Physicians' psychophysiological stress reaction in medical communication of bad news: A critical literature review

Stress arousal reappraisal and worked example effects on the neuroendocrine stress response during breaking bad news in medical education

Breaking bad news (BBN; i.e., the disclosure of a serious diagnosis) is a necessary but challenging task in the medical field, often raising stress levels among physicians. According to the biopsychosocial model of challenge and threat, stress responses can manifest as adaptive challenge states or maladaptive threat states. Prior research has proposed that specific patterns in neuroendocrine responses may signal challenge and threat. In this study, we employed a 2 × 2 design to examine the effects of stress arousal reappraisal (SAR; i.e., reframing bodily arousal as a functional response) and worked example (WE; i.e., stepwise demonstration of BBN) interventions on salivary cortisol, dehydroepiandrosterone, and alpha-amylase responses. A total of 229 third-year medical students participated in a BBN simulation. While significant activation (rise) and regulation (decline) of neuroendocrine markers were observed in response to the BBN encounter, neither the SAR nor the WE intervention affected their peak levels or the magnitude (area under the curve) of the response. Only the WE intervention decelerated the rise and decline in dehydroepiandrosterone levels around individual peaks, potentially indicating an attenuated stress response. These findings suggest that neither of the interventions induced the expected challenge pattern in neuroendocrine activity. However, due to the low temporal resolution of salivary measurements and the dynamic process of challenge and threat orientations, we propose that the neuroendocrine responses may have limitations in distinguishing between challenge and threat.

'A perfect match': how hematologists discuss donor options and risks with black and white patients considering allogeneic stem cell transplant

Patients of racial minorities have lower chance of securing a suitable donor, essential part of successful allogeneic stem cell transplant. In this simulated interview study, we sought to examine how hematologists discuss donor options and risks with patients with high-risk myeloid neoplasm considering transplant. Thirty-seven US hematologists participated (65% male; 65% white, 24% Asian, none Black), randomly assigned to meet with a Black or white patient actor. The hematologists emphasized the benefits of a full match with the white patient and high chance of securing a donor. Conversely, with the Black patient, they tended not to ask about ancestry, discuss the donor registry, race implications or challenges with donor search. Knowing the patient had children, many recommended haploidentical transplant. The unique circumstances of transplant argue for a focused communication including discussing race. While conversations should be tailored to each patient, limiting essential information on donor options may contribute to disparities.

Effective communication in pediatric palliative care: Evaluation of two educational videos

OBJECTIVES

In pediatric palliative care, effective communication is one of the most important skills. However, physicians often lack proper training. This study examines how to enhance medical students' ability to deliver a life-limiting diagnosis to parents. For this, we evaluated the effectiveness of two educational videos.

METHODS

We randomly assigned 114 medical students to two intervention groups and one control group. The intervention consisted of two different educational videos. We used self-assessment instruments and objective measures. Group-specific differences were analyzed using (repeated measures) Analysis of Variance, accounting for the effects of covariates, and t-tests.

RESULTS

Analysis of self-assessed communication skills identified a positive effect of the 'time x group' interaction (F (2) = 3.25, p = 0.042, np2= 0.055), indicating a statistically significant increase in both intervention groups. A positive effect of both videos on performance was observed for one item.

CONCLUSION

An acting or animated video can have a small but significant impact on self-assessed communication skills and objectively assessed behaviour for medical students with varying levels of experience in delivering bad news to parents.

PRACTICE IMPLICATIONS

Further research is required to investigate the long-term impact of educational videos on the communication behaviour of providers interacting with parents.

Improving breaking bad news communication skills through stress arousal reappraisal and worked examples

INTRODUCTION

Breaking bad news (BBN) is a distressing yet essential task in medicine, imposing emotional strain on both physicians and patients. Crucially, effective BBN relies on both verbal and nonverbal communication, which can be impaired by elevated stress associated with the task. Efficient teaching of communication skills continues to present a challenge, and the role of stress management in BBN encounters remains largely overlooked. In this study, we investigated the effects of stress arousal reappraisal (SAR; positive reframing of stress arousal) and worked example (WE; step-by-step demonstration of BBN) interventions on medical students' communication performance.

METHODS

This pre-registered randomised controlled trial employed a 2 × 2 between-subjects design to evaluate the individual and combined effects of SAR and WE interventions on the verbal and nonverbal communication performance of 221 third-year medical students. To do so, students completed a 40-min web-based learning module before disclosing bad news to a simulated patient within a 12-min consultation. Performances were videorecorded and assessed by three independent raters.

RESULTS

The WE intervention significantly improved both verbal and nonverbal communication performance, whereas the SAR intervention enhanced nonverbal communication only. Combining SAR with WE did not yield additional improvements in nonverbal communication beyond those achieved by either intervention alone.

DISCUSSION

These findings highlight the potential of both SAR and WE interventions to optimise resource-intensive simulated BBN training. By demonstrating the efficacy of WE in improving both verbal and nonverbal communication, this study advances the literature on the application of WEs in the BBN context. Furthermore, this study is among the first to demonstrate the importance of stress coping in delivering bad news effectively. Given their low threshold, both SAR and WE interventions represent promising tools for equipping medical students with essential BBN communication skills and are well-suited for integration into already time-constrained medical curricula.

How to break the news in amyotrophic lateral sclerosis/motor neuron disease: practical guidelines from experts

In amyotrophic lateral sclerosis/motor neuron disease (ALS/MND), it is necessary to communicate difficult news during the initial diagnosis and throughout the disease trajectory as the condition progresses. However, delivering difficult news to people with ALS/MND is an emotionally demanding task for healthcare and allied health professionals-one for which many feel ill-prepared because of limited training in this area. Ineffective communication of difficult news damages the patient-provider relationship and negatively impacts patient quality of life (QoL). To address this issue, we developed the A-L S-PIKES protocol based on available literature and our extensive clinical experience. It provides easy-to-follow, stepwise guidelines to effectively deliver difficult news to people with ALS/MND (PALS) that includes: Advance Preparation (preparing for the discussion logistically and emotionally); Location & Setting (creating a comfortable setting that fosters rapport); Patient's Perceptions (assessing PALS' understanding and perception of their condition); Invitation (seeking PALS' permission to share information); Knowledge (sharing information in a clear, understandable manner); Emotion/Empathy (addressing emotions with empathy and providing emotional support); and Strategy & Summary (summarizing the discussion and collaboratively developing a plan of action). A-L S-PIKES provides practical guidelines on how to prepare for and conduct these challenging conversations. It emphasizes effective communication tailored to the individual needs of PALS and their families, empathy, sensitivity, and support for PALS' emotional well-being and autonomy. The aim of A-L S-PIKES is to both enhance skills and confidence in delivering difficult news and to improve the QoL of PALS and their families. Future studies should systematically evaluate the feasibility and effectiveness of A-L S-PIKES to establish its utility in clinical practice.

