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Original Research
Family physicians ability versus other specialty physicians in breaking bad news skills to patient in Suez Canal University Hospital and family practice centres Sally Mohammed Moawed*, Ismail Mohammed Youssef, MD**, Hanan Abass Elgammal, MD* * Department of Family medicine, Faculty of medicine, Suez Canal University. ** Department of Neuro psychiatry , Faculty of medicine, Suez Canal University. Abstract: Objective: To assess family physicians ability to break bad news to the patient versus the ability of physicians from other specialties in breaking bad news. Patients and methods: A cross sectional study was carried out in family practice centers and Suez canal university hospital that are affiliated to faculty of medicine Suez canal university to compare the performance of family physicians in breaking bad news skill versus the performance of physicians from other specialties in this skill using a Breaking Bad News Assessment Schedule (BAS) which was a method of evaluating how well a physician breaks bad news to the patient. Results: the study found that the mean total skill score in the family physician group (78±10.8) was statistically significantly higher than that of the other specialties group (61±12.4) and the majority (91.7%) of the family physicians group were satisfied by their ability to break bad news, compared to (43.3%) of the other specialties physicians. Conclusion: the study revealed that the total performance of breaking bad news in the five areas and the mean of total score of breaking the bad news was higher in the family physician group than in the other specialties group. Keywords: breaking bad news, communication skills, terminal illness care. Introduction and Rationale: Bad news is defined as "any news that drastically and negatively alters the patient's view of her or his future 1. Bad news often is associated with a terminal illness such as cancer. However, bad news can come in many forms: the
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diagnosis of a chronic illness (eg, diabetes mellitus), disability, or loss of function (eg, impotence), a treatment plan that is burdensome, painful, or costly; and even information that physicians may perceive as neutral or benign 2 . In fact, many recent studies have found that most patients want to know the truth about their illness 2. Physicians frequently must break bad news to patients and their loved ones 3. How bad news is presented may affect patients' comprehension of and adjustment to the news as well as their satisfaction with their physician 4, 5. Historically, the emphasis on the biomedical model in medical training places more value on technical proficiency than on communication skills. Therefore, physicians may feel unprepared for the intensity of breaking bad news, or they may unjustifiably feel that they have failed the patient. The cumulative effect of these factors is physician uncertainty and discomfort, and a resultant tendency to disengage from situations in which they are called on to break bad news 6. Many physicians have had little or no formal training in how to break bad news, and many perceive a lack of time in which to present the news. Patients may have multiple physicians, making it unclear who should break the bad news 7. From the previously mentioned review, we need to assess the ability of both family physicians and other specialties in breaking bad news skill.
Subjects & Methods: A cross sectional study was carried out to compare the performance of the family physicians in breaking bad news skill versus the performance of the physicians
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from other specialties in this skill. The study involved 120 physicians each group involved 60 physicians selected by using stratified random sample. The study was carried out in the family medicine centers that were affiliated to the family medicine department in the Suez Canal University and in the out patients clinics that were affiliated to internal medicine department, pediatric department, oncology department and in the obstetric &gynecology department in the Suez Canal university hospital. Physicians from both genders and physicians with the following scientific degrees: M.B.B.Ch, master degree and MD were included in the study. Ministry of health physicians was excluded. The tool used in this study was self administered questionnaire that was distributed to the physicians involved in the study. It was completed by each physician as self assessment. The questionnaire was divided into two parts as following: (1)First part was designed to investigate the socio demographic data of the physicians and their job characteristics as following: Sex, Scientific degree, Years of experience, Specialty, if the physicians were involved in breaking bad news to the patient and any training courses in breaking bad news skill were received by physician during his /her pre or post graduate education. (2)The second part was Breaking Bad News Assessment Schedule (BAS) which was a method of evaluating how well a physician breaks bad news to the patient. It consists of 23 items divided into 5 subject areas. It was developed in Oxford, England 8 Subject Areas: -Setting stage: This section looks at whether the doctor facilitated an initial rapport before breaking the bad news. -Breaking the news: This section specifically focuses on Whether the doctor was sensitive to the patient's perspective when he/ she Delivered the news. -Eliciting concerns: This section focuses on whether the doctor actively attempted to gain a clear idea of the personal implications and meaning of the news to the patient, and the concerns that it generated.
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Original Research -Information giving: This sections looks at aspects other than giving the news itself. -General considerations: These points relate to the interview as a whole. According to the likert scale, the answer for each question was choosing one word from five words. These five words represent a gradual score that range from 1 to 5 in which 1 was minimum score and 5 is maximum score. Breaking bad news assessment score was calculated as a summation of answers of all 23 items in which minimum score was 23 and maximum score was 115.The adequacy of performance was considered if the total score was above 60% (>69point). Results: Results showed similar distributions of gender and qualifications. The experience of physicians in both groups was five years or more, with the mean being slightly higher among family physicians. Concerning the frequency of breaking bad news to patients, there was a slightly higher percentage among family physicians. Meanwhile, the difference in attending postgraduate courses in breaking bad news was striking, with almost all family physicians having attended such courses, compared to only 13.3% of physicians from other specialties. Performance was higher in the family physician group in all five areas of assessment. The differences were all statistically significant (p<0.00.1). The lowest area of performance in the family physicians group was in eliciting concern (88.3%) while in the other specialties group it was in the area of setting the stage (51.7%). the means of the performance scores of breaking bad news between physicians in the two groups demonstrates statistically significantly higher scores in the family physicians group (p<0.00l). This was evident in all tested areas. The widest difference between the two groups was in the area of setting the stage. Overall, the mean total skill score in the family physician group (78±10.8) was statistically significantly higher than that of the other specialties group (61±12.4).
