Doctors learn how to give bad news to patients

In a small room at Orlando Health, a somber scene unfolds: Dr. Morgan Wilber has to tell a mom and dad that their child is brain-dead.

But the “parents” are really professional actors, helping Wilber, an emergency medicine resident at Orlando Health, sharpen one of the most difficult and important skills in medical communication: giving bad news to patients.

“When a child or a person dies, that moment is like a snapshot in your mind,” said Noelle Moore, a mom who lost her baby and now observes residents and offers insight on their performances. “You never forget what the person says to you, how they say it and the different sights and sounds in that moment.”

For the past two years, Dr. Anthony Orsini has been training residents on delivering bad news.

His Breaking Bad News program is among the rising number of similar efforts across different levels of medical education that are emphasizing the importance of communications to young doctors.

“I tell doctors if you sit down with a patient, they’ll actually trust you more,” said Jake Poore, a patient experience expert and president and chief experience officer at the consulting firm Integrated Loyalty Systems. And harm goes beyond medical harm, “so why do you want to harm them emotionally.”

Experts say the push is partly driven by the Affordable Care Act, which has tied patient experience with reimbursements.

“Medical practice and society has changed,” said Dr. Analia Castiglioni, medical director of UCF’s College of Medicine’s Clinical Skills and Simulation Center. “It’s become more consumer-oriented. So now we’re teaching students how to be patient-centered. We have recognized it’s a skill that can be learned.”

Orsini, who’s a neonatologist at Arnold Palmer Hospital for Children, started researching the art of breaking bad news nearly two decades ago.

“I tried to find different ways of teaching this and what we found is that the only way to learn this is through experiential learning,” Orsini said.

He created hourlong sessions, where one resident gets a scenario, delivers the bad news to professional actors while being videotaped, and then sits down with doctors and lay people like Moore to review the performance.

“It’s very difficult to break bad news to a patient. More difficult than you expect,” Wilber said. “It’s one of those things you can’t have enough practice in.”

Research has shown that only a small percentage of physicians feel adequately prepared to break bad news to patients.

Most recently, Dr. Kimberley Monden and colleagues at Baylor University Medical Center found from a survey that only 40 percent of surgeons felt that they had training to effectively deliver bad news, even though more than 90 percent of respondents had said that delivering bad news was a very important skill.

“Where research is really lacking in this area is does this [training] translate in the real world, and that’s really hard to find that,” said Monden, director of surgical education at the Department of Surgery at Baylor. “It’s an obstacle for most researchers. Ultimately the patient knows if it was done well.”

The professional actors who worked with Wilber were satisfied with her performance. They liked that she sat down with them, leaned in, listened and even offered to pray with them. Orsini too was impressed, and he told Wilber that his suggestions were mostly nit-picking.

Wilber’s first training in breaking bad news was at UCF College of Medicine, where students practice different skills interacting with standardized patients who are mostly lay people.

Depending on the program, some students get an hour of lecture in breaking bad news, some get practice with standardized patients, and some get to participate in more hands-on training in programs like Orsini’s.

Castiglioni of UCF said that the majority of residents in the hospitals in Orlando get some form of training in breaking bad news.

But Orsini says that his program, which involves professional actors, is not common practice yet. Over the years, he has presented his program at different meetings, but to his surprise, many residency education programs that were interested to replicate what he does told him that they didn’t have the funds for it. Hiring three professional actors for a day costs about $2,500.

So he created the BBN Foundation four years ago to help others get their program off the ground. Foundations at Orlando Health gave him $30,000 to run the training at their hospitals.

He trained 16 pediatric residents last year and is aiming to train between 60 to 80 residents here. The BBN Foundation has helped train more than 300 residents in different hospitals over the last four years.

It has also begun designating Centers of Excellence for compassionate communication, which is for hospitals that have made a commitment to train at least four specialties for three years on breaking bad news.

Orlando Health is one of the three in the nation that’s received that designation so far.

“We tell [doctors] that from the moment you give a person bad news, you’re going to be a part of their life forever,” said Orsini. “It’s a very important thing and I think most lay people are shocked to learn that we don’t get trained in it.”

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