The mental state inferences in healthcare professionals scale: a psychometric study

BACKGROUND

Empathizing with patients is an essential component of effective clinical care. Yet, a debate persists regarding how healthcare professionals' emotions and performance are impacted when they engage in empathetic behaviors and attempt to discern patients' mental states during clinical interactions. To approach this issue, this study explores the psychometric properties of the Mental State Inferences in Healthcare Professionals Scale (MSIHPS), a novel eight-item scale to evaluate healthcare professionals' perceptions of their own disposition to infer patients' mental states during clinical interactions.

METHOD

The study was conducted across various units within a regional hospital and primary care units affiliated with the Canarian Public Health Service in Spain. Data collection took place over the course of 2022, spanning from February to November. The psychometric properties of the scale were analyzed, including an exploratory and a confirmatory factor analysis, to test reliability and validity. Additionally, an item response model was run to test potentially biased items. The study collected data from a sample of 585 healthcare professionals.

RESULTS

Overall, the results indicate that the psychometric properties of the tool are adequate. Furthermore, the unidimensionality of the scale was confirmed using the item response model, wherein the eight-items significantly contribute to predicting the latent construct.

CONCLUSION

The MSIHPS offers the opportunity to explore the role of mentalizing in a diversity of healthcare settings. This measure can be useful to explore the relationship between healthcare professionals' disposition to infer patients' mental states and other relevant variables in clinical interactions, such as empathy and clinical performance.

Protocols for breaking bad news in health care: a scoping review protocol

OBJECTIVE

This scoping review will map the available evidence on communication protocols for breaking bad news to adult patients and their families in health care.

INTRODUCTION

Breaking bad news to adult patients and their families is a challenging task for health care professionals. To address these challenges, communication protocols have been developed to support health care professionals in breaking bad news in a compassionate and effective manner while respecting each patient's individuality.

INCLUSION CRITERIA

This scoping review will consider all studies that focus on communication protocols (original or adapted versions) to break bad news to adult patients and/or their families (adults) in any health care context, regardless of the approach (face-to-face, telephone, video, or other). Quantitative, qualitative, and mixed methods studies; systematic reviews; and textual evidence papers will be considered for inclusion in this review.

METHODS

This review will be conducted in accordance with the JBI methodology for scoping reviews. The search strategy will aim to locate both published and unpublished evidence in English, Spanish, and Portuguese. The databases to be searched include CINAHL Plus Complete (EBSCOhost), MEDLINE (PubMed), Academic Search Complete, Psychology and Behavioral Sciences Collection, Scopus, and Web of Science Core Collection. Gray literature will also be searched for. Two independent reviewers will independently perform study selection and data extraction. Data will be extracted using a data extraction tool developed by the reviewers. Any disagreements that arise between the reviewers will be resolved through discussion or with an additional reviewer. Data will be presented in tabular and narrative format.

REVIEW REGISTRATION

Open Science Framework https://osf.io/s6ru7/.

The effect of guided group reflection on the ability and convenience of breaking bad news in pre-hospital emergency staff

BACKGROUND

Bad news refers to any information that create negative changes in a person's understanding or expectations of in present and future. Breaking Bad News (BBN) is a stressful task that may have disturbing effects on the professional performance and general health of the medical staff. Pre-hospital emergency staff often needs to deliver bad news to the patient or his family. This study was conducted to determine the effect of guided group reflection training on the ability and comfort of BBN in pre-hospital emergency staff.

METHODS

This quasi-experimental study was conducted on 95 staff of the pre-hospital emergency, in the test and the control groups. For the test group, a 4-hour training workshop on BBN was held, and then a group was formed in virtual space to discuss and exchange opinions about the scenarios of BBN and reflecting on it. Data collection tools were SPIKES Questionnaire and the Visual Analogue Mood Scale. The data were analyzed with SPSS V.18.

RESULTS

The mean score of the ability to BBN after the intervention was 44.01 ± 6.21 in the test group and 31.40 ± 4.51 in the control group, and a significant difference was found using the independent t-test (P = 0.0001). Besides, the mean scores of the convenience of BBN in post-test was 5.52 ± 1.64 in the test group and 3.50 ± 1.28 in the control group using the independent t-test with a significant difference (P = 0.0001).

CONCLUSION

According to the findings, training in guided group reflection improved the ability to BBN and its convenience in pre-hospital emergency staff. Therefore, it is suggested the use of this method in training for health care providers. Relating to BBN.

"I couldn't say goodbye": Thematic analysis of interviews with bereaved relatives who lost their loved ones during the COVID-19 pandemic

BACKGROUND

Delivering serious news is usually challenging for healthcare professionals and the pandemic of COVID-19 and related restrictions brought additional challenges in this process.

AIMS

To explore the experience of bereaved relatives with receiving serious news from healthcare professionals during the pandemic COVID-19.

DESIGN

A qualitative study using thematic analysis and a codebook approach of data collected in semi-structured interviews with bereaved relatives.

SETTING/PARTICIPANTS

Data were collected from July to August 2022 in person/via phone with bereaved relatives who lost their relatives during the pandemic (from March 2020 to March 2022). Participants were recruited using a convenience sample and snowball method through social media and through one university hospital palliative care unit that invited bereaved relatives of deceased patients treated at the unit to participate in this study.

RESULTS

A total of 22 participants, consisting of 4 men and 18 women, were interviewed for this study. Most of the participants were sons or daughters of individuals who had died (5 grandchildren, 14 sons/daughters, 2 spouses, 1 great-niece). Six themes were identified: Burden caused by visit ban, Fear of COVID-19, Inappropriate behaviour and communication of healthcare professionals, High need for emotional support, Need for detailed and honest communication, Tendency to make excuses for mistakes and lapses by healthcare professionals.

CONCLUSIONS

Delivering serious news during a pandemic was negatively influenced by a lack of contact with patients and a lack of support and empathetic communication with staff. Overcoming these circumstances can be achieved by frequent communication using various communication tools (such as videoconferences or phone calls), and maintaining empathy and honesty in the communication process.

Sharing Unpleasant Health Information with Patients: A baseline study exploring physician attitudes, practices and adherence to the SPIKES protocol at a tertiary hospital in Muscat, Oman

Objectives

This study aimed to investigate the knowledge, attitude and experiences in sharing unpleasant health information and adherence to the SPIKES protocol among physicians at a tertiary hospital in Muscat, Oman.

