news to a patient A 24-year-old student who was treated with NSAID after complaints of pain in right knee later diagnosed to suffer from a tumor in the right Tibia Sleep disorders and loss of appetite in a young mother of a 4-month-old baby that was diagnosed as Down syndrome Home-visit to a 65-years-old pharmacist suffering from end-stage cancer of lung who wishes to discuss with the doctor his coming death A 35 years old woman who was recently diagnosed as suffering from multiple sclerosis and didn’t receive information concerning the disease. Appears tense and anxious A 40-year-old with risk factors for heart disease who denies repeated measurements of high blood pressure A 50-year-old woman comes to the office after palpating a lump in her breast A 60-year-old patient who was sent to a gastroscopy after recurrent upper abdominal discomfort. You thought it is a peptic ulcer, but the biopsy results show cancer of stomach A 25-year-old woman who comes to the office to receive test results which show that she is suffering from Hodgkin’s disease 7 8 Breaking bad news to a patient who does not wish to know her condition Treatment of reactive depression after the birth of a disabled child Coping with a conversation on an approaching death Coping with a patient with anxiety after learning about a serious illness Coping with denial and getting compliance Preparing toward probable bad news in an uncertain situation Breaking bad news to an alert and intelligent patient who wishes to receive every bit of information Coping with a patient who does not wish to know any details about her disease and getting compliance from the patient
  3. 3. 12 G.E. Amiel et al. / Patient Education and Counseling 60 (2006) 10–15 outlined by the course directors. A group of six senior family physicians that served as tutors in the Department of Family Medicinewere asked to list common and/or critical encounters where they were required to deliver bad news to patients in their clinic. These encounters served as the examination blue print, and eight scenarios were developed. The course tutors evaluated the cases to assure that they would require the utilization of the skills taught in the course if they were to be dealt with successfully. An OSCE consisting of eight ‘long cases’ was hypothesized to be sufficient to achieve acceptable reliability. Simulated patients (SPs) or chronically ill patients with previous experience in role-playing were trained to present the scenarios. Each SP received 8 h of training, which included dealing with the communication challenges and the rating scales to be used for assessing the performance of the physicians. Trainers discussed with SPs their personal attitudes concerning breaking bad news, the objectives of the course and acceptable standards in breaking bad news according to the literature. A single simulated patient was assigned to each station, and participated in both the pre- and post-tests. SPs evaluated the candidates utilizing global ratings. Two 5-point Likert scale questionnaires were developed for each station. The first was a 7-item communication scale to assess principles and techniques in breaking bad news, common to all stations (Table 2). Based on the known guidelines for breaking bad news [4–6], items for evaluating basic communication skills were selected. The second questionnaire was a 3-to-4-item questionnaire, tailored for each scenario. Items chosen from the above guidelines were aimed at evaluating the specific communication problem/s the physician was required to deal with in each station. For example, one of the stations dealt with a 35 years old woman, who was discharged from a neurological ward, with a diagnosis of multiple sclerosis. The communication challenges the doctor had to cope with in this station were: 1. To acknowledge the patient’s anxiety. 2. To inform her about the natural (slowly progressive) history of the disease and treatment options. 3. To assure her of his/hers support during the illness. According to these challenges, the SP had to complete three evaluation items (on a 1–5 Likert scale): 1. To what extent did the doctor tried to find out what you know about the disease and its prognosis? 2. To what extent did the doctor explains the natural development of the disease? 3. To what extent did the doctor check your understanding of his/her explanation? Candidates were assessed on a total of 10–11 items using a 5-point rating scale in each of the eight stations. Table 2 Breaking bad news OSCE 1–5 global rating communication scale No. 1 (common to all stations) (1) To what extent did the doctor use appropriate verbal techniques in order to convey comfort and trust, encouraging you to cooperate during the interaction? (i.e. used open-ended questions, used lay language, did not talk too fast or gave long speeches) very much 5 4 3 2 1 not at all (2) To what extent did the doctor express non-verbal empathy toward your situation? (i.e. maintained attentive pose and eye contact; body language that conveyed warmth, sympathy and encouragement; touched you if it was appropriate) very much 5 4 3 2 1 not at all (3) To what extent did the doctor assess the presence of family and other resources that might help you cope with the situation? (i.e. wife, parents, children, friends; how good is the relationship and how much can you rely on it; what kind of support can you expect to receive: emotional or financial, if great expenses are under way due to the situation) very much 5 4 3 2 1 not at all (4) To what extent did the doctor manage to express personal commitment to you and your problem, and his full dedication while helping you throughout your struggle? (i.e. scheduled a close follow-up appointment to further discuss the situation; offered to refer or inquire with experts in the field; gave you the feeling that he/she cares what will happen to you in the near future) very much 5 4 3 2 1 not at all (5) To what extent did the doctor manage to give you as a patient a sense of hope without denying the truth or describing it unrealistically? (i.e. gave you a feeling that your problem is treatable; discussed options in a positive way; maintained a balance between explaining benefits of a treatment and side-effects) very much 5 4 3 2 1 not at all (6) To what extent did the doctor address your feelings? (i.e. asked a specific question about how you feel; touched upon specific concerns you have raised; expressed support when emotions have arisen) very much 5 4 3 2 1 not at all (7) Overall, to what extent were you satisfied with the doctor? Would you wish to continue to be his patient in the future very much 5 4 3 2 1 not at all
