Improving Perinatology Residents' Skills in Breaking Bad News: A Randomized Intervention Study

Abstract

Objective Breaking bad news (BBN) is particularly difficult in perinatology. Previous research has shown that BBN skills can be learned and improved when taught and practiced. This project evaluated whether a structured training session would enhance perinatology residents' skills in BBN.

Methods This was a randomized controlled intervention study with year 1 to 4 Perinatology residents from a medical school in Brazil, during the 2014/15 school year. A total of 61 out of 100 (61%) eligible residents volunteered to a structured training program involving communicating a perinatal loss to a simulated patient (SP) portraying the mother followed by the SP's immediate feedback, both video recorded. Later, residents were randomly assigned to BBN training based on a setting, perception, invitation, knowledge, emotion and summary (SPIKES) strategy with video reviews (intervention) or no training (control group). All residents returned for a second simulation with the same SP blinded to the intervention and portraying a similar case. Residents' performances were then evaluated by the SP with a checklist. The statistical analysis included a repeated measures analysis of covariance (RM-ANCOVA). Complementarily, the residents provided their perceptions about the simulation with feedback activities.

Results Fifty-eight residents completed the program. The simulations lasted on average 12 minutes, feedback 5 minutes and SPIKES training between 1h and 2h30m. There was no significant difference in the residents' performances according to the SPs' evaluations (p = 0.55). The participants rated the simulation with feedback exercises highly. These educational activities might have offset SPIKES training impact.

Conclusion The SPIKES training did not significantly impact the residents' performance. The residents endorsed the simulation with feedback as a useful training modality. Further research is needed to determine which modality is more effective.

Resumo

Objetivo É uma tarefa particularmente difícil transmitir más notícias em perinatologia. Habilidades de comunicação podem ser aprendidas, ensinadas e praticadas. O presente estudo avalia se uma sessão de treinamento estruturado para comunicar más notícias ampliaria as habilidades dos residentes de perinatologia.

Métodos Estudo de intervenção controlado e aleatorizado com residentes do 1° ao 4° ano do curso de perinatologia de uma faculdade de ciências médicas no ano letivo de 2014/15. Um total de 61 dos 100 residentes elegíveis (61%) voluntariaram-se para um programa de treinamento envolvendo comunicar uma perda perinatal para uma paciente simulada no papel da mãe, seguido do feedback imediato da atriz, ambos filmados. Posteriormente, os residentes foram aleatoriamente designados para um grupo de treinamento em más notícias baseado na estratégia SPIKES e revisão dos vídeos (intervenção) ou para um grupo-controle, sem treinamento. Todos os residentes retornaram numa segunda simulação análoga à primeira, com a mesma paciente simulada cega à intervenção. Avaliou-se as habilidades dos residentes segundo um checklist preenchido pela atriz. A análise estatística incluiu análise de covariância para medidas repetidas (ANCOVA-MR). Os residentes avaliaram a atividade de simulação com feedback.

Resultados O programa foi completado por 58 residentes. As simulações duraram em média 12 minutos, o feedback 5 minutos, e o treinamento SPIKES entre 1h e 2,5h. Não houve diferença significativa nas atuações dos residentes segundo a paciente simulada (p = 0.55). Os residentes avaliaram a simulação com feedback positivamente. Essas atividades podem ter reduzido o impacto do treinamento SPIKES.

Conclusão O treinamento SPIKES não teve impacto significativo na atuação dos residentes. Os residentes consideraram as simulações com feedback úteis. Mais pesquisas são necessárias para determinar qual modalidade é mais eficaz.

Keywords

medical - education - health communication - patient simulation - internship and residency - perinatology

Palavras-chave

educação médica - comunicação em saúde - simulação de paciente - internato e residência - perinatologia

Register Number at Registro Brasileiro de Ensaios Clínicos (REBEC, in the Portuguese acronym)

RBR8K3cyk

Contributions

All authors (Setubal M. S. V., Antonio M. A. R. G. M., Amaral E. M., Boulet J.) have participated in the concept and design; analysis and interpretation of data; drafting or revising of the manuscript, and they have approved the manuscript as submitted. All authors are responsible for the reported research.