Methods

This cross-sectional study was conducted at the Sultan Qaboos University Hospital from August to October 2022. An electronic, self-administered questionnaire was used to gather data from physicians across various departments.

Results

A total of 89 physicians completed the questionnaire (response rate = 22.3%). Most participants (n = 86, 96.6%) recognised the need for additional training in the delivery of unpleasant health information ('bad news'), with 78.7% (n = 70) expressing their willingness to undertake such training. Additionally, 32.6% (n = 29) reported negative experiences due to improper delivery of bad news, with an equal proportion admitting to disclosing bad news to patients' family without their consent. The majority (n = 77, 86.5%) demonstrated a high level of overall adherence to the SPIKES protocol, with 59.6-85.4%, 12.4-34.8% and 1.1-11.2% reported usually, sometimes and never following specific steps of the protocol, respectively. Marital status (P = 0.015) and qualifications (P = 0.032) were the only variables that were associated with adherence level, with married physicians and those with board and/or fellowship certificates reporting significantly better adherence compared to their counterparts.

Conclusion

Physicians in Oman encounter challenges in delivering unpleasant health information, underscoring the interplay of cultural influences, training and adherence to protocols. To address these challenges, targeted and frequent training programmes are recommended, starting from undergraduate medical education and extending to continuous opportunities for physicians at various career levels.

Advance care planning in perinatal settings: national survey of implementation using Normalisation Process Theory

BACKGROUND

Perinatal advance care planning (PnACP) is a process of formal decision-making to help families plan for their baby's care when recognised that they may have a life-limiting condition. While PnACP is recommended in policy, there is a lack of evidence to support implementation and development in the perinatal setting.

OBJECTIVE

To conduct an online survey of UK and Ireland perinatal providers to examine how PnACP is operationalised in current practice.

METHODS

A secure online questionnaire was developed to collect data on (1) 'what' is being implemented, (2) the 'processes' being used, (3) perceived impact and (4) unmet support needs. Data were analysed using basic descriptive statistics, thematic analysis and through a conceptual lens of Normalisation Process Theory.

RESULTS

Questionnaires were completed by 108 health professionals working in 108 maternity and neonatal services, representing 90 organisations across the UK and Ireland. This revealed many resources and examples of good practice to support PnACP. However, there was wide variation in how PnACP was conceptualised and implemented. Existing frameworks, pathways and planning tools are not routinely embedded into care, and respondents identified many barriers that negatively impact the quality of care. They called for better integration of palliative care principles into acute settings and more investment in staff training to support families at existentially difficult times.

CONCLUSIONS

Priorities for additional perinatal service development include greater sharing of best practice and effective strategies to target the unique challenges of PnACP, such as time-sensitive collaborative working and decision-making in the face of high uncertainty.

How to break bad news and how to learn this skill: results from an international North-Eastern German Society for Gynecological Oncology (NOGGO) survey among physicians and medical students with 1089 participants

BACKGROUND

Delivering bad news to patients is one of the most challenging tasks in medical practice. Despite its great relevance to patients, relatives, and medical staff, there is a paucity of data pertaining to training, experience, expectations, and preferences of physicians and medical students on breaking bad news.

METHODS

We conducted an international survey in Germany, Switzerland, and Austria using an online questionnaire among physicians and medical students.

RESULTS

A total of 786 physicians and 303 medical students completed the survey. Physicians stated that 32.7% deliver bad news several times a week and 45.2% several times a month. Difficulties controlling their emotions (35.1%) and remaining professional (43.4%) were the greatest challenges for physicians. Delivering bad news is associated with feelings of anxiety, both among experienced physicians (median of 3.8 out of 10.0) and medical students (median of 5.3). Conveying bad news is a burden to physicians and consequently has a substantial impact on their job satisfaction. All participants reported the need for more communication training concerning this subject. Only 49.5% of medical students and 67.3% of physicians mentioned having learned adequate communication skills. Our data demonstrate that communication training decreases the level of anxiety and increases the feeling of self-confidence towards breaking bad news. Preferred educational tools were seminars with simulation (students: 71.4%, physicians: 49.5%), observing more senior faculty (students: 57.4%, physicians: 55.1%), and supervision and feedback sessions (students: 36.3%, physicians: 45.7%). The largest barriers regarding education on communication were limited time (students: 77.0%, physicians: 74.9%) and missing awareness of supervisors (students: 60.6%, physicians: 41.1%).

CONCLUSIONS

Our study showed a great need for systematic training and education in breaking bad news among physicians and medical students. Hospitals, medical schools, and postgraduate training programs are strongly encouraged to fill this gap, and improve sustainable doctor-patient communication to overcome the psychological burden for physicians.

Physicians' Lived Experience of Breaking Bad News in Clinical Practice: Five Essentials of a Relational Process

The purpose of this study was to develop deeper knowledge about physicians' lived experiences of breaking bad news by identifying their common meanings and interrelatedness along with their potential alignment with process-oriented and relational aspects. Based on the methodology of descriptive phenomenology, in-depth interviews were conducted with 22 physicians from a wide variety of specialties. The participants were invited to freely reflect upon their experiences of breaking bad news by describing situations that had worked well and less well. Results showed that breaking bad news was fundamentally experienced as a relational process constituted by the five essentials of Becoming the bad messenger, Expecting the unpredictable, Being on stage, Professionally managing hope, and Mindfulness of the emotional relationship. In line with recent research, this study confirms that clinical communication involves much more than just delivering the message. However, it also contributes to existing knowledge by focusing on the phenomenology of physicians' experiences, which enables deeper understanding of the medical profession and the relational process of breaking bad news. As such, our findings are important to enable broader learning in, for example, medical education and continuing courses for clinical staff.

