Muhammad Zeeshan Sarwar  ( East Surgical Ward, King Edward Medical University Lahore )
Fakeha Rehman  ( Pathology Department, King Edward Medical University Lahore )
Syeda Mehak Fatima  ( Allied Health Sciences, King Edward Medical University Lahore )
Muhammad Suhail  ( Plastic Surgery, King Edward Medical University Lahore )
Syed Asghar Naqi  ( East Surgery, Mayo Hospital Lahore )

Objective:To evaluate the skill of postgraduate residents in breaking bad news to the patients in a tertiary care hospital.
Methods:The cross-sectional study was conducted at King Edward Medical university, Lahore, Pakistan, from January to April 2016, and comprised postgraduate residents of different specialties at Mayo Hospital, Lahore. The subjects were examined in terms of their personal experience in breaking bad news to the patients by means of a specifically-designed questionnaire based on six-step protocol of  Setting, Perception, Invitation, Knowledge, Empathy and Summarising model. Data was qualitatively and quantitatively analysed using SPSS 22.
Results:Of the 200 respondents, 141(70.5%) were males and 59(29.5%) were females. Overall mean age of the sample was 23 } 2.55years. Of the total, 94(47%) respondents were only fairly satisfied with their breaking bad news skill, while 130(65%) were eager to get training in this regard. The knowledge regarding breaking bad news protocols was lacking across all comparisons (p>0.05).
Conclusion:Majority of the residents had little satisfaction regarding their breaking bad news skill. It is necessary to plan special training for the residents in this key area.
Keywords:Breaking bad news, Communication skills, Evaluation, KEMU, Postgraduate resident. (JPMA 69: 695; 2019)

Introduction

Breaking bad news (BBN) to the patients and their relatives is a complex and stressful task. This communication skill is important as almost all physicians and surgeons have to break the bad news multiple times in their lifetime.¹ Bad news is defined as 'any news that drastically and negatively alters the patient view of her or his future'. ¹ The ability to provide this information may either strengthen or destroy the patient-physician relationship. ¹ Despite the importance of this skill in clinical practice, formal education for medical students to communicate bad news has been limited. Literature from the United Kingdom and the United States stressed upon need of structured training of medical students and residents in breaking the bad news. ¹ But in our setup, this communication skill is usually learned through trial and error or observation of senior colleagues. ¹ There are many protocols for breaking the bad news, like Background; Rapport; Explore; Announce; Kinding; Summarise (BREAKS), Advance preparation; Build a therapeutic relationship; Communicate well; Deal with patient and family reactions; Encourage and validate emotions (ABCDE), and Setting and listening skills; Patients perception; Invitation to give information; Knowledge; Explore emotions and empathise; Strategy and summarise (SPIKES) model. Though they have almost similar component, SPIKES model is the most commonly followed in clinical scenarios. ⁵ Local data on this aspect is scarce. Abbas et al. showed that 40% of the doctors working in palliative care setting in Pakistan could not break the bad news properly.6 While Jameel et al. showed that 85% of the participants were not comfortable in breaking the bad news. ⁴ The current study was planned to evaluate the BBN skill of postgraduate residents in a tertiary care setting.

Subjects and Methods

The cross-sectional descriptive knowledge, attitudes and practices (KAP) study was conducted at the King Edward Medical University, Lahore, Pakistan, from January to April 2016, and comprised postgraduate residents of different specialties at Mayo Hospital, Lahore. The sample size was calculated by using 95% confidence level, 4% margin of error with expected percentage communication skills spikes protocol as 9%.⁴ All postgraduate trainees working in medical, surgical and allied wards were included in the study, whereas house officers and consultants were excluded. Those who were absent due to educational leaves were also excluded.  Subjects were divided into two groups. One group comprised postgraduate trainees (PGTs) working in medicine and allied specialties, and the second group had PGTs working in surgery and allied specialties. List of the PGTs was obtained from the registrar office and PGTs were selected by simple random sampling technique using the computer-generated method. Written informed consent was taken from all the subjects, and approval was obtained from the institutional review committee. Data was collected using pre-designed, pre-tested questionnaire (Annexure)



which was validated after the discussion with academic members and subject specialists for content validity. All the respondents received a short and simple self-administered questionnaire in English, with a covering letter explaining the project and stating their rights as respondents to the survey. An interview-based questionnaire covering all the aspects of the SPIKES protocol was conducted by the same research team member to assess BBN skill of PGTs. The questionnaire consisted of two sections. The first section was regarding personal details of the  postgraduate residents including age, gender, department and year of training. The second section consisted of 31 items was based on the main BBN steps, especially the SPIKES model. Data was analysed using SPSS22. Quantitative variables like age were presented as mean } standard deviation. Qualitative variables, like  gender and responses, were presented as frequencies and percentages. Association between medical and surgical wards was calculated with chi square test. P<0.05 was considered significant.