  4. 4. G.E. Amiel et al. / Patient Education and Counseling 60 (2006) 10–15 13 Effectiveness of the intervention was determined by comparing pre- and post-course OSCE scores of the study and control groups. Table 3 Results of pre- and post-test scores for study and control groups 2.3. Study and control group Pre-test 58.5 (S.D. 12.7) 57 (S.D. 10.4) Post-test 68.4 (S.D. 9.2) 58.1 (S.D. 9.5) Statistical significance p < 0.01 – Thirty-four GPs participating in a CME program were invited to participate in the study. Seventeen physicians who selected the ‘breaking bad news’ course served as the study group, and 17 physicians who selected a ‘Balint group’ course served as the control group [13]. The two groups were matched for age, sex and years in practice as GPs. Mean age of participants was 43.7years (S.D. 6.74) and 46.4years (S.D. 5.49), respectively (t = À1.228; p = 0.208; z = 1.623; p = .106), 10 female and 7 male doctors constituted the BBN group, while 11 and 6, respectively, constituted the Balint group (x2 = 0.125; p = 0.50), mean years of practice as GPs was 17.8 years and 19.4 years, respectively (t = À0.769; p = 0.432; z = À0.828; p = 0.413). In the Balint course, GPs held group discussions about patients and situations in their clinic that triggered exceptional emotional reactions. A clinical psychologist and a senior family physician conducted these discussions. GPs tried to understand their personal feelings of transference and counter transference and to get an insight as to their influence on doctor–patient interaction. Participants in both groups confirmed that they had not undergone previous training for content of the modules offered. Both the study and control groups took the OSCE as a pre-test before starting their respective courses. They took the same post-test examination, i.e. with the same case scenarios and same SP in each station, at the completion of their respective courses. SPs had no information concerning the course the participants attended, they were blind to treatment versus control group. The specific scenarios in the examination were intentionally not dealt with in the breaking bad news course. 2.4. Analysis Mean scores and standard deviations were calculated for each participant, station and the rating scales used in the examination. Reliability for the overall examination was calculated by the internal consistency statistic Chronbach alpha. Mean scores and standard deviations were calculated for both experimental and control groups. Independent sample t-tests was used to determine if there were significant differences between the study and control groups on entry into the program ( p < 0.05), and effect size was calculated to determine the impact of the interventions given to both study and control groups [14]. 3. Results All 34 physicians took both the pre- and post-tests (Table 3). Overall mean score for the pre-test was 57.3, S.D. Study group (BBN) (n = 17) Control group Statistical (Balint) (n = 17) significance – p < 0.01 Range: 20–100 (100: high performance). Overall result in the pre-test and post-test OSCE in breaking bad news for general practitioners. The study group took a breaking bad news course and the control group a ‘Balint’ course. 11.3 (range: 20–100). No significant difference on the pretest was found between the scores of the GPs from the study and control groups (58.5, S.D. 12.7 versus 57, S.D. 10.4, respectively; range: 20–100). Overall reliability of the pretest was high for a 2 h OSCE (a = 0.81). The GPs in the study group significantly increased their average grade on the post-test as compared to the pre-test (58.5, S.D. 12.7 versus 68.4, S.D. 9.2; range: 20–100), effect size 0.94, whereas the improvement in the performance of the control group was minimal (pre-test 57, S.D. 10.4 versus 58.1, S.D. 9.5, for the post-test; range: 20–100), effect size 0.23. Overall reliability of the post-test was a = 0.78. 4. Discussion and conclusion 4.1. Discussion At no time is effective communication more important and challenging than when a physician is required to deliver bad news or tragic information to patients and their families. Receiving a medical diagnosis may be overwhelming regardless of the care the physician takes in communicating the news. Jonsen et al. have stated, ‘‘the truth may be brutal, but the telling of it should not be’’. ([15]). Little is known to date about actual physician performance in providing bad news and the emotional support they may or may not provide the patient. Many courses and guidelines aimed at improving the ability of physicians to present bad news have been described [2–6,16–25]. Most of these models and guidelines focused on the technique of breaking bad news, neglecting the accompanying emotions and personal attitudes of the involved physicians. The instruction module offered to physicians in the study group focused on providing the knowledge, skills and attitudes that would assist them with breaking bad news in diverse situations. The cases presented during the course represented a wide variety of possibilities that doctors might encounter during their day-to-day practice. Some of the cases were designed to deal not only with delivering the bad news but also on coping with its emotional consequences. Documentation of the effectiveness of courses devoted to learning how to break bad news, or the assessment of physician’s competence in breaking bad news are scarce. In
