Psycho-Oncology Psycho-Oncology 19: 975981 (2010) Published online 13 November 2009 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.

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Videotaped simulated interviews to improve medical students skills in disclosing a diagnosis of cancer
lique Bonnaud-Antignac1,2, Lo phane Supiot1,5 Ange c Campion3,4, Pierre Pottier1 and Ste
1 2

University of Nantes, Faculty of Medicine, Nantes, France CHU Nantes, Department of Medical Oncology, Nantes-St-Herblain, France 3 Department of Statistics (LC), Nantes-St-Herblain, France 4 rologie Nantes-Angers, CHU Nantes, Nantes, France INSERM U892, Centre de Recherche en Cance 5 Gauducheau, Department of Radiation Oncology, Nantes-St-Herblain, France Centre Rene * Correspondence to: Service rapie, Centre de Radiothe Gauducheau, 44800 Rene Nantes St-Herblain, France. E-mail: s-supiot@nantes. fnclcc.fr

Abstract
Objective: To assess the performance of the training course on the disclosure of a diagnosis of cancer intended for fth year medical students of the University of Nantes. Methods: The course comprised three sessions: (1) a group discussion that taught a six-point protocol (SPIKES) for delivering a diagnosis, (2) a videotaped simulated interview to assess protocol implementation and communication skills, and (3) feedback from a senior physician. The learning objectives were memorisation and implementation of the protocol, use of appropriate communication techniques to deal with the patients response, and identifying ones own reactions in a stressful situation. Two types of assessments were performed before and after each session: self-assessments by the students and a quantitative and qualitative external assessment by a psychologist and senior physician. In addition, recall of the six-point protocol was assessed during the end-of-the-year examination. Results: Overall, 108 students took part in the course during the 20042005 academic year. They felt that their competence improved after each session in terms of the three learning objectives. However, recall of the six-point protocol was inadequate. It was best among students who considered they had progressed most. Conclusions: Our training course on communication techniques helps students acquire condence in their skills in breaking bad news by backing theory with practice and feedback. The students make progress despite the psychological stress generated by simulated real-life conditions. Copyright r 2009 John Wiley & Sons, Ltd.
Keywords: cancer; diagnosis; medical students; simulated interviews; feedback; oncology

Received: 5 January 2009 Revised: 14 September 2009 Accepted: 14 September 2009

Introduction
A doctors disclosure of a diagnosis of cancer should occur within the context of a good patientdoctor relationship. However, despite the eorts made by both patients and doctors, the communication process can fall short of expectations (reviewed in [1]). The bearer of the bad news is usually a general practitioner or a consultant organ physician rather than an oncologist. For these doctors who do not often manage cancer patients, and in particular, for the youngest amongst them, a disclosure of cancer or of a cancer-related complication may be a dicult challenge. A general framework for breaking bad news has been proposed by the World Health Organization (WHO). It stipulates that the amount and type of information delivered should meet the individual patients expectations [2]. Both patients and medical students prefer such a patient-centred approach to non-disclosure or full disclosure [3,4].

Over the years, however, the part devolved to humanities (patients views and aective components) and communication techniques in medical school curricula has been increasingly overpowered by biomedical subjects, despite eorts to draw attention to the communication aspects of medical studies [58]. Available studies show that several sessions, accompanied by demonstrations, discussions, practice, and feedback, are needed to teach skills for delivering bad news (reviewed in [9]). For these reasons, the Faculty of Medicine of Nantes University (France) decided to oer a course on how to disclose a diagnosis of cancer to preresidency medical students in order that they might acquire the communication skills needed on the wards [10]. A pilot study on a planned training course was undertaken during the academic year 2003-2004 [11]. Its aims were to teach students the theory needed to cope with real-life situations and to enhance their understanding of the psychological

