Are We Training Our Fellows Adequately in Delivering Bad News to Patients? A Survey of Hematology/Oncology Program Directors

Breaking bad news in oncology practice: experience and challenges of oncology health professionals in Ethiopia - an exploratory qualitative study

OBJECTIVE

To explore the experience and challenges health professionals face during breaking bad news (BBN) to patients with cancer in the oncology centre of Black Lion Specialized Hospital (BLSH), Addis Ababa, Ethiopia 2019.

DESIGN

An exploratory qualitative phenominological study using in-depth interviews was carried out in the only radiotherapy integrated oncology centre in Ethiopia during March 2019. Purposeful maximum variation sampling was used to select participants. OpenCode (V.4.02) assisted thematic analysis approach was employed to analyse the data.

PARTICIPANTS

Eleven oncology health practitioners (oncologists, residents and nurses) working at the oncology centre were interviewed. Repeated interviews and analysis were done until theoretical saturation.

RESULTS

All participants were cognisant of the positive outcome of proper and effective practice of BBN. However, they were practicing it empirically, no standardised protocols or guidelines were in place. Four dimensions of challenges were mentioned: (1) setup centric: unconducive environment, lack of protocols or guidelines, inaccessible treatment, and psychotherapy or counselling services; (2) health care centric, such as inadequate expertise, inadequate time due to patient load,treatment backlog, and referral system; (3) patients/family centric: poor medical literacy level, poor compliance, and family interference; and (4) sociocultural: wrong perception of families on BBN and treatment modalities, and opposition from religious leaders.

CONCLUSION

BBN is challenging for professionals caring for patients in the oncology centre of BLSH. Hence, there is a critical need to improve practices. Change efforts may focus on the development of contextualised, content and context specific practice oriented training programmes and curriculum interventions. Raising awareness of the community and religious leaders regarding the nature and treatment of cancer may also be a helpful adjunct.

Clinical Experience Is Not a Proxy for Competence: Comparing Fellow and Medical Student Performance in a Breaking Bad News Simulation-Based Mastery Learning Curriculum

BACKGROUND

It is unknown whether traditional medical education ensures competence among fellows in the key skill of breaking bad news (BBN). While simulation-based mastery learning (SBML) has been used to train fourth-year medical students (M4s) in BBN, it is unclear if it adds similar value for fellows.

OBJECTIVE

We examined the effect of traditional medical training on BBN skills by comparing baseline fellow and M4 skills and confidence and assessed the impact of a BBN SBML curriculum for fellows.

METHODS

Fellows training in six programs at Northwestern University from November 2018 to May 2019 were eligible for inclusion. Fellows completed a BBN SBML curriculum including a pretest, individualized feedback using a previously published assessment tool, and ongoing deliberate practice until all achieved a minimum passing standard (MPS). The primary outcomes were checklist and scaled item scores on the assessment tool. Fellow performance was compared to a historical M4 cohort.

RESULTS

Twenty-eight of 38 eligible fellows completed the curriculum and were included for analysis. Fellows reported significantly more experience and confidence in BBN compared to M4s, yet their pre-training performance was significantly worse on checklist (57.1% vs 65.0%, P = .02) and scaled items; only 4% reached the MPS. After training, fellow performance significantly improved on checklist (57.1% to 92.6%, SD = 5.2%, P < .001) and scaled items; all reached the MPS.

CONCLUSIONS

Despite higher confidence and BBN clinical experience, fellows performed worse than untrained M4s, confirming that experience is not a proxy for skill. Programs must develop competency-based assessments to ensure entrustment of communication skills.

The New Oncologic Diagnosis Discussion: Perspectives of Pediatric Oncologists

PURPOSE

We aimed to understand how new diagnosis discussions are conducted in pediatric oncology, and the training provided for their conduct.

METHODS

This mixed-methods study used a sequential exploratory design. Qualitative interviews (n = 20) were conducted with pediatric oncologists (n = 15) and fellows (n = 5) at a single institution, focusing on the process used to convey the diagnosis and treatment plan to the family. Accreditation Council for Graduate Medical Education-accredited pediatric oncology fellowship program directors (n = 38) and fellows (n = 70) were subsequently surveyed to confirm qualitative results and elucidate the training that fellows receive in conducting new diagnosis discussions.

RESULTS

Our findings suggest that new diagnosis discussions in pediatric oncology are typically conducted in three stages: (1) concern for cancer; (2) confirmation of diagnosis; and (3) treatment plan/consent, and are fundamentally similar across settings; however, pediatric oncologists skillfully tailor their approach on the basis of clinical circumstances and parental needs. Decisions regarding inclusion of the child are primarily determined by parental preference, whereas inclusion of health care team members is driven by physician role (ie, trainee v program director) and health care organization-related factors. Physician preparation for discussions involves logistical, intellectual, and emotional components. Disclosure of prognosis is nuanced. There is variability across pediatric oncology fellowship programs in the provision of training for these discussions.