Evaluating the Effectiveness of the SPIKES Model to Break Bad News - A Systematic Review

Introduction: Breaking bad news to patients and families can be challenging for healthcare providers. The present study conducted a systematic review of the literature to determine if formal communication training using the SPIKES protocol improves learner satisfaction, knowledge, performance, or system outcomes. Method: MEDLINE, Embase, CINAHL Plus (Nursing & Allied Health Sciences), and PsycINFO Databases were searched with keywords BAD NEWS and SPIKES. Studies were required to have an intervention using the SPIKES model and an outcome that addressed at least one of the four domains of the Kirkpatrick model for evaluating training effectiveness. The Cochrane Risk of Bias Tool was used to conduct a risk of bias assessment. Due to heterogeneity in the interventions and outcomes, meta-analysis was not undertaken and instead, a narrative synthesis was used with the information provided in the tables to summarise the main findings of the included studies. Results: Of 622 studies screened, 37 publications met the inclusion criteria. Interventions ranged from the use of didactic lecture, role play with standardised patients (SPs), video use, debriefing sessions, and computer simulations. Evaluation tools ranged from pre and post intervention questionnaires, OSCE performance with rating by independent raters and SPs, and reflective essay writing. Conclusions: Our systematic review demonstrated that the SPIKES protocol is associated with improved learner satisfaction, knowledge and performance. None of the studies in our review examined system outcomes. As such, further educational development and research is needed to evaluate the impact of patient outcomes, including the optimal components and length of intervention.

Palliative Communication in the Pediatric Intensive Care Unit

Communication is a central aspect of nursing care and is especially important when pertaining to progressive illnesses and end of life. This article reviews basic palliative care terminology and outlines a variety of communication frameworks from the "dos" to the "don'ts." These communication strategies are meant to be added to the nurse's "toolbox" so that nurses may use them in various scenarios. These communication tools are meant to help mitigate the stress and discomfort nurses often feel when using palliative communication or delivering bad news.

From threat to challenge-Improving medical students' stress response and communication skills performance through the combination of stress arousal reappraisal and preparatory worked example-based learning when breaking bad news to simulated patients: study protocol for a randomized controlled trial

BACKGROUND

Breaking bad news (BBN; e.g., delivering a cancer diagnosis) is perceived as one of the most demanding communication tasks in the medical field and associated with high levels of stress. Physicians' increased stress in BBN encounters can negatively impact their communication performance, and in the long term, patient-related health outcomes. Although a growing body of literature acknowledges the stressful nature of BBN, little has been done to address this issue. Therefore, there is a need for appropriate tools to help physicians cope with their stress response, so that they can perform BBN at their best. In the present study, we implement the biopsychosocial model of challenge and threat as theoretical framework. According to this model, the balance between perceived situational demands and perceived coping resources determines whether a stressful performance situation, such as BBN, is experienced as challenge (resources > demands) or threat (resources < demands). Using two interventions, we aim to support medical students in shifting towards challenge-oriented stress responses and improved communication performance: (1) stress arousal reappraisal (SAR), which guides individuals to reinterpret their stress arousal as an adaptive and beneficial response for task performance; (2) worked examples (WE), which demonstrate how to BBN in a step-by-step manner, offering structure and promoting skill acquisition.

METHODS

In a randomized controlled trial with a 2 (SAR vs. control) x 2 (WE vs. control) between-subjects design, we will determine the effects of both interventions on stress response and BBN skills performance in N = 200 third-year medical students during a simulated BBN encounter. To identify students' stress responses, we will assess their perceived coping resources and task demands, record their cardiovascular activity, and measure salivary parameters before, during, and after BBN encounters. Three trained raters will independently score students' BBN skills performances.

DISCUSSION

Findings will provide unique insights into the psychophysiology of medical students who are tasked with BBN. Parameters can be understood more comprehensively from the challenge and threat perspective and linked to performance outcomes. If proven effective, the evaluated interventions could be incorporated into the curriculum of medical students and facilitate BBN skills acquisition.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05037318), September 8, 2021.

Neurologists' lived experiences of communicating the diagnosis of a motor neurodegenerative condition: an interpretative phenomenological analysis

BACKGROUND

Receiving the diagnosis of a motor neurodegenerative condition (MNDC) can be a life-changing experience. Although several studies of individuals' experiences have indicated dissatisfaction with aspects of how an MNDC diagnosis was communicated, few studies have addressed doctors' experiences of breaking bad news for these conditions, especially from a qualitative perspective. This study explored UK neurologists' lived experience of delivering an MNDC diagnosis.

METHODS

Interpretative phenomenological analysis was used as the overarching method. Eight consultant neurologists working with patients with MNDCs took part in individual, semi-structured interviews.

RESULTS

Two themes were constructed from the data: 'Meeting patients' emotional and information needs at diagnosis: a balancing act between disease, patient and organization-related factors', and 'Empathy makes the job harder: the emotional impact and uncovered vulnerabilities associated with breaking bad news'. Breaking the news of an MNDC diagnosis was challenging for participants, both in terms of achieving a patient-centred approach and in terms of dealing with their own emotions during the process.

CONCLUSIONS

Based on the study's findings an attempt to explain sub-optimal diagnostic experiences documented in patient studies was made and how organizational changes can support neurologists with this demanding clinical task was discussed.

Healthcare practitioners' experiences of breaking bad news: A critical interpretative meta synthesis

OBJECTIVE

To provide an overview of healthcare practitioners' experiences of breaking bad news.

METHOD

Interpretative meta synthesis of 14 qualitative papers identified through a systematic search. Data were extracted and constructs elicited via reciprocal translational analysis.

RESULTS

Findings comprised four inter-connected themes: (1) Discomfort, particularly difficult emotional and physical responses to breaking bad news; (2) Relational distress, connected to attachment and identification with patients; (3) Inadequate clinician, indicating the fear and rumination about the possibility of getting it wrong and the subsequent self-blame; and (4) Only human, highlighting a culture of invulnerability where practitioner self-care is deprioritised.

CONCLUSIONS

Breaking bad news provokes significant distress for practitioners, particularly where they experience strong attachment to or identification with a patient. Breaking bad news was understood as an isolating experience and staff's non-disclosure of difficulties appeared to sustain a culture of invulnerability in which admission of distress was not encouraged.

PRACTICE IMPLICATIONS

Given the adverse impacts and potential for practitioner burnout, organisations should acknowledge ramifications and offer time for staff to process the delivery of bad news, promote a culture of collective care and provide space for reflective practice.

To Treat or Not to Treat? Dilemmas when Deciding on Antineoplastic Treatment in Patients With Far Advanced Cancers

Patients with advanced cancers and their oncologists are often faced with difficult treatment decisions, especially when there are borderline situations of expected benefit or increased risk of complications. In this narrative review, we will explore the decision-making process for patients with advanced cancers and provide insights on how to approach this complex task, while didactically dividing the oncologist's assessments according to a mnemonic rule of the ABCDE of therapeutic decision-making. Part A (advanced cancer) recalls that the rule is to be used specifically for advanced cancers. Parts B (potential benefits) and C (clinical conditions and risks) represents the traditional risk vs benefit scale. In Part D, we discuss ways to identify and understand patients' desires, values, preferences, and beliefs. The prognostic estimation, from Part E, may function as an "adjust" for the antineoplastic treatment decision-making. Treatment decisions need to be conducted by skilled oncologists, in a patient-centered care, aiming to promote valuable oncology with lower rates of aggressive care.

