Delivering Bad News
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This month, a survey by the General Medical Council revealed that newly-qualified doctors and trainee surgeons undergo little preparation for the communication of bad news, for example with a dying patient, when typically a young medic may encounter as many as 40 cases of this type in their first year of practice. And another study from January this year showed that whilst 91% of physicians perceive delivering bad news as a key skill, only 40% felt they have the training to effectively deliver difficult announcements.
It is known that breaking bad news badly can adversely affect patient outcomes, for example poor communication with cancer patients has been shown to be associated with worse clinical and psychosocial outcomes, including worse pain control, worse adherence to treatment, confusion over prognosis and dissatisfaction at not being involved in decision making.
It is against this backdrop that Britain’s oldest surgical Royal College announces the results of their 2nd Annual Communication Skills Competition, which saw medical students and surgical trainees from around the UK and internationally submit 3-minute videos of themselves roleplaying a variety of challenging situations. Participants were invited to record scenarios involving talking with carers, communicating with (senior or junior) colleagues and face-to-face history-taking.
This year’s entries included clips showcasing how to deal with irate relatives, announce a sudden death or counselling parents before a child’s delicate surgery, among others. The first prize for the Royal College of Surgeons of Edinburgh (www.rcsed.ac.uk) 2016 skills competition was awarded to two female surgical trainees. Their work highlighted the use of a key mnemonic for delivering bad news which takes into account vital aspects such as showing empathy and support, whilst still providing essential medical information.
Beverley Yu, a 28-year-old core surgical trainee from the Royal Blackburn Hospital and 31-year-old Daniela Bondin a specialist trainee also from the RoyalBlackburn Hospital utilised the SPIKES protocol in their film. This approach for delivering bad news was developed to enable clinicians to fulfil the four most important objectives of the interview: gathering information from the patient, communicating clinical information, providing support to the patient, and obtaining the patient's collaboration in developing a treatment plan for the future[i].
“I don’t think there is enough emphasis on training surgeons on communication in general. Unlike surgical skills where progress can be tracked more easily with a logbook or complication rates, developing good communication abilities requires a lot more subjective feedback and reflection,”said Beverley Yu, one of the video’s co-producers originally from Hull and who is training to become an ENT surgeon. “I have accompanied family members when they have received bad news so having been on the receiving end, I better appreciate what a difference it makes when a doctor does have good communication skills and the reassurance it provides in when there is an uncertain future.”
“There is never a ‘good’ feeling when giving bad news but often these moments are one of the most important for patients and their families. For this reason, I think it’s essential that we always try and improve our skills to make these moments less painful or onerous for them,”said Daniela, who trained in Manchester and is a higher surgical ENT trainee and the video's co-producer. “As junior doctors we have personally seen and experienced good communication skills and other times when it has gone terribly wrong. Such moments are seen in all branches of medicine and is independent of the seniority of the doctor. We wanted to demonstrate a simple method that can be applied by any grade of doctor in any surgical speciality that gives them structure and can help make an already difficult situation run more smoothly.”
The SPIKES programme uses 6 steps to help to optimise patient and carer communications and has been developed, refined and validated over years to help clinicians help those they are caring for:
- Setting Up: this stage includes mental rehearsal, securing a private environment without interruptions, and arranging for significant others such as spouses or relatives to be present if the patient so wishes
- Assessing Perception: Through open-ended questions, gaining an accurate snapshot of what the patient knows or has been told so far, to individually tailor the news
- Obtaining Invitation: Assessing the desire and manner in which the patient would like to receive the information
- Giving Knowledge: Preparing the patient to help lessen shock through phrases such as “I’m sorry to…” or “Unfortunately…”, and provide medical facts in a non-technical way
- Emotions and Empathy: Responding to patients’ reactions which could involve tearfulness, silence or rage and let them know you recognise, understand and connect with their feelings
- Strategy and Summary: Ask if they are ready to discuss treatment plans and options – a clear plan for the future can help lessen anxiety
According to Mike Lavelle-Jones, consultant colorectal surgeon President of the RCSEd;
“Breaking bad news is a complex yet necessary task for surgeons. In addition to the verbal component of providing medical information, it also requires other skills such as responding to patients' emotional reactions, involving them in decision-making, dealing with the stress created by expectations for a cure, the involvement of multiple family members, and the dilemma of how to give hope when the situation is bleak.”
“Effective communication is vital for patient safety," said Dr Judy Evans; a consultant plastic surgeon, Honorary Secretary and the first-ever female Office Bearer of the RCSEd; who launched and led the competition, “Studies have shown that whilst surgeons tend to be generally thorough in providing details about clinical conditions and treatments, they often don’t explore patients’ or carers' emotional concerns or express empathy in as much depth as they could. Our video competitions will help tomorrow's surgeons get to grips with one of the toughest parts of our job.”
The winners received one year’s affiliation with the RCSEd Affiliate Network, and the choice to attend any RCSEd course or join surgeons from across the globe at the RCSEd’s prestigious annual Audit Symposium.
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