CONCLUSION

We identified common practices of pediatric oncologists as they prepare for and lead new diagnosis discussions in pediatric oncology. We found variability in the training that pediatric oncology fellows receive regarding how to conduct these discussions, highlighting a need for standardized training curricula.

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.

Advice to Clinicians on Communication from Adolescents and Young Adults with Cancer and Parents of Children with Cancer

Effective communication is integral to patient and family-centered care in pediatric and adolescent and young adult (AYA) oncology and improving healthcare delivery and outcomes. There is limited knowledge about whether AYAs and parents have similar communication preferences and needs. By eliciting and comparing communication advice from AYAs and parents, we can identify salient guidance for how clinicians can better communicate. We performed secondary analysis of semi-structured interviews from 2 qualitative communication studies. In one study, 80 parents of children with cancer during treatment, survivorship, or bereavement were interviewed. In the second study, AYAs with cancer during treatment or survivorship were interviewed. We asked AYAs and parents to provide communication advice for oncology clinicians. Using thematic analysis, we identified categories of advice related to three overarching themes: interpersonal relationships, informational preferences, and delivery of treatment, resources, and medical care. AYAs and parents provided similar advice about the need for compassion, strong connections, hopefulness, commitment, and transparent honesty However, AYAs placed additional emphasis on clinicians maintaining a calm demeanor.

A biopsychosocial approach to death, dying, and bereavement: a course on end-of-life education for medical students

Background: Despite the inevitable nature of death and dying, the conversations surrounding this subject are still uncomfortable for many physicians and medical students. Methods: A six-week humanities-based course, "A Biopsychosocial Approach to Death, Dying, & Bereavement," at Cooper Medical School of Rowan University, United States, which covers definitions of death and dying, the process of dying, ethical dilemmas, and new concepts of the grieving process. Through development of a curriculum using various academic and medical literature and resources, we sought to bring attention to the necessity of having a medical education curriculum on death and dying to prepare medical students for the difficult conversations and patient experiences that lie ahead of them. Qualitative data in the form of surveys and reflection papers submitted by students and quantitative data (Likert scores on course satisfaction) were collected and analyzed both pre- and post-course. Results: 90.7% (49/54) of the respondents answered that they agree or strongly agree with the statement that this selective course was useful in the student's medical education experience. The top three qualitative themes brought up the most in reflection papers (n=54) were: the utility and instruction of the course (21 times), the importance of hospice and palliative care (20 times), avoidance around topics of death (15 times). Conclusions : Medical students are often not prepared to cope with the realities of patient loss and of caring for the patient and their families throughout the dying process. We created this course to familiarize medical students with an aspect of the medical experience that is frequently neglected in traditional medical curricula. We learned that integrating such a course can help educate medical students facilitate important conversations, teach them to act with kindness and dignity in a physician-patient setting, and enhance their personal understanding of death and dying.

A biopsychosocial approach to death, dying, and bereavement: a course on end-of-life education for medical students

Background: Despite the inevitable nature of death and dying, the conversations surrounding this subject are still uncomfortable for many physicians and medical students. Methods: A six-week humanities-based course, “A Biopsychosocial Approach to Death, Dying, & Bereavement,” at Cooper Medical School of Rowan University, United States, which covers definitions of death and dying, the process of dying, ethical dilemmas, and new concepts of the grieving process. Through development of a curriculum using various academic and medical literature and resources, we sought to bring attention to the necessity of having a medical education curriculum on death and dying to prepare medical students for the difficult conversations and patient experiences that lie ahead of them. Qualitative data in the form of surveys and reflection papers submitted by students and quantitative data (Likert scores on course satisfaction) were collected and analyzed both pre- and post-course. Results: 90.7% (49/54) of the respondents answered that they agree or strongly agree with the statement that this selective course was useful in the student’s medical education experience. The top three qualitative themes brought up the most in reflection papers (n=54) were: the utility and instruction of the course (21 times), the importance of hospice and palliative care (20 times), avoidance around topics of death (15 times). Conclusions: Medical students are often not prepared to cope with the realities of patient loss and of caring for the patient and their families throughout the dying process. We created this course to familiarize medical students with an aspect of the medical experience that is frequently neglected in traditional medical curricula. We learned that integrating such a course can help educate medical students facilitate important conversations, teach them to act with kindness and dignity in a physician-patient setting, and enhance their personal understanding of death and dying.