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dimensions of these situations. Because medical studies are based on both theory and practical training, the course comprised three dierent types of session: (1) a group discussion on communication techniques that introduced the well-known sixpoint Buckman protocol for breaking bad news [12], (2) a videotaped simulated interview to assess the students ability to implement this protocol as well as their communication skills, and (3) feedback on the students performance from a psychologist and senior physician. Simulated interviews are a valid method for judging how a physician might perform on the ward and a more ethical approach than plunging novices directly into reallife situations [1317]. As our pilot study had demonstrated the feasibility of our training course and its utility in helping students memorise the six-point protocol [11], we decided the following academic year to extend the course to all medical students during their mandatory clerkship in an oncology department. We hypothesized that each of the three sessions would improve the students condence and competence in breaking bad news and help them memorise the six-point protocol. We, thus, assessed the performance of each individual session and analysed the students knowledge of breaking bad news at the end-of-the-year oncology examination.

Method Description of the course

Medical students in France complete a six-year curriculum before becoming residents: the rst two dicales, PCEM years (Premier Cycle dEtudes Me 12) are generally devoted to pre-clinical studies; the me Cycle dEtudes Me dinext four years (Deuxie cales, DCEM 14) are essentially clinical clerkship years. First- to third-year students at our medical school attend a programme on communication, psychology, and medical ethics focusing on the doctor-patient relationship [5]. Our training course on breaking bad news took place during the students clerkship in oncology (fth year). We have described the course in detail in our pilot study [11]. Session 1 was a lecture and discussion on suitable communication techniques derived from French and International references [1820] during which a well-known six-point stepwise protocol for delivering bad news (known as SPIKES) was presented [12,21]. The six points are: (1) S for setting (welcome the patient); (2) P for perception (nd out what the patient already knows); (3) I for invitation (ask what the patient wants to know); (4) K for knowledge (inform the patient about his or her disease); (5) E for exploring/empathy (respond empathically to the
Copyright r 2009 John Wiley & Sons, Ltd.

patients reaction to the news); and (6) S for strategy/summary (conclude and propose a treatment plan) [12]. Session 2 took place 18 weeks later. It was a videotaped simulated patient (actor)-doctor (student) interview during which students attempted to implement the six-point protocol and the communication techniques they had just learnt. No medical knowledge beyond that acquired by a junior medical student was needed. The doctor was considered to have had no prior contact with the patient, as is the case during a clerkship. A variety of situations were covered: breaking the news of a disease for the rst time, informing the patient of local recurrence or metastatic spread, or announcing the need for radical ablative surgery. The patients were played by professional actors. The actors were given the scenario, directions on how to play their part, and were told of the self-protection mechanisms sometimes used by healthcare professionals and patients, such as denial, belittlement, and avoidance [22]. During the simulated interview, a psychologist assessed the students ability to implement the protocol and to use appropriate communication techniques by completing a form derived from the six-point protocol [11,12]. He or she analysed the communication techniques used by the student (active listening, type of questions asked, rephrasing, silence, etc.) and whether the right technique was applied at the right time. At the end of the interview, the problems encountered by the student were discussed. The psychologists assessment form and comments were handed to the senior physician before session 3. Session 3 was an individual feedback session with a senior physician and took place 12 weeks later. The physician watched the video of the interview with the student, emphasized the six steps of the protocol, and described the techniques and skills he or she considered best suited to the fake case and to similar real-life situations. Twenty senior physicians took part in session 3. Session 1 was mandatory but student participation in sessions 2 and 3 was voluntary.

Assessment of learning objectives

The students had to memorise and implement the six-point protocol for breaking bad news, implement appropriate communication techniques in response to the patients response, and understand their own reactions to a stressful situation. Both selfassessment and external assessment by the psychologist, senior physician, and Faculty were used to nd out whether the objectives had been met.

Self-assessment
To determine the students self assessment of learning objectives, we used two methods: (1)
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appreciation of the value of each session with direct questions and (2) self-assessment before and after each session on a ten-point Likert scale. (1) Students had to complete a three-item questionnaire after each session: Had the session helped them understand the value of the sixpoint protocol, of communication techniques, and of self-knowledge? Each question had a closed response (yes, I noticed an improvement; no, I did not notice an improvement; I do not know) and an open response (why?). Open responses were analysed using a keywords in context method [23], by grouping words occurring frequently into a limited number of categories. Students also rated their ability to break bad news, implement communication techniques, and identify their own reactions on a tenpoint Likert scale, before the start of the course and after each session. Improvement was dened by an increase in their self-rated levels.