The Impact of Cancer Relapse and Poor Patient Outcomes on Health Care Providers Practicing in the Oncology Field

INTRODUCTION

Devastating cancer-related events are not uncommon, and these events have weakened communication performance and induced stress among health care providers (HCPs), particularly physicians. This study aimed to investigate the perspective of HCPs emotionally affected by poor clinical outcomes due to the failure of cancer therapy.

METHODS

A cross-sectional, online survey was conducted over 3 months among HCPs practicing in the field of oncology in Saudi Arabia, comprising physicians, pharmacists, and nurses. Data were analyzed using Statistical Package for Social Sciences version 26.0. A P-value <.05 was considered statistically significant.

RESULTS

This study demonstrated a positive correlation between HCPs' length of experience and emotional impact of treatment failure, albeit this was not statistically significant (P = .071). Analysis of their perspective toward failure of cancer therapies revealed a significant impact of occupation and sex (P = .014 and P = .047, respectively). Moreover, occupation played a significant role in shaping the viewpoint of HCPs toward the need for conducing further research to test the appropriateness of treatment protocols on local patients (P = .022). Despite the emotional responses of HCPs to suboptimal clinical outcomes, factors such as work burnout, lack of concentration and patience, work or personal problems, and under appreciation were frequently identified as triggers of such outcomes.

CONCLUSION

Our results revealed that poor clinical outcomes observed among cancer patients are emotional triggers for HCPs practicing in the oncology field. The emotional response is often perceived negatively, and can potentially lead to a decline in the quality of care provided to these patients.

Breaking bad news in the era of artificial intelligence and algorithmic medicine: an exploration of disclosure and its ethical justification using the hedonic calculus

An appropriate ethical framework around the use of Artificial Intelligence (AI) in healthcare has become a key desirable with the increasingly widespread deployment of this technology. Advances in AI hold the promise of improving the precision of outcome prediction at the level of the individual. However, the addition of these technologies to patient-clinician interactions, as with any complex human interaction, has potential pitfalls. While physicians have always had to carefully consider the ethical background and implications of their actions, detailed deliberations around fast-moving technological progress may not have kept up. We use a common but key challenge in healthcare interactions, the disclosure of bad news (likely imminent death), to illustrate how the philosophical framework of the 'Felicific Calculus' developed in the eighteenth century by Jeremy Bentham, may have a timely quasi-quantitative application in the age of AI. We show how this ethical algorithm can be used to assess, across seven mutually exclusive and exhaustive domains, whether an AI-supported action can be morally justified.

The effects of diverse fidelity scenarios on stress in medical students when taking patients' medical histories: A longitudinal study

Taking patients' medical history correctly is the basis of diagnosis and therapy. Medical students as a vulnerable group may perceive patient-physician interactions as stressful. This study examines stress among medical students in different degrees of fidelity when taking a patient's medical history. In this longitudinal study, students' stress levels were assessed during scenarios with different degrees of fidelity (role-play, simulated patient encounters and real patient encounters) using standardised questionnaires (State-Trait Anxiety Inventory and a distress scale) and the physiological measurement of heart rate variability. The stress level of participating medical students (N = 128) was expected to significantly increase during scenarios of increasing fidelity (M_roleplay  = 2.08 ± 0.92; SPEs: M_{simulatedpatient}  = 2.68 ± 1.08; RPEs: M_realpatient  = 3.35 ± 1.08; p < 0.001). Whereas physiological stress was significantly higher with real patients (N = 106), psychological stress was not affected by the fidelity of the scenarios (N = 85). Medical students experienced stress when taking patients' medical history. Medical students might be unaware of their perceived stress based on the results. Thus, they should know how to cope with stress in such situations.

Influence of Personal Experiences of Medical Students on Their Assessment of Delivering Bad News

BACKGROUND

We aimed to identify which attitudes and emotions accompany latter-year medical students as they experience situations where bad news is communicated.

METHODS

A cross-sectional study was conducted using the computer-assisted web interview (CAWI) methodology in a group of 321 fifth- and sixth-year medical students from 14 medical universities in Poland. Correlations were analyzed using Pearson's χ² test. For the categorical variables, subject profiles were analyzed using K-means clustering.

RESULTS

Students' self-assessments of their competence in delivering bad news (DBN) differed depending on the type of experience they had with it. More than half of the students had observed a situation of DBN (63.6%) and as many as 26.5% of the participants had received bad news themselves. These two groups were less likely to declare a lack of DBN-related skills (43.4% and 33.4%, respectively) than others. In this study, 9% of the students had personally delivered bad news. Only 13.4% of these students rated their DBN skills as insufficient. They were also the least likely to express concern regarding high levels of stress (29.6%) and anxiety (48%).

CONCLUSIONS

The ability to personally deliver bad medical news to a patient was the most effective form of gaining experience in DBN. Being a bearer of bad news may help students develop their own strategies for coping with difficult emotions and develop their professional competences, leading to improved medical care and patient comfort.

A randomized controlled trial assessing behavioral, cognitive, emotional and physiological changes resulting from a communication skills training in physicians caring for cancer patients

OBJECTIVE

This randomized study assesses behavioral, cognitive, emotional and physiological changes resulting from a communication skills training (CST) for physicians caring for cancer patients.

METHODS

Medical specialists (N = 90) were randomly assigned in groups to complete a manualized 30-h CST or to a waiting list. Assessments included behavioral (communication skills), cognitive (self-efficacy, sense of mastery), emotional (perceived stress) and physiological (heart rate) measures. Assessments were made at baseline (both groups), after CST program (training group), and four months after (waiting list group). All assessments were conducted before, during, and after a complex communication task with an advanced-stage cancer simulated patient (SP).

RESULTS

Trained physicians had higher levels of communication skills (from RR=1.32; p = .003 to RR=41.33; p < .001), self-efficacy (F=9.3; p = .003), sense of mastery (F=167.9; p < .001) and heart rate during the SP encounter (from F=7.4; p = .008 to F=4; p = .050) and same levels of perceived stress (F=3.1; p = .080).

CONCLUSION

A learner-centered, skills-focused and practice-oriented manualized 30-h CST induced multilevel changes indicating physician engagement in a learning process.

PRACTICE IMPLICATIONS

Trainers should consider the CST multilevel benefits (behavioral, cognitive, emotional and physiological) before, during and after a complex communication simulated task as an innovative way to assess the efficacy of a communication skills learning process.