  5. 5. 14 G.E. Amiel et al. / Patient Education and Counseling 60 (2006) 10–15 the few attempts that were found in the literature, the decision whether a physician is capable of adequately breaking bad news to a patient was usually based on one (or two at the most) interactions evaluated by communication experts [4,19–22]. The OSCE used in this study proved to be a reliable and valid tool to assess the ability of physicians in breaking bad news. Validity of the OSCE has been achieved through: (1) the questionnaire (content validity), which was developed by two experts in patient–doctor communication including BBN; (2) the OSCE scenarios, which were developed by three expert family physicians, based on their clinical experience. The large effect size (close to one standard deviation) for the study group provides evidence of the effectiveness of the intervention in this group of physicians. Global ratings of performance on OSCE stations have been shown to have promising psychometric properties [25]. Subjective global ratings have been shown to yield more reliable and valid information on the performance of practicing physicians than the objective detailed checklists of the traditional OSCE, which are characterized by a lack of flexibility in rewarding different approaches to problem solving [26]. The utilization of Likert scale type global ratings as opposed to detailed checklists as the assessment tool in our stations enabled the SPs to assess the quality of the doctor–patient interaction, and not merely the technical aspects of breaking bad news. It is well documented in the literature that SPs can be appropriate evaluators of communication skills [3,16]. Our findings also demonstrate the feasibility of utilizing welltrained SP as the evaluator of the physicians’ breaking bad news skills, and not necessarily a communication expert. SPs have also provided feedback to examinees after the encounter, which may prove to be an effective educational methodology [4]. As demonstrated in our study, the experience of the GPs does not always reflect competence. It is questionable, therefore, whether physicians who have practiced for many years, but have not obtained necessary communication skills, possess the required proficiency to adequately provide bad news to their patients. The present study demonstrated the effectiveness of the breaking bad news course developed for veteran GPs. Furthermore, by comparing the study and control groups, we demonstrated that a course focusing on the specific skills required to deliver bad news is significantly superior to a more diffuse experience of discussing communication issues and personal experiences as in the Balint group. It would appear that the consciousness raising experience and opportunity to discuss personal experience with colleagues, such as is practiced in the Balint group, does in of itself not improve doctors’ competence in delivering bad news, and dealing with patients’ feelings. Our study demonstrated that the OSCE can be utilized as a reliable and valid tool to assess physicians’ competence in BBN. Moreover, it can evaluate the quality of BBN training, as reflected by the participants’ performance at the end of the course. However, it will be necessary to further examine if our measure can serve as an effective screening tool for the identification of family physicians who are in need of enhancement of their communication skills. A major drawback of this assessment tool, as pointed out by the examinees, is the artificial situation in which the physician is required to deliver bad news to eight consecutive patients. Examinees reported that although they were obviously aware that it was a simulation, the OSCE was extremely demanding emotionally. Undoubtedly, in real life, family physicians do not experience such intensive encounters successively. Other drawbacks of the present study include the small size of the population, and the fact that participants chose the intervention instead of being selected randomly. Although most of them did not know what a Balint group was, their choice may express their personal perception that they do not need the breaking bad news course. However, in dealing with emotions, it was speculated that the Balint group might also contribute to breaking bad news skills as much as a specific course. Furthermore, we realize that this is not a direct reflection of performance in actual practice, and the predictive validity is yet to be determined. Therefore, this study is not complete without evaluation of these acquired skills as applied to real patients. The extent of long-term retention of these skills and the timing of reinforcement are unexplored fields that provide future challenges in the research of breaking bad news. 4.2. Conclusions The OSCE utilizing SPs as evaluators can be utilized as a reliable and valid tool to assess the communication skill of breaking bad news to patients. 4.3. Practice implications BBN training can and should be evaluated by valid and reliable measures. SPs can serve as reliable evaluators of BBN training. References [1] Forrester J. Postal diagnosis: breaking the bad news in the 17th century. Br Med J 1995;331:1694–6. [2] Fallowfield L, Jenkins V. Communicating sad, bad, and difficult news in medicine. Lancet 2004;363:312–9. [3] Rosenbaum ME, Kreiter C. Teaching delivery of bad news using experiential sessions with standardized patients. Teach Learn Med 2002;14:144–9. [4] Rosenbaum ME, Ferguson KJ, Lobas JG. Teaching medical students and residents skills for delivering bad news: a review of strategies. Acad Med 2004;79:107–17. [5] Buckman R. How to break bad news—a guide for health care professionals. Baltimore, MD: The Johns Hopkins University Press, 1992.