Results

Of the 200 respondents, 141(70.5%) were males and 59(29.5%) were females. Overall mean age of the sample was 23}2.55 years. Of the total, 94(47%) respondents were only fairly satisfied with their breaking bad news skill, while 130(65%) were eager to get training in this regard. The knowledge regarding breaking bad news protocols was lacking across all comparisons (p>0.05) (Table-1).



BBN skill of 85(65.9%) residents was developed by simple observation of their seniors who didn't receive any BBN training. A total of 104 (54.2%) residents had to break bad news several times in the preceding six months. There was no difference between the residents of surgical and medical wards (p=0.44). Communication skills of each resident was assessed based on the SPIKES model (Table-2).



Overall, 76(37.8%) individuals usually established rapport with the patient before BBN. Only 38(18.9%) respondents indulged in BBN to patients whereas 69(34.3%) did it to the attendants only due to family pressure. Only 19(9.5%) provided written material to the patient or attendants regarding complete understanding of the disease process. The only positive association was found between gender and BBN training (p<0.05).

Discussion

A major dilemma that healthcare providers are facing in the modern era is conveying of diagnostic and therapeutic facts and figures related to the disease of patient.^7-9 This study provides a valuable local perspective about the knowledge, awareness and attitudes of residents at Mayo Hospital with regards to the bad news broken to the patients. Patients today expect their physicians to give honest information about their health status. ¹⁰This study, therefore, provided an insight to better understanding of physician's pursuit in providing a better standard of care to their clients. Almost half of the respondents didn't follow any BBN guidelines to the patients or attendants whereas a significant majority was not aware of the SPIKES model. Almost one-third of the respondents in our survey (65%) were quite eager to receive BBN training. This is comparable to the results of a study conducted in Dutch medical schools where most residents recommended longitudinal programmes with experiential skills training sessions and clinical practice, and to involve simulated patients, physicians and psychologists in training programmes as well as practising physicians who may supervise students during clinical work. ¹¹ Most of the patients wish the news to be broken to them verbally at a peaceful place. Studies have revealed that an ideal location for a physician to do BBN is one that is comfortable, quiet, private with minimal interruptions and large enough to accommodate multiple staff and family members, if they are present^6,10,12 In our study, 35% participants took permission from the patients before BBN. In another study, 63% patients wanted the doctors to take explicit permission from them before BBN.¹⁰ In ourstudy, more than half the residents (58%) reported that they avoided giving information to the patient due to family pressure of not telling the patient about their situation. This is comparable to a study in which doctors described communication patterns mainly formed by their work experience and often guided by the patient's family requests. Doctor, patient and family characteristics and organisational features and resources were reported to affect the delivery of bad news.¹³ The patient'semotional reaction in response to a bad and unexpected news is a big challenge for most of the physicians. It is also an important component of the 6-step SPIKES protocol.¹ In our survey, 37.8% residents gave time to the patients to express their feelings and emotions after a BBN session. A study recommended that the physician should assess and respond to the emotional reactions and be attuned to the body language of the patients after listening to the bad news.¹⁴ Very few patients were usually provided with the written material explaining the disease course, therapeutic strategies and prognosis owing to the decreased literacy rate of the patients and lack of training workshops on BBN for the residents. It is evident from our study that interpersonal communication skills and professionalism are the mainstay of the process of achieving a desirable satisfaction level of the patients with their physicians while getting bad news. ^15-17A study conducted to determine the efficacy of communication skill training for giving bad news revealed that it significantly improved the skills of postgraduate medical residents. ¹⁸ There are some limitations of the current study. Firstly, the population selected comprised PGTs so it was not representative of the entire population. Secondly, verbal skills of the participants were not monitored. Thirdly, patient's perspective and feedback regarding a physician's communication skills was not considered. Future studies should focus on the involvement of practising physicians, validation of both verbal and nonverbal techniques and monitoring effects of improved communication skills in terms of patients-level outcomes. It is strongly recommended that doctors' BBN skills should be enhanced using different simple techniques, like training courses, conducting workshops, adoption of a step-wise protocol and focussing to remove barriers to communication in an effective and sympathetic way.

Conclusion

Majority of the residents had little satisfaction regarding their BBN skills. It is necessary to plan special training for the residents in this key area.
Conflict of Interest and Source of Funding: None to declare.
Disclaimer: The article has not been previously published or represented in any conference or any other relevant information.

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