Results Students characteristics

All fth year medical students in the academic year 20042005 (n 5 108; 69% female, 31% male) attended the training course during their twomonth clerkship in oncology. There were four consecutive clerkships during the year, that is, four groups of 2530 students. One student refused to participate in session 2 for personal reasons. The clinical scenarios were classied as either dicult (64%) and related to life-threatening cancer with a short life expectancy (e.g. metastatic disease or unresectable locally advanced tumours) or less dicult (36%), that is, curable cases. Most students (77%) were allocated a scenario that they might encounter on the wards (e.g. diagnosis of leukaemia during a haematology clerkship).

(2)

Self-assessment of skills
Assessment of the value of the sessions

External assessment
The psychologist and senior physician assessed whether the students had implemented the SPIKES protocol whilst the interview took place and during the feedback session. The assessment grid was derived from the items of the SPIKES protocol (getting the setting right, nding out what the patient knows already, nding out what the patient wants to know, giving information, responding to the patients reactions, treatment plan, and followup) [11]. A further external assessment was done during the end-of-the-year oncology examination (June 2005) asking a compulsory question: what are the steps in breaking the news of a serious disease? Students answers were analysed by searching for words or groups of words relating to the six-point protocol. Recall of the SPIKES protocol was assessed according to the number of exact items at the end-of-the-year examination.

Statistical analysis
To analyse trends in self-assessed competence levels after each session, we used Spearmans correlation test between number of sessions and students selfassessed competence score. To conrm the trends, we compared self-assessed competence levels before and after each step by using paired student T test. To assess for a correlation between self-assessed competence levels and students characteristics, we used ANOVA tests for repeated measures. We used Fisher Exact test or Pearsons Chi square test to compare results at the end-of-the-year examination and students characteristics.
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The closed questions on the value of each session were completed by 82, 68, and 83 of the 108 students for sessions 1 (theory), 2 (simulated interview), and 3 (feedback), respectively. Most students reported improved knowledge of how to break bad news (i.e. of the six-point protocol) after session 1. Half of them experienced no further improvement in knowledge immediately after session 2. However, the feedback given in session 3 boosted their condence in having the required knowledge (Figure 1(A)). Only half of the students felt that their skills in communication techniques had improved after sessions 1 and 2, but 77% felt more comfortable with these techniques after session 3 (feedback) (Figure 1(B)). About 70% of the students felt they understood their own reactions better after each session (Figure 1(C)). When the students were asked to defend the responses they had given to the closed questions on the value of each session, they gave the following explanations: They saw session 1 as a preparatory step to the framework underlying the simulated interview. They regretted that only theory and not practice had been used to teach communication techniques. They insisted that practice was required in order to be able to grasp the problems of breaking bad news and in order to improve skills. They were rather self-critical about their own performance in session 2. They found it dicult to lead up to the question of asking what the patients wants to know and also found it dicult to respond empathically to the patients reaction to the news, especially if the patients reaction was unexpected. They found it hard to make a conscious eort to implement the communication techniques they had been taught and to master nonverbal communication. The simulated interview had
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Figure 1. Students self-evaluation of curricular objectives by answering to the question Has this session helped you understand the value of (A) the 6-point protocol, (B) communication techniques, (C) knowing your own reactions? (Step 1: After the theoretical session; Step 2: after the simulated interview; and Step 3: after feedback)

unveiled their spontaneous verbal and nonverbal reactions and made them realise the uniqueness of each situation and the need to adapt. The psychologist had helped them gain awareness of how selfprotective they were. In their opinion, the simulated interview introduced a bias that needed to be remedied by facing a real-life situation. They felt that the feedback from an experienced physician in session 3 helped them come to terms with their own self-criticisms, understand how important it is to break bad news stepwise, and recognise their own verbal and nonverbal inadequacies.