Mindfulness Improves Otolaryngology Residents' Performance in a Simulated Bad-News Consultation: A Pilot Study

INTRODUCTION

Delivering bad news is a stressful moment for both patient and clinician. As poor bad-news consultation quality may lead to misunderstandings, lack of treatment adherence, acute or even post-traumatic stress in patients, training interventions to improve communication skills and stress-management are necessary. Mindfulness is a recognised stress-management strategy that has shown its efficacy in reducing stress in both health professionals and students. We then supposed that a short mindfulness meditation session performed just before a simulated breaking bad-news consultation to patients with laryngeal cancer may help ear, nose and throat (ENT) residents to master their stress and improve their management of this consultation. This study aims at showing how a short mindfulness meditation performed before a simulated bad-news consultation may improve performance in its realisation by ENT residents.

MATERIALS AND METHODS

We enrolled 53 ENT residents, randomised in 2 groups. The first group completed a 5-minute mindfulness session while the other group listened to a control track. Thereafter, every resident completed an 8-minute simulated bad-news consultation with a standardised patient. Two blinded expert assessors evaluated their performance on a 25-point grid (BNC-OSAS). Residents self-assessed their stress before and after the intervention and simulated patients rated their perception of physician's empathy.

RESULTS

The performance was significantly better in the mindfulness group than in the control group (m = 19.8, sd = 3.2 and m = 17.4, sd = 3.7 respectively, F(1,45)=5.27, p = 0.026, d = 0.67), especially in the communication and knowledge subdomains. There was no significant difference in perceived stress between the 2 groups. Empathy perceived by simulated patients was positively correlated to residents' performance.

CONCLUSION

A short mindfulness meditation is effective for improving ENT residents' performance in a simulated bad-news consultation. These results encourage further assessments of this method with objective measures of physiological stress. More research is required concerning the feasibility and efficacy of mindfulness before daily clinical activities such as stressing bad-news consultation.

Development and validation of The Breaking Bad News Attitudes Scale

BACKGROUND

Communication of bad news plays a critical role in the physician-patient relationship, and a variety of consensus guidelines have been developed to this purpose, including the SPIKES protocol. However, little is known about physicians' attitudes towards breaking bad news and to be trained to deliver it. This study aimed to develop and validate a self-report questionnaire to assess physicians' attitudes towards principles of the SPIKES protocol and training on them.

METHODS

The Breaking Bad News Attitudes Scale (BBNAS) was administered to 484 pediatricians and 79 medical students, recruited at two scientific conferences and two medical schools in Brazil. The questionnaire structural validity, reliability, and associations with other variables were tested.

RESULTS

The BBNAS showed adequate validity and good reliability, with two factors measuring attitudes towards the SPIKES strategy for braking bad news (α = 0.81) and the possibility to be trained on it (α = 0.77), respectively.

CONCLUSION

The novel questionnaire is a psychometrically sound measure that provides information on physicians' agreement with the SPIKES protocol. The BBNAS can provide useful information for planning training and continuing education programs for clinicians on communication of bad news using the SPIKES as a framework.

Breaking bad news: tackling cultural dilemmas

Requesting that serious diagnoses be concealed from patients, a widespread phenomenon in many cultures, presents a professional dilemma. Practical and sensitive communication strategies are needed.

METHODOLOGY

In this paper, we use analysis of the existing literature to develop a communication tool for practitioners facing requests for diagnostic non-disclosure. Our approach builds on existing strategies, in providing a mnemonic communication tool, permitting more than one outcome, and focusing on the need for mutual understanding and cooperation.

RESULTS

Existing work on this dilemma highlights the need to appreciate the family's standpoint, affirm their benevolent intentions and correct misperceptions. To this end, we have developed a mnemonic tool, 'ARCHES', to be used in situations where the family has requested diagnostic non-disclosure. The model has six stages: acknowledge the request for non-disclosure, build the relationship, find common ground, honour the patient's preferences and outline the harm of non-disclosure, provide emotional support and devise a supportive solution.

CONCLUSION

Facing requests for diagnostic non-disclosure is a challenge of communication. The dilemma is particularly marked when practising across cultures. Our model gives a structure for building rapport with the family and realigning their misperceptions while upholding the patient's right to knowledge.

Discussing Prognosis with Empathy to Cancer Patients

PURPOSE OF REVIEW

Our goal was to provide healthcare professionals (HCPs) with evidence-based data about what can be done to handle prognostic discussions with empathy.

RECENT FINDINGS

First, disclosing prognosis involves a good reason to do so and making sure that the patient will be able to process the discussion. Second, communication tips are given for the three dimensions of empathy: "establishing rapport with the patient," which should not be overlooked; the emotional dimension, which involves an accurate understanding of the patient and communication skills; and the "active/positive" dimension which is about giving hope, explaining things clearly and helping patients take control with shared decision-making and a planned future. Although communication tips are helpful, empathy training should be based more on the development of HCPs' emotional skills, in order to help them regulate their emotions and thus be more comfortable with those of patients and families. Furthermore, research into empathy toward minorities and relatives is needed.

The experience of speech-language therapists and audiologists when delivering bad news: A qualitative analysis

BACKGROUND

As part of their professional responsibilities, speech-language therapists and audiologists are required to deliver bad news.

AIMS

The aim of this qualitative study is to describe and characterize the subjective experience of speech-language therapists and audiologists when delivering bad news to clients or their family members.

METHODS & PROCEDURES

A group of 156 speech-language therapists and audiologists replied in writing to an open question asking them to describe a clinical encounter in which they delivered bad news. The texts that were generated in response to this question served as a data base. Qualitative content analysis was used to analyse data and generate themes.

OUTCOMES & RESULTS

Thematic analysis of participants' texts revealed the challenges inherent to the delivery of bad news. Four main themes emerged from text analysis: difficulty in phrasing the news; the deliverer's emotional experience; the receiver's reaction; and being alone or in companion with another healthcare provider during the delivery of the bad news.

CONCLUSIONS & IMPLICATIONS

Speech-language therapists and audiologists experience difficulties similar to those experienced by other healthcare professionals when delivering bad news. Nevertheless, speech-language therapists and audiologists seem to perceive the delivery of bad news situation in a broader sense than the conventional definition given to this term in the medical arena. What this paper adds What is already known on the subject The task of delivering bad news is stressful to healthcare professionals. Most of the literature on the topic pertains to physicians. Little is known regarding the delivery of bad news in speech-language therapy and audiology. What this paper adds to existing knowledge This study highlights the challenges that speech-language therapists and audiologists encounter when delivering bad news. Furthermore, it illuminates the implicit perceptions of these professionals regarding what is considered 'bad news'. What are the potential or actual clinical implications of this work? The emotional challenges associated with the delivery of bad news underscore the importance of support and training regarding the delivery of bad news. It is especially important to prepare for a client's difficult questions, and to prefer a collaborative approach to the delivery of bad news.

