VOLUME 24

NUMBER 31

NOVEMBER 1 2006

JOURNAL OF CLINICAL ONCOLOGY

T H E

A R T

O F

O N C O L O G Y:

When the Tumor Is Not the Target

Breaking Bad News: Learning Through Experience

Stephanie J. Arnold and Bogda Koczwara
From the Orange Base Hospital, New South Wales; and the Flinders Medical Centre, Adelaide, Australia. Submitted August 7, 2006; accepted August 25, 2006. Presented in part at the Cancer Council of Australia Medical Student Competition on Cancer Education for the 21st Century Opportunities and Challenges. April 2005, Sydney, Australia. Authors disclosures of potential conicts of interest are found at the end of this article. Address reprint requests to Bogda Koczwara, MD, Department of Medical Oncology, Flinders Medical Centre, Flinders Dr, Bedford Park, SA, Australia 5042; e-mail: Bogda.koczwara@ inders.edu.au. 2006 by American Society of Clinical Oncology 0732-183X/06/2431-5098/$20.00 DOI: 10.1200/JCO.2006.08.6355

INTRODUCTION

WHY IS BREAKING BAD NEWS SO DIFFICULT?

She sits in bed, propped up by two pillows, wearing a white hospital gown, staring out of the window. Her ngers pick at somethingis it a tissue? listlessly, distractedly. Ive been told to see her and get a history. Im nervousshe doesnt look well and certainly is in no cheerful mood to talk. But I do as Im told, and approach her with a smile: Hello, Im a medical student; do you mind chatting to me about why youre in the hospital? She turns and wearily looks me up and down was my cheerfulness too forced? Oh, I suppose so, if you must. Not much else for me to do, is there? So I pull up a chair and we get started. Dianne tells me that she noticed a lump on her neck some weeks ago, and dismissed it at rst, thinking, must have knocked myself on something, but when it didnt go away, she visited her local doctor. Before she knew it, he ordered some tests, and had her admitted to the hospital overnight for a lymph node biopsy. And here she wasit was midmorninganxiously awaiting her test results. They said it could be lymphoma, she told me, which is a death sentence, isnt it? My friends mother had a blood cancer a couple of years ago, and it was horribleall her hair fell out, she was so sick. Those last few months. . .she was in so much pain. And then she burst into tears. Im going to die of cancer, Dianne sobbed, Im so young, I have two children. What is my husband going to do? And what about workI cant afford to take time off! Desperately, I offered up the box of tissues by her bed wanting to get out of the room and feeling completely helpless. Time out! Lets leave it there for a minute. Tell me, Dianne, how are you feeling? Our moderator cut in. And you, Stephanie, what do you think about the way you approached this patient? I was in a simulation. Dianne no longer had a lump and had wiped away her tears, revealing the actor beneath. I felt blocked, said the actor. Your offering me a tissue was an indication that you didnt want to listen to my problems, you just wanted me to stop crying! I agreed, but for different reasonsI had no idea how to help a very distressed patient deal with terribly bad news and was actually very upset myself.

Breaking bad news and communicating with distressed patients are some of the most important yet challenging tasks required of the medical profession. The benets of good communication skills are well known. Evidence shows that patients who rate highly their doctors communication style have increased cancer-related self-efcacy and reduced emotional distress.1 Aside from patient satisfaction, the quality of doctor-patient communication can inuence compliance and reduce the risk of a malpractice claim.2 Accounts of patients distressed by the insensitive delivery of bad news are regrettably all too familiar.3 Communicating with distressed patients can be difcult. Doctors suffer signicant stress when faced with the task of breaking bad news.4 They often react emotionally to the patients distress and may feel guilt and a sense of failure for not fullling the patients expectations.5 Increasing advances of technology and modern medicine can create an erroneous perception of infallibility of the medical profession leading to unrealistic expectations by society and within the profession itself.6 Such unrealistic expectations, compounded by poor communication skills, can lead to physician burnout and stress.7 Even in the setting of realistic expectations, breaking bad news is never easy. Perhaps, one of the reasons is in the nameit is bad news that clinicians deal with and dealing with human tragedy is never easy, irrespective of how skilled one may be. The natural response to human tragedy is sadness and compassion. As the connection between the doctor and a patient grows stronger, so does the emotional connection. Perhaps, breaking bad news can never be easyperhaps it shouldnt be easy.
IS BREAKING BAD NEWS AN ACQUIRED SKILL?