Self-rating of skills
The ten-point Likert scale rating of the value of each session was completed by 90, 83, 59, and 76 of the 108 students before session 1 and after sessions 1, 2 and 3, respectively. Thirty-ve students completed all three questionnaires. The students considered that their ability had improved on all three counts: breaking the news (R 5 10.558, P Spearmano0.001), using appropriate communication techniques (R 5 10.469, P Spearmano0.001), and understanding their own reactions (R 5 10.385, P Spearmano0.001) (Figure 2). The rating for how to
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break the news improved two-fold after the course (signicant increasepo0.001following each step of the course), with the most marked increases occurring after sessions 1 and 2. The rating for ability to implement communication techniques rose 1.7-fold (signicant increasepo0.05following each step of the course), with a moderate rise after each session. Self-understanding improved 1.4-fold, with no signicant increase following session 1, but with a high increase after the simulated interview (po0.001), and little but signicant change after session 3 (p 5 0.003). There was no dierence in rating between male and female students, between dicult or less dicult scenarios, and according to whether the student had or had not experienced a similar situation during their clerkship.

External assessment of skills

According to the psychologists assessment of the correct use of the six-point protocol for breaking bad news during the simulated interview, most students were able to welcome the patient, get to know what the patient already knew about their disease, provide information, and conclude (Figure 3(A)). However, the psychologist considered
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Figure 2. Mean Likert scores for self-assessed competence in breaking bad news, using communication techniques, and selfknowledge. (0: baseline; Step 1: after the theoretical session; Step 2: after the simulated interview; and Step 3: after feedback)

Figure 3. (A) Psychologists assessment of the implementation of the six-point protocol during the simulated interview. (B) End-ofthe-year faculty assessment of knowledge of the six-point protocol

that only few students were able to take into account what the patient wanted to know and that more than 30% of the students experienced diculty in adjusting to the patients reactions. At the end-of-the-year examination, two-thirds of the students had memorised the following points: (1) welcoming the patient, (4) informing the patient about their disease, (5) responding empathically to the patients reaction to the news, and (6) concluding and proposing a treatment plan (Figure 3(B)). However, less than half of the students correctly recalled the need to (2) nd out what the patient
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already knows and (3) ask what he or she wants to know. Female students were more likely to remember the six steps of the protocol than male students (mean number of steps 4.6 vs 3.8, p 5 0.011) especially step (1) (85.1 vs 67.7%, p 5 0.036), step (2) (62.2 vs 41.2%, p 5 0.042), and step (5) (75.7 vs50%, p 5 0.008). Recall was not signicantly better if the students had to deal with a dicult scenario or a situation already encountered during their clerkship. The students who considered that they had made considerable progress during the
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course recalled more of the steps of the six-point protocol than others (po0.001).