"It Just Hit Me Like a Ton of Bricks": Improving the Patient Experience of Receiving a Breast Cancer Diagnosis at an Older Age

The purpose of the current study was to describe the experiences of older women receiving a diagnosis of early-stage breast cancer. Thematic analysis informed by techniques from constructivist grounded theory was used to analyze interviews with 54 women aged ≥65 years an average of 19.6 months after diagnosis. Two themes were identified: The Overwhelming Shock of Receiving a Diagnosis and Contextualizing the Diagnosis in Relation to Age. Results suggest these participants were deeply shocked by a diagnosis that clinicians may view as highly treatable. Age-related factors impacting how the bad news was received include misunderstanding risk factors, the impact of comorbidities, concurrent life events, and evolving perceptions of cancer at her life stage. To establish a solid foundation for age-appropriate communication when giving bad news, these participants help clinicians acknowledge what women may be thinking. Potential clinician responses to the variety of concerns are presented. [Research in Gerontological Nursing, 14(2), 79-89.].

Neurologists' current practice and perspectives on communicating the diagnosis of a motor neurodegenerative condition: a UK survey

BACKGROUND

The communication of a life-changing diagnosis can be a difficult task for doctors with potential long-term effects on patient outcomes. Although several studies have addressed the experiences of individuals with motor neurodegenerative diseases in receiving this diagnosis, a significant research gap exists regarding professionals' perspectives, especially in the UK. This study aimed to assess UK neurologists' current practice and perspectives on delivering the diagnosis of a motor neurodegenerative disease, explore different aspects of the process and detail the potential challenges professionals might face.

METHODS

We conducted an anonymised online survey with 44 questions, grouped into four sections; basic demographic information, current practice, the experience of breaking bad news and education and training needs.

RESULTS

Forty-nine professionals completed the survey. Overall, participants seemed to meet the setting-related standards of good practice; however, they also acknowledged the difficulty of this aspect of their clinical work, with about half of participants (46.5%) reporting moderate levels of stress while breaking bad news. Patients' relatives were not always included in diagnostic consultations and participants were more reluctant to promote a sense of optimism to patients with poorer prognosis. Although professionals reported spending a mean of around 30-40 min for the communication of these diagnoses, a significant proportion of participants (21-39%) reported significantly shorter consultation times, highlighting organisational issues related to lack of capacity. Finally, the majority of participants (75.5%) reported not following any specific guidelines or protocols but indicated their interest in receiving further training in breaking bad news (78.5%).

CONCLUSIONS

This was the first UK survey to address neurologists' practice and experiences in communicating these diagnoses. Although meeting basic standards of good practice was reported by most professionals, we identified several areas of improvement. These included spending enough time to deliver the diagnosis appropriately, including patients' relatives as a standard, promoting a sense of hope and responding to professionals' training needs regarding breaking bad news.

Giving and receiving a diagnosis of a progressive neurological condition: A scoping review of doctors' and patients' perspectives

OBJECTIVE

Delivering a life changing diagnosis can be a distressing experience for patients and a challenging task for professionals. Diagnosis delivery can be especially difficult for individuals with neurodegenerative diseases such as motor neurone disease (MND), multiple sclerosis (MS) and Parkinson's disease (PD). This review aims to scope the literature on doctors' and patients' perspectives on diagnosis delivery for these conditions in order to enhance our understanding in this area and identify potential research gaps.

METHODS

A scoping review methodology was used, and data were summarised using content analysis.

RESULTS

47 studies fulfilled the inclusion criteria. Studies showed that although patients were generally satisfied with diagnosis delivery, a considerable proportion was still dissatisfied with aspects of the consultation, especially the information and time provided and the doctor's approach. Only six studies addressed doctors' perspectives, which focused more on doctors' practice.

CONCLUSION

There was a significant research gap in professionals' perspectives. The review also found that although basic standards of good practice were being met, a significant proportion of patients were dissatisfied with diagnosis communication.

PRACTICE IMPLICATIONS

Professionals delivering such diagnoses need to assess and respond to patients' information needs, provide time for questions and maintain an empathic attitude.

Hilariously Bad News: Medical Improv as a Novel Approach to Teach Communication Skills for Bad News Disclosure

A targeted, improv-based exercise was developed as a novel skills training approach to bad news disclosure for medical professionals and trainees, focusing on specific characteristics that influence these conversations including nature of the bad news, implications, personal responsibility, and status differences.

Evaluation of emergency medical services staff knowledge in breaking bad news to patients

Objective

The aim of the study was to investigate knowledge of breaking bad news (BBN) among medical personnel in the emergency medical services (EMS).

Methods

A cross-sectional survey was conducted of 148 individuals employed in EMS. An interview was conducted using a structured questionnaire.

Results

Of study participants, 89.2% were not aware of any formal BBN procedure and 58.1% had not participated in any form of training. Compared with males, females were more likely to report that dealing with the emotional state of the family or the patient was the most difficult aspect of BBN. Only a few participants were aware of the SPIKES protocol for BBN, and none knew what the acronym meant. Sex, educational level, occupation, work experience and workplace were not associated with knowledge of BBN procedures.

Conclusions

Knowledge of BBN in both male and female EMS staff was insufficient. EMS personnel held different opinions about the method of BBN. Even staff who have participated in specific BBN training or have extensive professional experience were pessimistic about BBN skills in self-assessments.

"I Keep it Together at Work but Fall Apart at Home": The Experience of Israeli Homeroom Teachers Coping With the Death of a Student in their Class

This qualitative study examines the experiences of 16 Israeli high school homeroom teachers coping with the death of a student from their class. We used in-depth, semistructured, face-to-face interviews. Analysis of the findings revealed three key themes: (a) After their initial sense of shock and pain upon learning of the death of one of their students, the homeroom teachers were immediately asked to convey the bad news to their class. (b) The teachers experienced profound grief, had difficulty dealing with the student's absence, and invested resources in preserving the student's memory through various activities. (c) The teachers claimed that the experience affected their personal lives and stated that memories of it continued to surface long afterwards. Some found it difficult to function and even chose to leave the profession. The discussion raises the need for early assessment and planning in schools to address loss-related issues and provide support for teachers.

