Ability of primary care physician's to break bad news: A performance based assessment of an educational intervention

https://doi.org/10.1016/j.pec.2005.04.013Get rights and content

Abstract

Objective

We have previously described a breaking bad news (BBN) training program for primary care physicians [Ungar L, Alperin M, Amiel GE, Beharier Z, Reis S. Breaking bad news: structured training for family medicine residents. Patient Educ Couns 2002;48:63–68]. In this paper, we present the assessment of an educational intervention aimed at improving this important skill.

Methods

The assessment tool was an eight station objective structured clinical examination (OSCE) utilizing standardized patients (SPs). Intervention and control groups of 17 general practitioners (GP) each were evaluated before and after an educational intervention, or a Balint group (control).

Results

Intervention group GPs significantly increased their average grade on the post-test as compared to the pre-test (58.5, S.D. 12.7 versus 68.4, S.D. 9.2), effect size 0.94. Improvement in the control group was minimal (pre-test 57, S.D. 10.4 versus 58.1, S.D. 9.5 for the post-test), effect size 0.23. Reliability of the OSCE was α = 0.81.

Conclusion

The performance assessment used in this study proved to be a reliable and valid tool to assess the ability of physicians to break bad news. It provided evidence of the effectiveness of the intervention.

Practice implications

BBN training can and should be evaluated by valid and reliable measures. SPs can serve as reliable evaluators of BBN training.

Introduction

There was a time when it was an acceptable practice to break bad news to a patient who was suffering from a terminal illness by mail, often without even seeing the patient [1]. Fortunately, the medical profession has made tremendous strides in dealing with this area of practice [2], [3]. Consensus guidelines on how to break bad news to patients as outlined by Rosenbaum et al. [4] Buckman [5] and by Baile et al. [6] represent some of the many attempts to establish basic principles for breaking bad news (BBN).

A number of studies have shown that physicians experience difficulty when required to deliver bad news [7]. Lack of skills and the reluctance to deal with the patient's feelings have been reported as the main causes for physicians’ avoidance of this task [8], [9]. To overcome these problems, courses for breaking bad news have been implemented [10]. Of crucial importance is the effectiveness and outcome of such interventions, i.e. do they improve the ability of participating physicians to breaking bad news, and to what degree do participants retain these skills. Assessment of the impact of such courses on competence is rare [2]. We were unable to find studies that reported on the development of a reliable performance based assessment of the ability of physicians to deliver bad news to patients. The purpose of this study was to: (1) evaluate the reliability and validity of a competence based assessment, utilizing simulated patients as evaluators, to assess primary care physicians’ ability to deliver bad news; (2) evaluate the effectiveness of a training program in breaking bad news offered to a group of general practitioners (GPs) as part of a continuing medical education (CME) program.

Section snippets

Course framework and teaching modalities

In 1991, a mandatory course for second year family medicine trainees on how to break bad news was introduced into our residency training program. Since 1996, this course has also been offered as a CME course for practicing GPs. The guiding textbook for this course has been ’How to break bad news’ by Buckman [5].

A group of certified family physicians and a social worker identified common and important situations dealing with bad news in primary care that served as the basis for developing the

Results

All 34 physicians took both the pre- and post-tests (Table 3). Overall mean score for the pre-test was 57.3, S.D. 11.3 (range: 20–100). No significant difference on the pre-test was found between the scores of the GPs from the study and control groups (58.5, S.D. 12.7 versus 57, S.D. 10.4, respectively; range: 20–100). Overall reliability of the pre-test was high for a 2 h OSCE (α = 0.81).

The GPs in the study group significantly increased their average grade on the post-test as compared to the

Discussion

At no time is effective communication more important and challenging than when a physician is required to deliver bad news or tragic information to patients and their families. Receiving a medical diagnosis may be overwhelming regardless of the care the physician takes in communicating the news. Jonsen et al. have stated, “the truth may be brutal, but the telling of it should not be”. ([15]).

Little is known to date about actual physician performance in providing bad news and the emotional

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