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The majority (91.7%) of the physicians in the family physicians group were satisfied, compared to (43.3%) of the physicians in the other specialties group. The difference was statistically significant (p<0.001). There was statistically significant difference in the need for training courses in breaking bad news between physicians in the two study groups (p=0.03). It is evident that almost all physicians in the other specialties (98.3%) have expressed such a need, compared to 86.7% of the family physicians. No statistically significant associations could be detected with either satisfaction or need. The only family physician with inadequate performance was dissatisfied with own performance, and expressed the need for more training courses in this skill. It is evident that all physicians from other specialties groups with inadequate performance (100.0%) had not attended postgraduate courses in breaking bad news, compared to 77.8% of those with adequate performance and this was statistically significant. there was a statistically significant relation between adequacy of performance and satisfaction with skill performance (p<0.001). About two thirds of those with inadequate performance were satisfied (63.9%), compared to only 12.5% of those with inadequate performance. Meanwhile, no statistically significant relation could be detected between adequacy of performance and need for more training courses in this skill. Table 1 demonstrates statistically significant moderate positive correlations between the scores of performance and physician's qualification, the experience years. This was shown for both groups separately and combined. The strongest correlation was between experience years and performance score among family physicians (r=0.69). As regards the number of times of breaking bad news, it had a statistically significant weak positive correlation with the scores of performance only in the family physicians group (r=0.26). In order to identify the independent predictors of the score of performance of the skill of breaking bad news, multiple
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Original Research linear regression analysis was done. The best fitting model is presented in Table 2. It is evident that being a family physician, with longer experience years, having broken bad news to patients more frequently, and having attended postgraduate courses in breaking bad news were the statistically significant independent positive predictors of the performance score. The strongest predictor, as indicated by the standardized beta coefficient was the experience years, followed by being a family physician. The model collectively explains 62% of the variation in the performance score, as indicated by the value of r-square. . Discussion: The result of current study showed that the total performance of breaking bad news (98%) and the mean of the total skill score of performance in family physicians group (78±10.8) were higher than the total performance of breaking bad news (60%) and the mean of the total skill score of performance in the other specialties physicians group (61±12.4). This result may be due to emphasis on the principles of family medicine, including the importance of patientcentered interviewing, basic communication techniques and providing continuity care to patients makes the family physician in an ideal position to compassionately, yet clearly, convey devastating news. Having already developed a sense of mutual trust, the family physician is often in the position to break such news 9. Also, using the biopsycho-social approach in the family medicine that stress on the psychological issues and social issues and their effect on the health make the family physicians in better position for breaking bad news. The lower performance of other specialties physicians in the present study could be explained by the study that was done by Sonia Dosanjh, Judy Barnes and Mohit Bhandar 10. This study aimed to examine residents' perceptions of barriers to delivering bad news to patients. The residents discussed the barriers that prevent breaking bad news guidelines from being implemented in day-to-day practice such as lack of emotional support from health professionals,
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available time as well as their own personal fears about the delivery process prevented them from being effective in their roles. Residents relayed the need for increased focus on communication skills and frequent feedback with specific emphasis on the delivery of bad news.