Differential Responses of Urinary Epinephrine and Norepinephrine to 24-h Shift-Work Stressor in Physicians

Multiple stressors, including 24-h-shifts characterise the working environment of physicians, influencing well-being, health and performance. We aimed to evaluate the effect of the stressor 24-h-shift on the adrenal medullary and sympathoneural system in physicians with the hypothesis that shift work might have different impacts on both systems. Twenty-two physicians collected two 12-h-urine samples ("daytime" and "nighttime") during a 24-h shift ("on-duty") and on a free weekend ("off-duty"), respectively. Urinary excretion rates per m² body surface area were assessed for the catecholamines epinephrine, norepinephrine and their respective free O-methylated metabolites metanephrine and normetanephrine by LC-MS/MS-analysis. The stressor provoked differential responses of epinephrine and norepinephrine. Epinephrine excretion rates showed significant increases from off to on duty. The largest proportional change (off-duty to on-duty) for epinephrine was observed for nighttime (205%), the increase for daytime was 84%. An increase in norepinephrine from off to on duty was only visible for nighttime collections. For the catecholamine metabolites, normetanephrine paralleled norepinephrine and exhibited an increase in excretion from off to on duty during nighttime collections of 53% whereas there was no change during daytime collections (3%). In conclusion: Whilst the 24-h-shift-work stressor in physicians activates the sympatho-adrenomedullary system, represented by epinephrine, the sympathoneural response through norepinephrine reflects mainly an ambulatory position during working hours.

Beliefs held by breast surgeons that impact the treatment decision process for advanced breast cancer patients: a qualitative study

Introduction

Although guidelines do not recommend chemotherapy for patients with advanced cancer when death is imminent, many reports suggest the tendency to continue this treatment has been increasing every year. This study aimed to construct a model to clarify the beliefs and communication of doctors who administer chemotherapy to patients with recurrent or metastatic (hereafter, “recurrent/metastatic”) breast cancer, and determine how these beliefs are related to the process of treating patients.

Materials and methods

Semi-structured interviews were conducted with 21 breast surgeons, and interview contents were analyzed using the grounded theory approach in order to conceptualize the treatment process.

Results

The process of chemotherapy for patients with recurrent/metastatic breast cancer differed based on two beliefs held by doctors. One was a “belief that the patient is an entity who cannot accept death,” and throughout the treatment process, these doctors consistently avoided sharing bad news that might hurt patients, and always discussed aggressive chemotherapy. They proposed treatments as long as options remained, and when they ultimately judged that the physical condition of patients could not withstand further treatment, treatment was terminated despite the patient hoping for continuation. The other was a “belief that the patient is an entity who can accept death.” From early on after recurrence/metastasis, these doctors repeatedly gave patients information including bad news about prognosis, and when they judged that further treatment would hinder a patient’s ability to have a good death, they proposed terminating treatment.

Conclusion

We demonstrated that breast surgeons treating recurrent/metastatic breast cancer patients have two beliefs and constructed a model of the treatment process based on those beliefs. This offered breast surgeons, who make decisions regarding treatment without clearly-defined guidelines, a chance to reflect on their own care style, which we believe will contribute to optimal patient care.

Endocrine and psychological stress response in simulated doctor-patient interactions in medical education

BACKGROUND

Training of doctor-patient interactions by means of patient actors is considered a useful didactic tool in medical education. However, though students report it as being highly stressful little systematic research has verified this notion.

AIMS

To assess the endocrine and psychological stress responses of students in the doctor vs. the observer role in simulated doctor-patient interactions.

METHODS

Salivary cortisol and anxiety was assessed in N = 86 participants of a mandatory course on doctor-patient interactions on three consecutive days. During two of these days they were in the observer role and gave feedback to another student and on one of these days they were in the doctor role and were being given feedback. Saliva was sampled at 4 points in time per day: prior to interaction (T1); after watching the video of the interaction (T2); after feedback (T3); after observation of another interaction (T4). Assessments on observer days took place at the respective time points and at the same time of the day. 3-way mixed ANOVAs were computed with the factors "day of data sampling" (F1); "day with doctor role" (F2); "measurement time"(F3).

RESULTS

Significant two-way interactions F1 × F2 and three-way interactions F1 × F2 × F3 were observed both for cortisol and for anxiety (all p < .001). Neither cortisol nor anxiety were related to task severity. Anxiety at T1 correlated with cortisol increase from T1 to T2 (r = .266; p = .013).

DISCUSSION

Results confirm that playing the doctor role in a simulated doctor-patient interaction represents a significant stressor in medical students. Effect sizes considerably exceed those observed in laboratory stress. This brings about new questions regarding moderating factors, effects of repetitions and relationship to medical performance. The ecological validity of this stressor can also make it a useful tool in basic endocrine research.

Narrative medicine: A comparison of terminal cancer patients' stories from a Dutch hospice with those of Anatole Broyard and Christopher Hitchens

Not all physicians readily discuss death with their terminal patients. To explore whether physicians discuss dying with their terminal patients and to pursue an in-depth understanding of patients' perceptions of death, we interviewed terminal cancer patients in a Dutch hospice and compared their stories to quotes from two autobiographies on dying from cancer, Christopher Hitchens' Mortality and Anatole Broyard's Intoxicated by my illness. This narrative medicine study could potentially teach physicians they should discuss impending death to prevent the use of an invasive medical treatment that typically extends the quantity, but not the quality, of life.

The learning effects of different presentations of worked examples on medical students' breaking-bad-news skills: A randomized and blinded field trial

OBJECTIVES

Effective instructional approaches are needed to enable undergraduates to optimally prepare for the limited training time they receive with simulated patients (SPs). This study examines the learning effects of different presentation formats of a worked example on student SP communication.

METHODS

Sixty-seven fourth-year medical students attending a mandatory communication course participated in this randomized field trial. Prior to the course, they worked through an e-learning module that introduced the SPIKES protocol for delivering bad news to patients. In this module, a single worked example was presented to one group of students in a text version, to a second group in a video version, and to a third group in a video version enriched with text hints denoting the SPIKES steps.

RESULTS

The video-with-hints group broke bad news to SPs significantly more appropriately than either of the other groups. Although no further condition-related effects were revealed, students who learned from the text version most frequently (although non-significantly) ignored unpleasant emotions (standardised emotional cues and concerns) expressed by the SPs.

CONCLUSIONS

The learning effect was strongest when the video-based worked example was accompanied by hints.

PRACTICE IMPLICATIONS

Video-related learning approaches that embed attention-guiding hints can effectively prepare undergraduates for SP encounters.