Medical EducationBreaking bad news is a teachable skill in pediatric residents: A feasibility study of an educational intervention
Introduction
Good communication skills are critical to the practice of excellent and effective medicine [1], [2], [3]. This includes the delicate and complex skill of breaking bad news. These skills are so critical that breaking bad news poorly can negatively affect patient relationships and have lasting impact on patients and families [1], [2], [4], [5], [6]. It is clear that patients [3], [6], [7], [8], [9] and physicians [1], [9], [10], [11], [12], [13], [14] still feel that many physicians struggle to achieve competence in these skills. Even for experienced clinicians, delivering bad news is a source of considerable stress [9], [10], [15]. Physiologic stress responses have even been noted in both novice and experienced physicians in simulated patient encounters that involve breaking bad news [15], [16].
Competence in breaking bad news is not always associated with increased experience. One study compared communication competency in medical students, residents, and attending physicians. Interestingly, while novice medical students had the lowest competence, no difference was found among more senior students, residents, and attending physicians [17]. Another study of novice and experienced physicians during a simulated bad news encounter found experience was inversely related to stress response, but performance was inversely related to burnout and fatigue, not inexperience alone [18].
Many residency and fellowship programs lack formal instruction on the delivery of bad news [19], [20], [21], [22]. Traditional medical education focused on mastery of pathology and disease treatment may result in inadequate teaching and evaluation of less tangible skills (e.g., communication) necessary for excellent patient care. While the Accreditation Council for Graduate Medical Education (ACGME) clearly prioritizes interpersonal skills and communication as one of the core competencies, and requires residents to achieve competence in this area [23], [24], [25], [26], programs define “competence” differently, creating inconsistent education and evaluation.
Much of the literature evaluating the education of physicians on the delivery of bad news is based on attitudes [13], [9], [27], [28]. Most publications report that trainees do feel more comfortable with delivering bad news after an educational intervention [27]. There are few studies, however, that evaluate the objective skill of trainees in the delivery of bad news and/or the effectiveness of an educational intervention to improve bad news delivery. A few studies demonstrate improvement in this skill after an educational intervention for oncology trainees [29], [30], [31] and family practice trainees [32], but there is little evidence in pediatric trainees. Residents have indicated less preparation and training in breaking bad news in the pediatric setting compared to adult patient encounters [11]. The objectives for this study were to evaluate the acquisition and retention of breaking bad news skills, specifically telling a parent or grandparent that a child has died, in pediatric residents after an educational intervention.
Section snippets
Trainee population
All first-year pediatrics and combined internal medicine/pediatrics residents at our institution, a free-standing tertiary care children's hospital, were invited to participate. There were no specific selection criteria, only availability and willingness to participate. Consent was obtained prior to baseline assessment. Institutional Review Board approval was obtained prior to standardized patient (SP) encounters.
Rationale for communication curriculum selected
The teaching intervention selected for this study was “The GRIEV_ING Death
Participation
Of 44 first-year residents (34 pediatrics, 10 medicine-pediatrics), 29 (27 pediatrics, 2 medicine-pediatrics) participated in all three phases of the study. No residents voluntarily declined, however limitations in availability due to clinical obligations prevented some residents from participating in one or more SP encounters.
Inter-rater reliability
Four raters independently assessed the pre-test SP encounters. The ICC 2,1 values, to evaluate inter-rater reliability of a randomly selected single rater, were 0.46 for
Discussion
This study demonstrated that first-year pediatric residents’ communication skills when notifying parents or grandparents of a child's death significantly improved following an educational intervention based on the GRIEV_ING Protocol. The residents maintained this performance improvement for 3 months. These results suggest this skill is teachable and retainable, and illustrate the need and value of increased education and development of this complex skill. Our results suggest it would be
Financial disclosure
The authors have no financial relationships relevant to this article to disclose.
Conflict of interest
The other authors have no conflicts of interest to disclose.
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