• References

• 1 Prinds C, Hvidt NC, Mogensen O, Buus N. Making existential meaning in transition to motherhood--a scoping review. Midwifery 2014; 30 (06) 733-741 . Doi: 10.1016/j.midw.2013.06.021
• 2 Simkin P. The meaning of labor pain. Birth 2000; 27 (04) 254-255 . Doi: 10.1046/j.1523-536x.2000.00254.x
• 3 Romm J. Breaking bad news in obstetrics and gynecology: educational conference for resident physicians. Arch Women Ment Health 2002; 5 (04) 177-179 . Doi: 10.1007/s00737-002-0145-3
• 4 Peters MD, Lisy K, Riitano D, Jordan Z, Aromataris E. Providing meaningful care for families experiencing stillbirth: a meta-synthesis of qualitative evidence. J Perinatol 2016; 36 (01) 3-9 . Doi: 10.1038/jp.2015.97
• 5 Peters MD, Lisy K, Riitano D, Jordan Z, Aromataris E. Caring for families experiencing stillbirth: Evidence-based guidance for maternity care providers. Women Birth 2015; 28 (04) 272-278 . Doi: 10.1016/j.wombi.2015.07.003
• 6 Fallowfield L, Jenkins V. Communicating sad, bad, and difficult news in medicine. Lancet 2004; 363 (9405): 312-319 . Doi: 10.1016/S0140-6736(03)15392-5
• 7 Henley A, Schott J. The death of a baby before, during or shortly after birth: good practice from the parents' perspective. Semin Fetal Neonatal Med 2008; 13 (05) 325-328 . Doi: 10.1016/j.siny.2008.03.003
• 8 Lisy K, Peters MDJ, Riitano D, Jordan Z, Aromataris E. Provision of Meaningful Care at Diagnosis, Birth, and after Stillbirth: A Qualitative Synthesis of Parents' Experiences. Birth 2016; 43 (01) 6-19 . Doi: 10.1111/birt.12217
• 9 Horwitz N, Ellis J. Paediatric SpRs' experiences of breaking bad news. Child Care Health Dev 2007; 33 (05) 625-630 . Doi: 10.1111/j.1365-2214.2007.00742.x
• 10 Gold KJ, Kuznia AL, Hayward RA. How physicians cope with stillbirth or neonatal death: a national survey of obstetricians. Obstet Gynecol 2008; 112 (01) 29-34 . Doi: 10.1097/AOG.0b013e31817d0582
• 11 Ellis A, Chebsey C, Storey C. , et al. Systematic review to understand and improve care after stillbirth: a review of parents' and healthcare professionals' experiences. BMC Pregnancy Childbirth 2016; 16: 16 . Doi: 10.1186/s12884-016-0806-2
• 12 Tobler K, Grant E, Marczinski C. Evaluation of the impact of a simulation-enhanced breaking bad news workshop in pediatrics. Simul Healthc 2014; 9 (04) 213-219 . Doi: 10.1097/SIH.0000000000000031
• 13 Jacques AP, Adkins EJ, Knepel S, Boulger C, Miller J, Bahner DP. Educating the delivery of bad news in medicine: Preceptorship versus simulation. Int J Crit Illn Inj Sci 2011; 1 (02) 121-124 . Doi: 10.4103/2229-5151.84796
• 14 Kingdon C, O'Donnell E, Givens J, Turner M. The Role of Healthcare Professionals in Encouraging Parents to See and Hold Their Stillborn Baby: A Meta-Synthesis of Qualitative Studies. PLoS One 2015; 10 (07) e0130059 . Doi: 10.1371/journal.pone.0130059
• 15 Sullivan AM, Warren AG, Lakoma MD, Liaw KR, Hwang D, Block SD. End-of-life care in the curriculum: a national study of medical education deans. Acad Med 2004; 79 (08) 760-768
• 16 Bowyer MW, Hanson JL, Pimentel EA. , et al. Teaching breaking bad news using mixed reality simulation. J Surg Res 2010; 159 (01) 462-467 . Doi: 10.1016/j.jss.2009.04.032
• 17 Vail L, Sandhu H, Fisher J, Cooke H, Dale J, Barnett M. Hospital consultants breaking bad news with simulated patients: an analysis of communication using the Roter Interaction Analysis System. Patient Educ Couns 2011; 83 (02) 185-194 . Doi: 10.1016/j.pec.2010.05.016
• 18 Rushton JL, Hicks PJ, Carraccio CL. The next phase of pediatric residency education: the partnership of the Milestones Project. Acad Pediatr 2010; 10 (02) 91-92 . Doi: 10.1016/j.acap.2010.01.001
• 19 Ministry of Education. Proposição de Conteúdo dos Programas de Residência Médica (Resolução N° 2, de 17 de maio de 2006): Residência Médica em Pediatria com Duração de Três Anos: Áreas de Atuação Pediátrica com Duração de Dois Anos . http://portal.mec.gov.br/pet/191-secretarias-112877938/sesu-478593899/15776-proposicao-de-conteudo-dos-programas-de-residencia-medica-resolucao-no-2-de-17-de-maio-de-2006 . Accessed February 24, 2016
• 20 Ministry of Education. Proposição de Conteúdo dos Programas de Residência Médica (Resolução N° 2, de 17 de maio de 2006): Residência Médica em Obstetrícia e Ginecologia . http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=6511-ginecologia-obstetricia-sesu-rm&category_slug=agosto-2010-pdf&Itemid=30192 . Accessed February 24, 2016
• 21 Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002; 325 (7366): 697-700 . Doi: 10.1136/bmj.325.7366.697
• 22 Reed S, Shell R, Kassis K. , et al. Applying adult learning practices in medical education. Curr Probl Pediatr Adolesc Health Care 2014; 44 (06) 170-181 . Doi: 10.1016/j.cppeds.2014.01.008