Traditionally, communication skills for doctors were taught in an informal way, on ward rounds and through observation of more experienced clinicians. In a survey from 1998, the American Society of

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The Art of Oncology: When the Tumor Is Not the Target

Clinical Oncology attendees showed that only 6% of physicians have received any formal training in delivering bad news.8 More importantly, the majority ranked their ability to discuss bad news with their patients as poor to fair.8 Data show that communication skills do not necessarily improve with years of medical practice alone.9 In recent years a variety of resources have emerged highlighting the importance of communication skills training for cancer professionals, but the evidence for the efcacy of various strategies remains limited. The strongest evidence comes from randomized clinical trials of communication skills training that offered face-to-face learning involving communication with the patient or simulated patient, coupled with opportunities to practice skills and receive feedback in a learner focused environment.10-12 Research shows that communication is a skill that can be learned.13 Like anatomy and physiology, the principles of communication skills can be delivered through didactic means such as tutorials and lectures, textbooks, and other aides, like CD-ROMS and web sites. However, unlike basic clinical science, communication skills may require learning on another, more cognitive and behavioral, level (Table 1). The skills of good communication need rening and practicing through experience. Practicing communication skills in a structured setting allows for feedback from the object of the communication that cannot be achieved through a didactic session. This is especially so when it comes to highly emotive areas of communication, where nuances of verbal and nonverbal communication are important; in such areas, feedback can only be obtained through practice with a live human being. Few, if any, books, videos, or CD-ROMS have the emotional impact required to teach students how to communicate appropriately with distressed patients. While observing a senior clinician communicating with a distressed patient may be feasible for some, such encounters, aside from intruding on the intimacy of the distressing experience for the patient, cannot be directly experienced or repeated for further improvement. In a simulation, a scenario can be repeated as necessary, interrupted, or modied to provide an opportunity to practice different techniques in a nonconfrontational setting.14 The student receives real-time feedback on her performance from her peers, the facilitator, and, most importantly, the patient. Actors can assume a variety of roles to suit the teaching session, such as being angry, tearful, or in denial. This broadens the experience for participants, who can then adjust their communication techniques to suit different circumstances. Many doctors can easily recall the sense of terror when asked to participate in a role play; they nd the scrutiny of the rest of the group

confronting, and performing in front of their peers frightening and embarrassing.15 They also feel nervous about how they will react emotionally to an upset patient. Clinicians are often not used to receiving feedback in front of their peersan experience often more stressful for those who have been in clinical practice for a long time. And, nally, because breaking bad news is intrinsically distressing, being watched by others can aggravate a sense of vulnerability for the clinician who is already upset by the difcult conversation. Despite these anxieties and the initial skepticism, feedback from participants in role play education is usually positive.16 The challenge is to overcome the initial reluctance of participants.
IS IT TIME TO FOLLOW MEDICAL SCHOOLS?

Given the reluctance of more senior clinicians to engage in role play, training medical students in developing appropriate communication skills may be the answer. Many medical schools have embraced principles of experiential learning and are introducing communication skills training to the curriculum of their students and junior doctors.17-19 Starting early makes sensestudents are taught an important skill at the time when they are most receptive to knowledge and when they are least embarrassed by the trials of role play. But leaving communication skills training to medical students alone leaves unaddressed the issue of a large number of practicing clinicians today who have never received training in communication skills and who may never develop such skills now that their medical training is over.20 Is it time to follow medical schools and offer comprehensive communication training programs for fellows and practicing clinicians? In the US, communication skills workshops are now available at selected programs.16 In Australia, attendance at a communication skills workshop is now mandatory for all advanced trainees in medical oncology, and a regular workshop is run at the annual meeting of the Medical Oncology Group of Australia. The workshop also provides an opportunity for refresher training for practicing oncologists. Incentives from medical indemnity programs may further motivate practicing clinicians to refresh their skills. After all, dealing with a simulated patient is a better opportunity to practice, rehearse, and rene ones skills than when dealing with a real person struggling to cope with devastating news. Like any other skill, breaking bad news can be practiced to make easier an experience that is never easy.
EPILOGUE