A biopsychosocial approach to death, dying, and bereavement: a course on end-of-life education for medical students

Background: Despite the inevitable nature of death and dying, the conversations surrounding this subject are still uncomfortable for many physicians and medical students. Methods: A six-week humanities-based course, “A Biopsychosocial Approach to Death, Dying, & Bereavement,” at Cooper Medical School of Rowan University, United States, which covers definitions of death and dying, the process of dying, ethical dilemmas, and new concepts of the grieving process. Through development of a curriculum using various academic and medical literature and resources, we sought to bring attention to the necessity of having a medical education curriculum on death and dying to prepare medical students for the difficult conversations and patient experiences that lie ahead of them. Qualitative data in the form of surveys and reflection papers submitted by students and quantitative data (Likert scores on course satisfaction) were collected and analyzed both pre- and post-course. Results: 90.7% (49/54) of the respondents answered that they agree or strongly agree with the statement that this selective course was useful in the student’s medical education experience. The top three qualitative themes brought up the most in reflection papers (n=50) were: the utility and instruction of the course (23 times), the importance of hospice and palliative care (23 times), and respecting patient autonomy (16 times). Conclusions: Medical students are often not prepared to cope with the realities of patient loss and of caring for the patient and their families throughout the dying process. We created this course to familiarize medical students with an aspect of the medical experience that is frequently neglected in traditional medical curricula. We learned that integrating such a course can help educate medical students facilitate important conversations, teach them to act with kindness and dignity in a physician-patient setting, and enhance their personal understanding of death and dying.

A biopsychosocial approach to death, dying, and bereavement: a course on end-of-life education for medical students

Background: Despite the inevitable nature of death and dying, the conversations surrounding this subject are still uncomfortable for many physicians and medical students. Methods: A six-week humanities-based course, “A Biopsychosocial Approach to Death, Dying, & Bereavement,” at Cooper Medical School of Rowan University, United States, which covers definitions of death and dying, the process of dying, ethical dilemmas, and new concepts of the grieving process. Through development of a curriculum using various academic and medical literature and resources, we sought to bring attention to the necessity of having a medical education curriculum on death and dying to prepare medical students for the difficult conversations and patient experiences that lie ahead of them. Qualitative data in the form of surveys and reflection papers submitted by students and quantitative data (Likert scores on course satisfaction) were collected and analyzed both pre- and post-course. Results: 90.7% (49/54) of the respondents answered that they agree or strongly agree with the statement that this selective course was useful in the student’s medical education experience. The top three qualitative themes brought up the most in reflection papers (n=50) were: the utility and instruction of the course (23 times), the importance of hospice and palliative care (23 times), and respecting patient autonomy (16 times). Conclusions: Medical students are often not prepared to cope with the realities of patient loss and of caring for the patient and their families throughout the dying process. We created this course to familiarize medical students with an aspect of the medical experience that is frequently neglected in traditional medical curricula. We learned that integrating such a course can help educate medical students facilitate important conversations, teach them to act with kindness and dignity in a physician-patient setting, and enhance their personal understanding of death and dying.

Improving communication with parents: the Neonatal Intensive Care Unit Empathy Workshop

OBJECTIVE

To implement an "Empathy Workshop" focused on improving Neonatal Intensive Care Unit (NICU) health care provider communication skills.

METHODS

Staff-led, small group "Empathy Workshops" were conducted over a 2 year period. NICU parents answered a section of the "Picker Institute Parent Experiences of Neonatal Care Survey" in the pre- and post-intervention periods. NICU health care providers completed the "NICU Provider Communication Skills Self-Assessment" at three time points.

RESULTS

Parent survey scores significantly improved in two questions: referring to child by first name (p = 0.02) and being offered emotional support from the staff (p = 0.03) or information on parent support groups (p = 0.03). Fifty-seven NICU providers completed all three self-assessments. Following the workshop, providers were significantly more comfortable with daily communication, discussing end of life issues, managing anxiety around difficult conversations, and handling a combative situation.

CONCLUSIONS

The "Empathy Workshop" successfully enhanced NICU provider communication skills, thereby improving emotional support demonstrated to NICU parents.

Objective Evaluation of a Simulation Course for Residents in the Pediatric Emergency Medicine Department: Breaking Bad News

INTRODUCTION

Breaking bad news (BBN), especially in the pediatric emergency medicine department, requires significant skill and delicacy due to the acute context of a busy emergency department (ED) and the lack of prior rapport with the patients and families. Pediatric literature on breaking bad news has mostly focused on pediatric oncology and pediatric critical care, with limited literature focused on pediatric emergency medicine. Review of the literature also reveals that most existing studies solely assess the learners' self-ratings of efficacy and comfort, and far fewer studies objectively evaluate learners' actual performance using simulation. Our objectives for this study was to use an objective assessment tool to assess residents' breaking bad news skills, pre- and post-simulation training, specifically in the setting of a pediatric emergency medicine department.