Discussion
Each of the three sessions of our course improved the students condence in their skills with regard to the three objectives we had set: (1) implementing and memorising the six-item protocol for breaking bad news, (2) improving their ability to use appropriate communication techniques, and (3) helping them identify their own reactions when breaking bad news. Several studies have highlighted the advantages of a course in breaking bad news using videotape presentations and actors to play patients [24,25]. Simulated interviews are now used in many countries but have not yet been used for initial training in France [26,27]. Their ability to improve students skills in breaking bad news has been investigated [1417]. However, our study is dierent in that it focused on the assessment of each step of a three-pronged course, and has shown the need not only for a simulated interview but for a theory class and for individual feedback. Each component of the course was important and tended to develop dierent skills. The theory class provided knowledge on how to break bad news. The videotaped simulated interviews boosted the students selfcondence in having the required knowledge. Feedback on attitudes, behaviour, and use of skills from the psychologist [28], and especially from the senior clinician, increased their understanding of the protocol and their awareness of the importance of communication techniques. Our study, thus, strongly suggests that formal university training on how to break bad news should include multiple sessions and opportunities for demonstration, reection, discussion, practice, and feedback [9]. The six-point protocol proposed by Buckman [12] was not that easy to implement and memorise by students. Although most managed to nd out what the patient knows during the simulated interview, many omitted to mention the item during the end-of-the-year examination. This was a rather disappointing result as our pilot study had indicated that course participants were less likely to forget steps than other students [11]; the students in this study may have been less motivated than those in the pilot study. In general, the students with the best recall were those who felt that they had progressed most and were probably the most motivated. Female students recalled the six steps of the protocol better than male students, and may have a greater aptitude for general learning or a greater interest in communication [29]; a point that may have aected the students performance is the absence of a mnemonic for the six-point protocol in French (SPIKES in English).
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The students understanding of the use of appropriate communication techniques progressed after each session, although their appreciation of their true value was greatest after feedback from the psychologist and physician, once they had applied the techniques during the simulated interview. According to the results of the self-assessment questionnaire, each session improved the students understanding of their own reactions when breaking bad news. However, according to their Likert rating, it was the simulated interview that helped them most, probably, in part, thanks to early feedback from the psychologist. Other teams have also noted improvements in the self-perceived communication skills of medical or nursing students and oncology fellows after training, in particular after simulated interviews [30,31]. Our study has several limitations that need to be addressed in future studies. First, we used a nonvalidated questionnaire comprising a restricted number of items based on the SPIKES protocol [11] for the psychologists assessment of student performance during the simulated interview. However, a validated questionnaire needs to be developed. Second, because of the large number of students doing their clerkship in dierent hospitals, we were unable to obtain all students ten-point Likert rating. This may aect the statistical signicance of our results. Third, we have no long-term follow-up data. Medical students who understand ethical issues, gain self-knowledge about relationships, and feel more condent in breaking bad news may not necessarily use appropriate communication techniques once they have qualied. Further studies on our cohort will help determine the impact of simulated interviews on residents competencies. Fourth, a bias in our study is the nature of the assessor. Communication skills were assessed by the psychologist, the students themselves, and by the physician, but not by the one person truly concerned, the patient. In future, cancer patients could be called upon to rate the interpersonal and communication skills of medical students [32]. Interestingly, students who considered they had made progress during the course recalled more of the steps of the six-point protocol at the end-of-theyear examination. One possible explanation is that students who make progress may believe that communication with patients may be controlled by physicians themselves and, therefore, benet more from educational interventions. These parameters will have to be analysed using validated questionnaires in further studies of our cohort. The challenge is now to improve the competencies of less motivated students. In conclusion, although each session improved the students feeling of competence, the students did not actually develop perfect recall of the six steps of the protocol even though this protocol was
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taught using a highly practical approach. The practical approach was welcomed by the students despite the stress generated by a situation simulating real life. This three-steps training course on the disclosure of a diagnosis of cancer is still ongoing at the University of Nantes.

Acknowledgements
The authors wish to thank all who took part in the training sessions: psychologists (Elisabeth Jegaden, Jean-Charles Le ronique Barbarot, Drezen, Myriam Auger), physicians (Ve le ` ne Se nellart, Ste phanie Emmanuelle Bourbouloux, He Bordenave, Christine Digabel, Jaafar Bennouna, Dominique Berton-Rigaud, Gaelle Quereux, Sonia Marques, Jean-Marc rie Delecroix, Isabelle Doutriaux, Magali LeClasse, Vale blanc, Gaelle Brocard, Tyen LHaridon, Thierry Chatellier, de ric Maud Aumont-Le Guilcher, Franc - ois Thillays, Fre Rolland), and actors (Ligue dImprovisation de NantesAtlantique), as well as all those who provided support (Dr J not, Centre Franc Y Ge - ois Baclesse, Caen, Professors Alain de Me decine de Mouzard and Jean-Michel Rogez, Faculte Nantes). Sponsors: Gauducheau Fonds de Recherche du Centre Rene gis Bataille), Ligue De partementale (Professor Franc - ois-Re Contre le Cancer de Loire-Atlantique, and the French vention, dEduMinistry of Health (Fonds National de Pre cation et dInformation Sanitaires)

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Psycho-Oncology 19: 975981 (2010) DOI: 10.1002/pon