Breaking Bad News: Healthcare and Communication

With this reflective commentary I want to look at what I have learnt whilst writing my masterclass on breaking bad news. I will also review the literature related to this topic and to the broader topics of communication skills and the education of communication skills. I wrote my masterclass on breaking bad news because it is something that I encounter regularly in clinical practice and I feel that it is so important that it is done well. Evidence shows that if breaking bad news is not done well it can have a detrimental effect on both the patient and the doctor, which is especially significant given the frequency that it occurs in clinical practice. Breaking bad news affects all clinical specialties, particularly those involving cancer and palliative care, with oncologists doing it roughly 20,000 times over their careers. Both doctors and patients can suffer from stress and anxiety related to breaking bad news and when done poorly it can lead to "poorer health outcomes".

With my masterclass my aim was to provide a succinct overview of breaking bad news whilst also looking at some recent evidence and literature. In addition to having structured teaching sessions, another way to improve skills is through reflection and also through the observation of others and the giving and receiving of feedback. Through this process I have learnt more about reflective practice and different models of reflection, for example Gibbs’ and Kolb. Through the process of writing and presenting my masterclass I have also gained other skills, for example learning about the technological aspects of making the presentation and the benefits of technology enhanced learning. Whilst studying around this module and reading around my masterclass topic I have also learnt about different educational theories, including constructivism, and how the psychology theory of transactional analysis relates to communication in the clinical workplace and also to education.

In starting to plan my presentation I researched journals and articles on breaking bad news. I also contacted the staff at the hospital library who were able to help me access useful journal articles and were able to direct me to useful resources. I have not done many literature searches or journal reviews since medical school so this experience was a good opportunity for me to refresh these skills. My search generated a large number of articles and it was good practice for me to review the different facts and information available and consider what information would be most useful for my target audience and how to present it in a clear manner.

Mayer’s principles of multimedia learning states that information is better presented in a concise manner and when it is divided into clear "user paced" segments (N). I try and follow this when writing presentations but in the past I have often struggled with wanting to put too much information on each slide and making the slides too busy. Writing this masterclass was also the first time I had made an audio recording over a power point presentation. This was interesting for me from a technology point of view as it involved using software that I hadn’t used before. Recording the presentation involved some trial and error with different headphones, microphones and settings on my computer. I am pleased that I managed to get the technical aspect of the presentation sorted and it will be useful for me in the future to be able to have these skills.

Breaking bad news is something every doctor will encounter during their training and clinical practice. One definition of bad news is any "news that drastically and negatively alters the patient’s view of his or her future" (f). Bad news can also be more simply defined as what the patient perceives as bad news. Most people first think of ‘bad news’ as relating to a cancer diagnosis, or a death of a loved one, but it could also be something like a significant sports injury or a new diagnosis of a life altering medical condition. Not only doctors deliver bad news, many other specialists will also often be involved, for example nurses, clinical nurse specialists, midwives and physiotherapists, so it is a relevant topic for many allied healthcare professionals to learn about.

It is a topic which is particularly important for me because about eighteen months ago I received feedback from a patient and his family that they felt that I had broken bad news poorly. I am not alone, a study in 2011 by Brown et al. gave questionnaires to cancer patients asking about their experience of breaking bad news and only 60% were satisfied with the experience that they had had. Following my experience I have reflected on my method of breaking bad news and have taken opportunities to observe others when possible. Literature suggests that it is something that many doctors find difficult and sometimes worry about. The research by Aoun et al, that I discussed in my masterclass, found that 65% of the neurologists they contacted for the study reported suffering from stress and anxiety at the thought of telling someone the diagnosis of motor neuron disease. As such I thought it was an important and relevant topic to do a teaching masterclass on.

Throughout medical school and our medical careers we are encouraged to reflect on our experiences in order to learn and improve. Reflective practice is considered so important that it is recommended by the General Medical Council, the regulatory body for doctors, and it is also required as part of our regular appraisal and revalidation (g). John Dewey wrote about reflection and its relation to education in 1933 and his work has influenced many others since, such as Schon and Kolb (h, i). Dewey described reflection as "active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it, and further conclusions to which it leads" (Dewey 1933, as referenced in h). In 1984 Kolb created an experiential learning cycle. This cycle has four stages, which are all important and required to enable learning. The four stages are "concrete experience" (the event happening), "reflective observation" (reviewing what happened), "abstract conceptualization" (why is this important, what have you learnt) and "active experimentation" (what will you do next). Kolb’s work also influenced others and another example of a reflective model is Gibbs’ Reflective Cycle published in 1988 (1,2). Gibbs’ model works through the reflective process with the "description" of the events, what your "feelings" were surrounding the event and doing an "evaluation" of the event, for example thinking about what went well (2). Next in the process is coming to a "conclusion", what you will learn from the event, and the final step is your ongoing "action" to implement the changes or further develop your learning. I used Gibb’s reflective model to support my reflection on the experience of breaking bad news that resulted in the complaint.