METHODS

34 residents were evaluated on their performance in breaking bad news via videotaped simulation encounters before and after teaching intervention. The "Modified Breaking Bad News Assessment Scale" (mBAS) was used as the assessment tool. A paired t-test analysis was conducted to examine the mean difference in pre- and post-simulation scores in each of the five mBAS domains.

RESULTS

Breaking bad news performance score improves one to two weeks post-intervention, and was statistically significant in three of five domains.

CONCLUSION

Our study shows that breaking bad news is a teachable skill that can be improved by simulated education in the pediatric emergency medicine department. This study demonstrates the utility of simulation course in improving breaking bad news skills in the pediatric emergency medicine department. Future work in developing focused simulation curriculums is important to improve provider communication skills and patient-physician relationships.

Are future medical oncologists sufficiently trained to communicate about palliative care? The medical oncology curriculum in Flanders, Belgium

BACKGROUND

Palliative care is considered an integral part of oncology and communicating this with patients is an unavoidable task for oncologists. This contribution investigated to what extent communication skills for communicating palliative care with patients are trained in the formal academic training program in medical oncology in Flanders, Belgium. The programme is based on the recommendations for a Global Core Curriculum in Medical Oncology, developed by The American Society of Clinical Oncology (ASCO) together with the European Society for Medical Oncology (ESMO).

METHODS

For this qualitative study, data were collected using document analysis from the ESMO/ASCO recommendations and the documents of the Flanders' medical oncology programme complemented with interviews with Flemish medical oncology trainees.

RESULTS

Few recommendations for training communication skills to communicate about palliative care were found in the ASMO/ASCO recommendations and even less in the Flanders' programme documents. Trainees are mainly exposed to palliative care communication during the clinical practice of their training. Only very few lectures or seminars are devoted to palliative care and even less on communication about palliative care. They reported several barriers to communicate about palliative care.

CONCLUSIONS

This study revealed promising developments for the training of Flemish medical oncologists to discuss palliative care. However, there is still a need for more theoretical training on palliative care complemented with communication skills trainings. Communication training in general needs to be fully integrated as a core skill within the medical curriculum at large and should be promoted as lifelong learning and competency development.

Post-fine-needle aspiration biopsy communication and the integrated and standardized cytopathology report

Communication between cytopathologists and patients and their care team is a critical component of accurate and timely patient management. The most important single means of communication for the cytopathologist is through the cytopathology report. Implementation of standardized terminology schemes and structured, templated reporting facilitates the ability of the cytopathologist to provide a comprehensive and integrated report. Cytopathology has been among the pathology subspecialties that have led the way in developing standardized reporting, beginning with the 1954 Papanicolaou classification scheme for cervical-vaginal cytology and continuing through the Bethesda systems for gynecological cytology and several nongynecological cytology systems. The effective reporting of cytopathology necessarily becomes more complex as it addresses increasingly sophisticated management options, requiring the integration of information from a broader range of sources. In addition to the complexity of information inputs, a wider spectrum of consumers of these reports is emerging, from patients themselves to primary care providers to subspecialized disease management experts. Both these factors require that the reporting cytopathologist provide the integration and interpretation necessary to translate diverse forms of information into meaningful and actionable reports that will inform the care team while enabling the patient to meaningfully participate in his or her own care. To achieve such broad and focused communications will require first the development of standardized and integrated reports and ultimately the involvement of cytopathologists in the development of the clinical informatics needed to treat all these items of information as structured data elements with flexible reporting operators to address the full range of patient and patient care needs. Cancer Cytopathol 2017;125(6 suppl):486-93. © 2017 American Cancer Society.

Doctors' Perceptions and Practices of Breaking Bad News: A Qualitative Study From Greece

There is limited information about doctors' communication behaviors and their salient beliefs with regard to bad news disclosure in Greece. In this qualitative study we investigated the self-reported practices of doctors on breaking bad news, their perceptions about the factors affecting the delivery of such news, and their beliefs about the most appropriate disclosure manner. A focus group discussion and individual interviews were conducted. Twenty-five resident and specialist doctors from primary health care and hospital settings participated. We analyzed the collected data with content analysis techniques. Participants were found to acknowledge the importance of appropriate and effective delivery of bad news; however, none of them reported the implementation of empirically informed communication practices. They described communication patterns mainly formed by their work experience and often guided by the patient's family requests. Doctor, patient, and family characteristics and organizational features and resources were reported to affect the delivery of bad news. Participants perceived the most appropriate disclosure manner as an individualized approach to each patient's unique needs. They suggested an interdisciplinary, collaborative management of the delivery process and the establishment of formal supportive services. These findings may provide useful information for the development of tailored, empirically informed curriculum interventions and educational programs in order to address several barriers to communication. Sociocultural characteristics that influence the disclosure practice, as well as physicians' perceptions that are consistent with the optimal information delivery, should be taken into account. System-level strategies that focus on the development of patient-centered communication also need to be prioritized.

