Telling the patient and the family the bad news -- it's a daunting first-time experience for physicians and a staple of television medical dramas frequently portrayed as "There's a first time for everything. Just get out there and do it." But in real life, how do medical/health professionals learn to communicate a less than positive diagnosis or prognosis of an illness or -- even worse -- the death of a loved one?
Two papers published in the August issue of Simulation in Healthcare: the Journal of the Society for Simulation in Healthcare, explore recent studies in "real life" teaching approaches that seek to improve the necessary communications skills in breaking bad news.
In "Evaluation of the Impact of a Simulation-Enhanced Breaking Bad News Workshop in Pediatrics," medical educators report on a simulation-based training that, according to the ratings of participating pediatric residents, produced a 100% improvement in their communication skills. Most importantly, when evaluating the residents' post-workshop skills, parents who had previously received "bad news" and experts [a physician and bereavement social worker] reported improvement in 14 of 17 of the communications skills measured. Authors Kathleen Tobler, M.D., Estee Grant, M.D., and Cecile Marczinkski, PhD of Alberta Children's Hospital in Alberta, Canada, developed their simulation-based workshop -- which featured teaching scenarios with actors, observations, and debriefings -- because "the way news is communicated is highly memorable and has a significant impact on a family's coping and experience going forward." They also observed that "physicians consistently identify a desire and need for further education" in developing these communications skills.
The second article, "Teaching Communications Skills -- Using Action Methods to Enhance Role-Play in Problem-Based Learning," illustrates the use of structured techniques, including "action methods" brought from psychodrama and sociodrama. Authors Walter Baile, M.D. and Adam Blatner, M.D. at the University of Texas MD Anderson Cancer Center in Houston, TX, found such methods, including role-creation, doubling, role-reversal, group-processing, and role-training, can substantially enhance the effectiveness of role-play to teach communication skills for challenging conversations. A particularly effective method in creating empathy and group involvement is "doubling," where participants watching a role-play are invited to stand behind the chair occupied by the learner playing a character, imagine what the learner might be feeling or thinking, and speak their thoughts in the first person as if they were a voice-over or the learner's "alter-ego." The authors found this technique and the others they used can also reveal important unspoken thoughts and emotions. Attending to hidden feelings and thoughts and using self-reflection to anchor new learning can, for example, "raise awareness of how a doctor's own anxiety can lead them to avoid end-of-life discussions with patients and families or to be overly optimistic about available treatments."
The journal's founding and current editor-in-chief, David Gaba, M.D. of Stanford University School of Medicine and the Veterans' Administration Palo Alto Health Care System, notes that "people often think about simulation in terms of teaching the clinical and technical skills in healthcare, but it is increasingly being used to teach a variety of non-technical skills." He added that "these papers delve into the important skills of communication, whether with patients, families, or co-workers. I chose the first paper on bad news disclosure in pediatrics because it provides actual data on the impact of such training, and in a particularly challenging task; the second because it introduces "action methods" -- from psychodrama and socoiodrama -- that are new to the simulation community. While many of us use role-play in our simulation teaching, the additional techniques presented in these papers may greatly enhance our work."
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