• 23 Reed S, Kassis K, Nagel R, Verbeck N, Mahan JD, Shell R. Breaking bad news is a teachable skill in pediatric residents: A feasibility study of an educational intervention. Patient Educ Couns 2015; 98 (06) 748-752 . Doi: 10.1016/j.pec.2015.02.015
• 24 Rosenbaum ME, Ferguson KJ, Lobas JG. Teaching medical students and residents skills for delivering bad news: a review of strategies. Acad Med 2004; 79 (02) 107-117
• 25 Field MJ, Behrman RE. When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families. Washington (DC): National Academies Press (US); 2003
• 26 Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000; 5 (04) 302-311 . Doi: 10.1634/theoncologist.5-4-302
• 27 Saviani-Zeoti F, Petean EB. Breaking bad news: doctors' feelings and behaviors. Span J Psychol 2007; 10 (02) 380-387
• 28 Buckman R. How to Break Bad News: A Guide for Health Care Professionals . Baltimore, MD: Johns Hopkins University Press; 1992
• 29 Werner P, Karnieli-Miller O, Eidelman S. Current knowledge and future directions about the disclosure of dementia: a systematic review of the first decade of the 21st century. Alzheimers Dement 2013; 9 (02) e74-e88 . Doi: 10.1016/j.jalz.2012.02.006
• 30 Ministry of Health. National Cancer Institute. [Breaking Bad News: Sharing Health Care Challenges]. Rio de Janeiro, RJ: INCA; 2010
• 31 Amiel GE, Ungar L, Alperin M, Baharier Z, Cohen R, Reis S. Ability of primary care physician's to break bad news: a performance based assessment of an educational intervention. Patient Educ Couns 2006; 60 (01) 10-15 . Doi: 10.1016/j.pec.2005.04.013
• 32 Bonnaud-Antignac A, Campion L, Pottier P, Supiot S. Videotaped simulated interviews to improve medical students' skills in disclosing a diagnosis of cancer. Psychooncology 2010; 19 (09) 975-981 . Doi: 10.1002/pon.1649
• 33 Hammoud MM, Morgan HK, Edwards ME, Lyon JA, White C. Is video review of patient encounters an effective tool for medical student learning? A review of the literature. Adv Med Educ Pract 2012; 3: 19-30 . Doi: 10.2147/AMEP.S20219
• 34 Greiner AL, Conklin J. Breaking bad news to a pregnant woman with a fetal abnormality on ultrasound. Obstet Gynecol Surv 2015; 70 (01) 39-44 . Doi: 10.1097/OGX.0000000000000149
• 35 Daetwyler CJ, Cohen DG, Gracely E, Novack DH. eLearning to enhance physician patient communication: a pilot test of “doc.com” and “WebEncounter” in teaching bad news delivery. Med Teach 2010; 32 (09) e381-e390 . Doi: 10.3109/0142159X.2010.495759
• 36 Fortin AH, Haeseler FD, Angoff N. , et al. Teaching pre-clinical medical students an integrated approach to medical interviewing: half-day workshops using actors. J Gen Intern Med 2002; 17 (09) 704-708 . Doi: 10.1046/j.1525-1497.2002.00628.x
• 37 Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Med Teach 2013; 35 (10) e1511-e1530 . Doi: 10.3109/0142159X.2013.818632
• 38 Bokken L, Rethans JJ, van Heurn L, Duvivier R, Scherpbier A, van der Vleuten C. Students' views on the use of real patients and simulated patients in undergraduate medical education. Acad Med 2009; 84 (07) 958-963 . Doi: 10.1097/ACM.0b013e3181a814a3
• 39 Meert KL, Eggly S, Pollack M. , et al; National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Parents' perspectives on physician-parent communication near the time of a child's death in the pediatric intensive care unit. Pediatr Crit Care Med 2008; 9 (01) 2-7 . Doi: 10.1097/01.PCC.0000298644.13882.88
• 40 Kim L, Hernandez BC, Lavery A, Denmark TK. Stimulating reflective practice using collaborative reflective training in breaking bad news simulations. Fam Syst Health 2016; 34 (02) 83-91 . Doi: 10.1037/fsh0000195
• 41 Meyer EC, Sellers DE, Browning DM, McGuffie K, Solomon MZ, Truog RD. Difficult conversations: improving communication skills and relational abilities in health care. Pediatr Crit Care Med 2009; 10 (03) 352-359 . Doi: 10.1097/PCC.0b013e3181a3183a
• 42 Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. Lancet 2002; 359 (9307): 650-656 . Doi: 10.1016/S0140-6736(02)07810-8
• 43 Rosenbaum ME, Kreiter C. Teaching delivery of bad news using experiential sessions with standardized patients. Teach Learn Med 2002; 14 (03) 144-149 . Doi: 10.1207/S15328015TLM1403_2
• 44 Liénard A, Merckaert I, Libert Y. , et al. Is it possible to improve residents breaking bad news skills? A randomised study assessing the efficacy of a communication skills training program. Br J Cancer 2010; 103 (02) 171-177 . Doi: 10.1038/sj.bjc.6605749
• 45 Defey D, Diaz Rosselo JL, Friedler R, Nuñez M, Terra C. Duelo por un Niño que Muere antes de Nacer: Vivencias de los Padres y del Equipo de Salud. 3a ed. Montevideo: Gnosos; 1997