Strategies and challenges for communicating the diagnosis of cancer in cross-cultural clinical settings-Perspectives from South African healthcare professionals

Communicating the diagnosis of cancer in cross-cultural clinical settings is a complex task. This qualitative research article describes the content and process of informing Zulu patients in South Africa of the diagnosis of cancer, using osteosarcoma as the index diagnosis. We used a descriptive research design with census sampling and focus group interviews. We used an iterative thematic data analysis process and Guba's model of trustworthiness to ensure scientific rigor. Our results reinforced the use of well-accepted strategies for communicating the diagnosis of cancer. In addition, new strategies emerged which may be useful in other cross-cultural settings. These strategies included using the stages of cancer to explain the disease and its progression and instilling hope using a multidisciplinary team care model. We identified several patients, professionals, and organizational factors that complicate cross-cultural communication. We conclude by recommending the development of protocols for communication in these cross-cultural clinical settings.

The P-A-C-I-E-N-T-E Protocol: An instrument for breaking bad news adapted to the Brazilian medical reality

Summary Objective: There are plenty of published tools for breaking bad medical news; however, none of them is culturally appropriate to our reality or published in the Brazilian literature. This study proposes a genuinely Brazilian communication tool and evaluates its acceptance among doctors and nurses. Method: This was a prospective study. The data were collected after specific training of doctors and nurses on the bad news communication techniques based on the P-A-C-I-E-N-T-E ("patient," in Portuguese) Protocol. This instrument is in accordance with the Brazilian reality and was based on the SPIKES communication tool. Results: The worst task to be performed during communication is "talking about death" followed by "discussing the end of curative treatment attempts" and "diagnosis" itself. Among the respondents, 48% reported they did not receive formal training for communicating. Also, 52% of respondents do not use any systematic approach in their daily practice when communicating with patients, but 97% considered the proposed P-A-C-I-E-N-T-E Protocol as a useful and appropriate communication tool. Conclusion: The P-A-C-I-E-N-T-E Protocol proved to be suitable to the Brazilian context.

Going straight to the source: A pilot study of bereaved parent-facilitated communication training for pediatric subspecialty fellows

BACKGROUND

Medical trainees consistently report suboptimal instruction and poor self-confidence in communication skills. Despite this deficit, few established training programs provide comprehensive, pediatric-specific communication education, particularly in the provision of "bad news." To our knowledge, no programs currently use bereaved parent educators to facilitate communication training for pediatric subspecialty trainees.

PROCEDURE

The authors designed and implemented a pilot communication training seminar in which bereaved parent educators and faculty facilitators led small groups in interactive, role-play scenarios. Surveys incorporating a retrospective preprogram assessment item to account for response-shift bias were used to assess short- and long-term changes in trainee comfort with delivering "bad news."

RESULTS

Fifteen pediatric fellowship trainees participated in the communication seminar; complete data were available for 12 participants. After accounting for response-shift bias, participants reported significant improvement in overall preparedness, breaking bad news to a patient and family, and including the adolescent or young adult patient in conversations. Additionally, participants reported a significant improvement in their ability to address a patient and family's need for information, emotional suffering at the end of life (EOL), if and when a patient should be included in the conversation, and EOL care decisions. The participant's self-perceived improvement in comfort and preparedness persisted over time.

CONCLUSIONS

Communication training for pediatric subspecialty trainees using bereaved parent educators is feasible and effective. Both medical trainee and bereaved parent participants benefited from involvement in this pilot study. Further iterations of this training will be modified to assess objective measures of improvement in trainees' communication skills.

Communication Skills Assessment Using Human Avatars: Piloting a Virtual World Objective Structured Clinical Examination

INTRODUCTION

Proficiency in communication skills is a core competency of residency training. We evaluated the feasibility, acceptability and applicability of a virtual world objective structured clinical examination that enables practice based learning and assessment of resident communication skills.

METHODS

A virtual clinical encounter situated in 2 practice settings was developed that uses a human avatar physician and a standardized patient. Following an online tutorial house staff participated in 4 communication tasks, including shared decision making, delivering bad news, obtaining informed consent and disclosing a medical error. Validated instruments and semistructured interviews were used to assess house staff acceptability and applicability of the platform. Three faculty members used ACS (Affective Competency Scale) and communication specific assessment instruments to evaluate house staff performance.

RESULTS

A total of 12 urology house staff completed the simulation. Direct costs were approximately $1,000. The virtual world was easy to use and immersive. Applicability directly correlated with presence (Pearson r = 0.67, p = 0.01) and co-presence (Pearson r = 0.8, p = 0.002). House staff identified problems with 1) limited nonverbal cues, 2) too much information presented and 3) a lack of immediate feedback. The ICC (intraclass correlation) of faculty assessments was high for ACS at 0.53 (95% CI 0.36-0.69) for single measures, 0.77 (95% CI 0.63-0.86) for average measures and less for other assessment instruments.