  6. 6. G.E. Amiel et al. / Patient Education and Counseling 60 (2006) 10–15 [6] Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5:302–11. [7] Sykes N. Medical students’ fears about breaking bad news. Lancet 1989;2:564. [8] Dosanjh S, Barnes J, Bhandari M. Barriers to breaking bad news among medical and surgical residents. Med Educ 2001;35: 197–205. [9] Cantwell BM, Ramirez AJ. Doctor–patient communication: a study of junior house officers. Med Educ 1997;3:17–21. [10] Ptacek JT, Ptacek JJ, Ellison NM. ‘‘I’m sorry to tell you. . .’’ physicians’ reports of breaking bad news. J Behav Med 2001;24: 205–17. [11] Ungar L, Alperin M, Amiel GE, Beharier Z, Reis S. Breaking bad news: structured training for family medicine residents. Patient Educ Couns 2002;48:63–8. [12] Sharp PC, Pearce KA, Konen JC, Knudson MP. Using standardized patient instructors to teach health promotion interviewing skills. Fam Med 1996;28:103–6. [13] Brock CD, Stock RD. A survey of Balint group activities in U.S. family practice residency programs. Fam Med 1990;22:33–7. [14] Lipsey MW. Designed sensitivity. London, UK: Sage Publications, 1990. p. 31–32. [15] Jonsen A, Siegler M, Winslade W. Clinical ethics, 3rd ed., New York, NY: McGraw-Hill, 1992. p. 53. [16] Ladyshewsky R, Gotjamanos E. Communication skill development in health professional education: the use of standardized patients in combination with a peer assessment strategy. J Allied Health 1997;26:177–86. 15 [17] Cushing AM, Jones A. Evaluation of a breaking bad news course for medical students. Med Educ 1995;29:430–5. [18] Betson CL, Fielding R, Wong G, Chung SF, Nestel DF. Evaluation of two videotape instruction programmes on how to break bad news for Cantonese speaking medical students in Hong Kong. J Audiovisual Media Med 1997;20:172–7. [19] Balie 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. [20] Ptacek JT, Eberhardt TL. Breaking bad news: a review of the literature. J Am Med Assoc 1996;276:496–502. [21] Miller SJ, Hope T, Talbot DC. The development of a structured rating schedule (the BAS) to assess skills in breaking bad news. Br J Cancer 1999;80:792–800. [22] Ambuel B, Mazzone MF. Breaking bad news and discussing death. Prim Care 2001;28:249–67. [23] Greenberg LW, Ochsenschlager D, O’Donnell R, Mastruserio J, Cohen GJ. Communicating bad news: a pediatric department’s evaluation of a simulated intervention. Pediatrics 1999;103:1210–6. [24] Viadya VU, Greenberg LW, Patel KM, Strauss LH, Pollack MM. Teaching physicians how to break bad news: a 1-day workshop using standardized parents. Arch Pediatr Adolesc Med 1999;153: 419–22. [25] Cohen R, Rothman AI, Poldre P, Ross J. Validity and generalizability of global ratings in an objective structured clinical examination. Acad Med 1991;66:545–8. [26] Norman GR, Davis D, Lamb S, Hannah E, Caulford P, Kaigas T. Competency assessment of primary care physicians as part of a peer review program. J Am Med Assoc 1993;270:1046–51.

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