Table 1. Suggested Elements of Effective Communication Skills Training Element Learner centered Experiential Skill focused Participatory Practice based Action Learning objectives are shaped by the learning needs of participants Drawing on and relevant to the previous experience of participants Designed to practice and rene a skill rather than knowledge alone Involving participation and face-to-face contact Allowing repetition of a skill and modication of approach involving feedback

I step outside for a moment, take some deep breaths and compose myself. Once again I approach Dianne and once again she is upset, teary, inconsolable. However, things go better this time: she cries, I hold her hand, we talk about her kids and her husband, her expectations, and her hopes. As I thank Dianne, she gives me a tearful smile, but this time the tears do not feel as frightening.
REFERENCES
1. Zachariae R, Pedersen CG, Jensen AB, et al: Association of perceived physician communication style with patient satisfaction, cancer-related selfefcacy, and perceived control over the disease. Br J Cancer 88:658-665, 2003 5099

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Arnold and Koczwara

2. Levinson W, Roter DL, Mullooly JP, et al: Physician-patient communication: The relationship with malpractice claims among primary care physicians and surgeons. JAMA 277:553-559, 1997 3. Dias L, Chabner BA, Lynch TJ, et al: Breaking bad news: A patients perspective. Oncologist 8:587-596, 2003 4. Faulkner A: Communication with patients, families and other professionals. BMJ 316:130-132, 1998 5. Baile WF, Kudelka AP, Beale EA, et al: Communication skills training in oncology. Cancer 86:887-897, 1999 6. Quill TE, Suchman AL: Uncertainty and control: Learning to live with medicines limitations. Humane Medicine 9:109-120, 1993 7. Armstrong J, Holland J: Surviving the stresses of clinical oncology by improving communication. Oncology 18:363-368, 2004 8. Kramer P: Doctors discuss how to break bad news. ASCO Daily News 1:8-9, 1998 9. Cantwell BM, Ramirez AJ: Doctor patient communication: A study of junior house ofcers. Med Educ 31:17-21, 1997 10. Falloweld L, Jenkins V, Farewell V, et al: Efcacy of Cancer Res UK communication skills training model for oncologists: A randomized controlled study. Lancet 359:650-656, 2002 11. Razavi D, Delvaux N, Marchal S, et al: The effects of a 24-h psychological training program on attitudes, communication skills and occupational stressing oncology: A randomized study. Eur J Cancer 29A:1858-1863, 1993

12. Razavi D, Delvaux N, Marchal S, et al: Does training increase the use of more emotionally laden words by nurses when talking with cancer patients? A randomized study. Br J Cancer 87:1-7, 2002 13. Fellowes D, Wilkinson S, Moore P: Communication skills training for health care professionals working with cancer patients, their families and/or careers. The Cochrane Library, Issue 3, Indianapolis, IN, John Wiley & Sons Ltd, 2006 14. Wakeeld A, Cooke S, Boggis C: Learning together: Use of simulated patients with nursing and medical students for breaking bad news. Int J Palliat Nurs 9:32-38, 2003 15. Joyner B, Young L: Teaching medical students using role play: Twelve tips for successful role plays. Med Teach 28:225-229, 2006 16. Back AL, Arnold RM, Tulsky JA, et al: Teaching communication skills to medical oncology fellows. J Clin Oncol 21:2433-2436, 2003 17. Kalet A, Pugnaire MP, Cole-Kelly K, et al: Teaching communication in clinical clerkships: Models from the Macy initiative in health communications. Acad Med 79:511-520, 2004 18. Wagner PJ, Lentz L, Heslop SD: Teaching communication skills: A skillsbased approach. Acad Med 77:1164, 2002 19. Scalliet P, Etienne AM: Teaching communication and stress management skills to junior physicians dealing with cancer patients: A Belgian Interuniversity Curriculum. Supp Care Cancer 14:454-461, 2006 20. Walker LG: Communication skills: When, not if to teach. Eur J Ca 32A:1457-1459, 1996

Authors Disclosures of Potential Conicts of Interest

The authors indicated no potential conicts of interest.

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