CONCLUSIONS

A virtual world objective structured clinical examination is a feasible, acceptable and applicable method of communication skills assessment. Improving nonverbal cues, focusing on individual skill sets and providing immediate feedback are measures to be adopted in future iterations of this platform.

Standardized Patient Training Programs: an Efficient Solution to the Call for Quality Improvement in Oncologist Communication Skills

Several key medical and oncologic professional societies have endorsed the importance of physician communication as a quality improvement metric. Despite this clear message, there remain substantial barriers to communication skills training (CST) in oncologic specialties. Herein, we describe the major barriers to communications training and propose standardized patient (SP) programs as efficient and strategic starting points and as expansion opportunities for new and existing CSTs.

Palliative Care Training in Surgical Oncology and Hepatobiliary Fellowships: A National Survey of Program Directors

BACKGROUND

Despite previous literature affirming the importance of palliative care training in surgery, there is scarce literature about the readiness of Surgical Oncology and hepatopancreaticobiliary (HPB) fellows to provide such care. We performed the first nationally representative study of surgical fellowship program directors' assessment of palliative care education. The aim was to capture attitudes about the perception of palliative care and disparity between technical/clinical education and palliative care training.

METHODS

A survey originally used to assess surgical oncology and HPB surgery fellows' training in palliative care, was modified and sent to Program Directors of respective fellowships. The final survey consisted of 22 items and was completed online.

RESULTS

Surveys were completed by 28 fellowship programs (70 % response rate). Only 60 % offered any formal teaching in pain management, delivering bad news or discussion about prognosis. Fifty-eight percent offered formal training in basic communication skills and 43 % training in conducting family conferences. Resources were available, with 100 % of the programs having a palliative care consultation service, 42 % having a faculty member with recognized clinical interest/expertise in palliative care, and 35 % having a faculty member board-certified in Hospice and Palliative Medicine.

CONCLUSIONS

Our data shows HPB and surgical oncology fellowship programs are providing insufficient education and assessment in palliative care. This is not due to a shortage of faculty, palliative care resources, or teaching opportunities. Greater focus one valuation and development of strategies for teaching palliative care in surgical fellowships are needed.

Breaking bad news is a teachable skill in pediatric residents: A feasibility study of an educational intervention

OBJECTIVE

Patients and physicians identify communication of bad news as a skill in need of improvement. Our objectives were to measure change in performance of first-year pediatric residents in the delivery of bad news after an educational intervention and to measure if changes in performance were sustained over time.

METHODS

Communication skills of 29 residents were assessed via videotaped standardized patient (SP) encounters at 3 time points: baseline, immediately post-intervention, and 3 months post-intervention. Educational intervention used was the previously published "GRIEV_ING Death Notification Protocol."

RESULTS

The intraclass correlation coefficient demonstrated substantial inter-rater agreement with the assessment tool. Performance scores significantly improved from baseline to immediate post-intervention. Performance at 3 months post-intervention showed no change in two subscales and small improvement in one subscale.

CONCLUSIONS

We concluded that breaking bad news is a complex and teachable skill that can be developed in pediatric residents. Improvement was sustained over time, indicating the utility of this educational intervention.

PRACTICE IMPLICATIONS

This study brings attention to the need for improved communication training, and the feasibility of an education intervention in a large training program. Further work in development of comprehensive communication curricula is necessary in pediatric graduate medical education programs.

Enhancing the Empathic Connection: Using Action Methods to Understand Conflicts in End-of-Life Care

Empathy is a core feature of patient-centered care. It enables practitioners to better understand the patient and family concerns that are key to patient and family satisfaction, prevention of anxiety and depression, and provider empowerment. Current methods of teaching communication skills do not specifically focus on enhancing the ability to "stand in the patient's shoes" as a way of connecting with the patient and/or family experience and understanding feelings that may be a source of conflict with providers. In this paper, we present a model for deepening empathic understanding based upon action methods (role-reversal and doubling) derived from psychodrama and sociodrama. We describe these techniques and illustrate how they can be used to identify hidden emotions and attitudes and reveal that which the patient and family member may be thinking or feeling but be afraid to say. Finally, we present data showing that these methods were valuable to participants in enhancing their professional experience and skills.