I presented my masterclass to some medical colleagues of mine and they gave me some feedback. One comment I received was that my delivery style was not very varied. Using Kolb’s cycle I watched my presentation again and thought more about my delivery style. I think this would be easier if I was presenting to a ‘live audience’ as I would be able to react to the audience and this would make my delivery style more dynamic. This is important to think about because when I have attended lectures or presentations previously I have found them much more interesting and memorable if the presenter has had a more engaging delivery style. I think that it is more difficult to achieve this when recording a presentation onto a computer, so in the future I think it is useful to be aware of it and to make more of a conscious effort, for example with my tone of voice. Another part of the feedback I received was that I could have made the slides more interesting with use of animation or a joke and that this would be more likely to maintain audience interest. This is supported by a study by Issa et al. in 2013 which found that presentations using Mayer’s multimedia design principles lead to better understanding and retention of the lecture material by medical students (m, N). One of Mayer’s principles states "people learn better from words and pictures than from words alone" (N). In the future I will be mindful of Mayer’s principles when writing presentations and aim to improve learning with appropriate graphics and pictures (N).

The other technique I would usually use to maintain attention during a presentation would be to ask questions, but this is not really possible when doing an online presentation such as this one. I agree that therefore it is more necessary to think of other features of the presentation that would help to keep the audience interested, and will keep this in mind when writing future presentations. Some other feedback that I received was that I should have discussed the study that I referenced at the end of my presentation in more detail, for example how did the researchers decide which communication skills were good or not. It would have been good to have been able to go into more detail when discussing the study and also I could have elaborated on other parts of the presentation, but I was limited by the allocated time for the presentation. If this had been a face to face presentation then some of those questions could have been answered at the end with time of questions and a discussion. In the future I will bear in mind that this type of presentation by its very nature is less interactive and perhaps should go into more detail during the talk as there would be less opportunity for questions afterwards.

This module has also been the first time that I have learnt about the concept ‘blended learning’ (3). Blended learning is using technology to support traditional ‘face to face’ learning (3). This was the first time that I had used online resources with recorded presentations and also the first time that I have created such a presentation. As an extension of this it was also useful to learn, during the module, about technology enhanced learning and using technology in teaching and learning (k). The term technology enhanced learning encompasses all types of technology used in teaching and learning, for example the use of phone apps or online lectures. In 2011 Robin et al. published a journal article discussing the use of technology to support medical education (k). They describe how with an ever increasing amount of medical research and new information available it is vital for doctors to maintain up to date knowledge throughout their careers (k). One important way this is made possible is through digital resources, including online journals, online lectures, social media, virtual environments and podcasts, particularly looking into the future when pupils will have grown up surrounded by technology (k, L). I have had experience using some of these technologies during my medical education, for example looking up up to date medical research online, and it is useful for me to learn about the types of technology and digital resources that can be used to support learning.

As discussed, continued learning and professional development is vital to maintain skills and clinical practice in medicine. People have different learning styles and will respond to different teaching methods differently. One way to continue professional learning is through reflection on events that have occurred and another way is to generate discussion and reflection is via simulation, role play and problem based learning. These are great ways to practice all types of skills, and can be used to develop communication skills and practicing breaking bad news. Role play with actors is also the method by which communication skills are examined in both undergraduate and postgraduate medical exams. New technology (‘technology enhanced simulations’) is often incorporated into simulation training, and has shown to lead to better learning outcomes (O). One of the most useful aspects of this type of learning is reflecting on it afterwards and also giving and receiving feedback to colleagues. Constructivism theory is based on the idea that learners build new knowledge on the foundations of previous knowledge constructs (P). Knowledge about constructivism can be used to support teaching, for example, working in small groups in a simulation environment can allow teachers to find out more about students existing knowledge, which is important to build upon to understand new topics (P). Constructivism theory also favors learning in groups and using active learning techniques like problem solving, which are methods seen in simulation and problem based learning (P).

Berne in 1968 described transactional analysis, which looks at interactions between people (5,6). This is relevant is many different situations; in the clinical setting when interacting with other team members, when interacting with patients (for example when breaking bad news) and also in the educational setting (for example when teaching and giving feedback). He described three ego states of being: the parent, adult and child (4,5). These can further be subdivided, for example the parent can be critical or nurturing (4). These states describe how people interact with one another. The adult state is rational, logical and interacts based on events in the "here and now" (4,5). The child ego state relates to previous experiences, for example if a patient was being told what to do by a doctor, they might react defensively or angrily as they may think back to a similar experience when they were younger. In this scenario the doctor would be taking on a ‘parent’ role and the patient a ‘child’ role (4,5). Research by Whitley-Hunter stated that "without the capability to recognize a person’s ego, state of mind and body language, there is a chance of compromising patient care" (6). I think this is particularly important when looking at difficult communication topics, like breaking bad news.

Writing my masterclass has allowed me to revise the basic principles of breaking bad news and also to read around recent literature on the topic. I chose the topic because it is an important skill for clinicians to have and it is something that I sometimes have struggled with. Whilst reflecting on the process of writing my presentation I have learnt about Dewey, Kolb and Gibbs’ reflective theories (h). Having given my presentation to colleagues I found their feedback very valuable and it helped me with my reflection and gave me learning points to take forward for future presentations. It was interesting to learn about Mayer’s multimedia design principles and when writing presentations in the future I will use these to influence how I write and design my slides (N). As well as developing my writing and presenting skills I have also learnt about the technological aspect of producing an electronic presentation. As part of this I also learnt about the use of technology enhanced learning and blended learning (K). In the future I will try and incorporate this more into any teaching that I do, for example giving links to web resources in advance or using an interactive poll during the presentation. Another type of teaching I have learnt about is the use of simulation, role play and problem based learning, particularly when developing communication skills. These methods of teaching can benefit from the use of digital technologies and can be supported by an understanding of Constructivism (P). I have also looked at Berne’s theory of transactional analysis and its importance in communication, both in clinical scenarios and in the teaching environment (5).