A Structured End-of-Life Curriculum for Neonatal-Perinatal Postdoctoral Fellows

Death in tertiary care neonatal intensive care units is a common occurrence. Despite recent advances in pediatric palliative education, evidence indicates that physicians are poorly prepared to care for dying infants and their families. Numerous organizations recommend increased training in palliative and end-of-life care for pediatric physicians. The purpose of this study is to develop a structured end-of-life curriculum for neonatal-perinatal postdoctoral fellows based on previously established principles and curricular guidelines on end-of-life care in the pediatric setting. Results demonstrate statistically significant curriculum effectiveness in increasing fellow knowledge regarding patient qualification for comfort care and withdrawal of support (P = .03). Although not statistically significant, results suggest the curriculum may have improved fellows' knowledge of appropriate end-of-life medical management, comfort with addressing the family, and patient pain assessment and control.

Delivering bad news to a patient: a survey of residents and fellows on attitude and awareness

PURPOSE

Delivering bad news (DBN) to a patient or patient's family is one of the most difficult tasks for physicians. As a complicated task, DBN requires better than average communication skills. This study investigated trainee's attitude and awareness of DBN based on a self-assessment of their experiences and performance in practice. Survey subjects were also asked to assess their perception and the need for education in conducting DBN.

METHODS

A survey was carried out on their experiences with DBN, how they currently deal such situations, how they perceive such situations and the need for education and training programs. A SPIKES protocol was used to assess how they currently deal with DBN.

RESULTS

One hundred one residents and fellows being trained in a teaching hospital participated in the survey. Around 30% had bad experiences due to improperly delivered bad news to a patient. In terms of self-assessment of how to do DBN, over 80% of trainees assessed that they were doing DBN properly to patients, using a SPIKE protocol. As for how they perceived DBN, 90% of trainees felt more than the average level of stress when they do DBN. About 80% of trainees believed that education and training is much needed during their residency program for adequate skill development regarding DBN.

CONCLUSION

We suggest that education and training on DBN may be needed for trainees during the residency program, so that they could avoid unnecessary conflict with patients and reduce stress from DBN.

Applying sociodramatic methods in teaching transition to palliative care

We introduce the technique of sociodrama, describe its key components, and illustrate how this simulation method was applied in a workshop format to address the challenge of discussing transition to palliative care. We describe how warm-up exercises prepared 15 learners who provide direct clinical care to patients with cancer for a dramatic portrayal of this dilemma. We then show how small-group brainstorming led to the creation of a challenging scenario wherein highly optimistic family members of a 20-year-old young man with terminal acute lymphocytic leukemia responded to information about the lack of further anticancer treatment with anger and blame toward the staff. We illustrate how the facilitators, using sociodramatic techniques of doubling and role reversal, helped learners to understand and articulate the hidden feelings of fear and loss behind the family's emotional reactions. By modeling effective communication skills, the facilitators demonstrated how key communication skills, such as empathic responses to anger and blame and using "wish" statements, could transform the conversation from one of conflict to one of problem solving with the family. We also describe how we set up practice dyads to give the learners an opportunity to try out new skills with each other. An evaluation of the workshop and similar workshops we conducted is presented.

Identifying and acquiring the contextual skills and knowledge for nursing practice in assisted reproductive technology: a grounded theory study

AIMS AND OBJECTIVES

To identify the contextual knowledge and skills required for practice.

BACKGROUND

Nursing practice in assisted reproductive technology (ART) makes a significant contribution to patient care. Despite this, the knowledge and skills integral to this area of practice have not been clearly articulated, particularly from an Australian perspective.

DESIGN

A constructivist grounded theory design was used to gain the perspective of ART nurses in relation to how they understood their clinical practice as well as the issues and challenges that they faced.

METHODS

Individual in-depth interviews were undertaken with 15 registered nurses working in ART units across Australia. Constant comparative data analysis was used to determine the main categories.

RESULTS

Contextual knowledge and skills was one category to emerge from this research, and this is the focus of this paper. The findings in respect of knowledge and skill included three main subcategories: required skills and knowledge; acquisition of skills and knowledge; and factors influencing acquisition.

CONCLUSIONS

The role of the ART nurse which must be performed within the context and competency standards of nursing requires a framework that could define and contribute to specialised ART nursing practice standards.

RELEVANCE TO CLINICAL PRACTICE

The nursing role is instrumental to effective ART treatment and care. The standard of clinical practice will depend in part on the ability of specialist nurses to articulate their practice, and their professional development needs to optimise quality and effectiveness. The results of this study demonstrate that contextual knowledge and skills are a key aspect of this specialised nursing role.

Breaking bad news in a Southeast European population: a survey among cancer patients in Albania

OBJECTIVE

The purpose of this study was to explore the attitudes of cancer patients, their family, and community members in Albania, a post-communist country in Southeast Europe, regarding breaking bad news.

METHODS

One hundred and fifty consecutive cancer patients, 150 respective relatives, and an age-sex-residence matched sample of 150 individuals in Tirana district were interviewed from September 2009-January 2010 about attitudes related to diagnosis disclosure. Logistic regression was used to assess the association of diagnosis disclosure with demographic characteristics.

RESULTS

Community members were the most in favor, whereas the patients' relatives were the least in favor of diagnosis disclosure. Most of the patients, who were aware of their diagnosis, were not satisfied with the disclosure approach employed by the medical staff. The odds of favoring diagnosis disclosure were significantly higher among younger, male, urban, and more educated patients.

CONCLUSION

This survey identified important characteristics of cancer patients, their relatives, and a community-based sample in Albania that could predict the willingness to disclose a fatal diagnosis. Establishment of a formal training of health professionals regarding breaking bad news should be considered in order to ensure a proper approach of communicating diagnosis to cancer patients in transitional Albania.

Using sociodrama and psychodrama to teach communication in end-of-life care

End-of-life discussions can be stressful and can elicit strong emotions in the provider as well as the patient and family. In palliative care, understanding and effectively addressing emotions is a key skill that can enhance professional competency and patient/family satisfaction with care. We illustrate how in coursework for a Master's degree in palliative medicine we used dramatic "action methods" derived from sociodrama and psychodrama in the portrayal of two challenging cases to train providers in the emotional aspects of caring for patients with advanced cancer. We describe the specific techniques of constructing and enacting case scenarios using warm-ups, role-creation, doubling and role-reversal. In particular, we illustrate how these techniques and others were used to reveal and address the "hidden" emotions, attitudes, and values that were central to the communication dilemma. Finally, we present an evaluation completed by the 26 participants who attended the course.

How Tolstoy and Solzhenitsyn Define Life and Death in Cancer

Reason for the study:

Clinicians use conserving care in their therapeutic decisions. Discussing death as part of the treatment influences patient’s perception and their acceptance of death. We compare 2 literary patients’ perceptions of cancer and death (Solzhenitsyn’s Cancer Ward and Tolstoy’s The Death of Ivan Ilyich), with a contemporary patient perception.

Results:

The patient interview revealed naive cancer perceptions: every treatment option should be tried. In Solzhenitsyn’s novel, the main character finds a goal in love; Tolstoy conceptualizes death as a solution for patients’ moral issues.

Conclusions:

Tolstoy’s novel shows death as an honest prospect. Solzhenitsyn’s novel shows the opposite: the prospect of love and life helps the protagonist patient psychologically through his disease. The patient interview revealed no discussion of death at all.

Training oncology practitioners in communication skills

Many practitioners in oncology receive no or little training in how to effectively communicate with patients and families who are dealing with cancer. Moreover medical teachers are not always aware of the pedagogy of teaching communication skills in a way that results in performance improvement in this area. In this paper a method of small group teaching that was used to instruct medical oncology fellows in the essentials of communication using a retreat format that lasted three days is described. The paper covers the theoretical basis for the teaching format as well as the specific components of the workshops. It describes the process of facilitation using a "learner-centered" approach using standardized patients who take on the role of cancer patients along the trajectory of the illness. It discuss the use of small group process to facilitate skills acquisition and other strategies that facilitate learning such as reflective exercises, open role play and parallel process. It concludes with a consideration of the various ways that such workshops can be evaluated.

Provision of bereavement care in neonatal units in the United Kingdom

OBJECTIVE

To establish what bereavement care services are available in neonatal units in the United Kingdom and to establish the availability to staff (doctors, nurses, and chaplains) of bereavement education, training, communication, and multicultural support. For families who lose a baby in the neonatal period, the support they receive from hospital staff can be pivotal in their ability to cope with their grief. Hospital staff are not always trained to provide this support. Limited evidence is available regarding hospital-based bereavement care in neonatology or its impact on outcome.

INTERVENTIONS

Questionnaire survey of selected doctors, nurses, and chaplains in 200 neonatal units in the United Kingdom.

MEASUREMENTS AND MAIN RESULTS

We had responses from 100% of neonatal units surveyed. Of 600 individuals, 320 responded; 11% of doctors had never received any formal training in bereavement care, compared with 0.8% of nurses and 1.2% and chaplains. In addition, 31% of respondents thought the training they received was inadequate. Knowledge of grief theorists was poor. Up to 99% of units were helping parents create memories through photographs or handprints. Parents were uniformly given the chance to be with their baby at the time of death (99% overall). Siblings were encouraged to be present 71% of the time; 75% of respondents felt that information about the needs of different faith groups was available. Formal psychological support was offered to 45% of families after bereavement.

CONCLUSIONS

Studies have shown that parents value clear communication, education about grieving, and demonstrated emotional support by staff. Our study has shown that there are deficiencies in staff training and education in this area. Educators must promote the inclusion of content on bereavement/end-of-life care. Additional education on cultural issues would be helpful. Managing the bereavement process well to minimize morbidity for families and healthcare providers is an important challenge for the future.