Although most residents realize important guidelines in the delivery of bad news, their own fears, a general lack of supervisory support and time constraints form barriers to their effective interaction with patients .So the lower performance of breaking bad news in the other specialties physicians in this study may be due to hospital based day to day practice, lack of available time, lack of communication skills, lack of professional support and personal fear from being engaged in such situations. In the current study, it was found that the weakest area of performance with the lowest score in the family physicians group was in the eliciting the concern (88.3%). This was in agreement with a recent survey of oncologists showed that handling emotions was by far the most difficult element in breaking bad news 11 Another study conducted at San Diego County, California was not in agreement with the present regarding the difficulty in eliciting concern. The study measures surgeons’ attitudes toward self-perceived competence, importance, need for training in the communication skills. Most respondents rated their competence high except in the skills relating to giving the patient bad news. They found all skills important and indicated a need for training in them. Younger surgeons rated their competence and the importance significantly lower in the skills relating to giving the patient bad news 12. These variables between the present study and California study may be due to difference in the tools of assessment of competences used in both studies and different setting of breaking bad news. Also, difference in specialty and culture may play a role in this variability. In the current study the weakest areas of performance in the other specialties group were in setting the stage (51.7%) then in giving bad news (58.3%) then in
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Original Research eliciting concern (60%).this was in agreement with a review of empirical work done by Elwyn et al, 13 that shows that physicians lack skill in telling bad news and dealing with their patients’ feelings (13, 14, 15, 16). Anther study done by Ford and Fallowfield, was in agreement with the current study regarding weak performance and difficulty in eliciting patient concerns. The study found in a content analysis of doctor–patient interactions that oncologists of a large teaching hospital in London delivered patients all the relevant information concerning their diagnosis, treatment options and prognosis, but abstained from discussing patients’ emotions or well being 17. Also, weak performance in giving bad news and difficulty in eliciting patient concerns that was found in the current study could be explained by a study that was done by Cantwell and Ramirez, 18.It found that many junior house officers in two hospitals in London felt they lacked adequate skills in psychological issues and never inquired about the emotional adjustment of a dying patient. Their major reasons for not addressing death with their patients were lack of time, wishing to avoid awkward questions and inadequate skill. So the weak performance in giving bad news and difficulty in eliciting patient concerns that was found in the other specialties group in the current study may be due to general lack of competence at delivering bad news and a poor “patient-centered” interviewing style that was also found among residents of general internal medicine at Wayne State University, who delivered a diagnosis of lung cancer to a simulated patient 19. In the current study there was statistical significance in the difference of the level of physician’s satisfaction between two study groups. The level of satisfaction among family physicians (91.7%) was higher than the level of satisfaction of other specialties physicians (43.3%). The higher level of satisfaction in the family physicians group may be due to their adequate level of knowledge about communication skills, availability of several guidelines on how to break bad news to the patient and stressing on the
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bio-psycho-social approach in their consultation. Also in the current study, there was no statistical significance between adequacy of performance and level of satisfaction in the family physician group. This result may be referred to the application of continuous professional development program in the family practice which made the physicians searching for higher level of performance that can affect their satisfaction. On the other hand, there was statistically significant relation between the level of physician’s satisfaction and adequacy of performance in the other specialties group. Lack of knowledge about communication skills, stressing on biomedical model and stress experienced by physicians during the process of breaking bad news may explain the lower level of satisfaction among other specialties physicians group. The result of current study regarding the difference in satisfaction level may be due to the stress experienced by the physicians during the process of breaking bad news despite adequate performance or following recent guidelines or recommendation. This explanation presented in the investigation done by Ptacek J.T et al 16, the goal of this investigation was to gain a better understanding of the processes associated with communicating bad news to patients. The majority of physicians reported following most of the published recommendations for delivering bad news. However, the number of recommendations followed was not correlated with self-reported stress and effectiveness in news delivery. Overall, physicians reported that the transaction was moderately stressful for them, that the stress lasted beyond the recalled transaction, and that they were effective in delivering the news in a way that reduced patient distress. The fact that many of the physicians reported that their stress lasted beyond the transaction itself and result in low level of satisfaction suggests that training in the delivery of bad news should include guidance on cognitive and behavioral coping strategies to help physicians deal with their own discomfort and raise their satisfaction level.
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Original Research In the present study, it was found that the majority of the study groups need training in breaking bad news communication skills. (86.7%) of the physicians in the family physicians group and (98.3%) of the physicians in the other specialties group expressed their need for training in this skill. This result was in agreement with the study done by Sise and his colleagues, 20, demonstrated that surgical specialists perceived a high rating of importance for a set of skills related to giving the bad news to the patients and interactions with patients. They also expressed a belief in the need for training in these skills. A similar relationship between age and the rating of importance was found for the skill of listening to patients and family’s anxieties. All age groups felt it was either fairly or extremely important (between 86% and 92%). Extreme importance was more commonly chosen by those in age groups 40 to 49 and 50 to 59 years. The belief in a need for training in the 12 skills was supported by a significant majority of all age groups. In the current study the most statistically significant relation was between adequacy of performance and attending postgraduate courses in breaking bad news in other specialties physicians group. The same was observed by the European Donor Hospital Education Program (1995) which was a part of a randomized controlled study to assess the effects of workshop attendance on the competence of intensive-care-unit doctors in breaking bad news. For ten experimental and ten controls doctor the researchers reported positive changes in the communication skills of doctors after the course 21. Finally, the multiple linear regression model for the scores of performance that was performed in this study showed that being a family physician was strong predictor for high score and consequently adequate performance. Communication of bad news is an essential skill for any family physicians. As a result, family physicians are in an ideal position to help physicians from other specialties in correction of breaking bad news skill and to help patients with a terminal disease face their illness with compassion and dignity 22.
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Limitations of the study: Since it is a self-assessed questionnaire, may be there are problems with bias, such as prestige bias. The data are self reports by physicians; no attempts were made to assess the actual behaviors by physician in giving bad news to patients as it can be done by direct observation. Thus, respondents may over report that they engaged in such steps more than they actually did, and may have not performed some of the steps in a competent fashion. These possibilities only serve to emphasize the need for more educational interventions for physicians in this important area of communication. The study did not assess the performance in different types of bad news. How physicians communicate bad news may be dependent upon the clinical situation and their familiarity with the medical condition. Finally, this study did not attempt to assess patients' opinions about how bad news is communicated to them or impact of the way of breaking bad news on patient satisfaction. Conclusion: The study revealed that the total performance of breaking bad news in the five areas and the mean of total score of breaking the bad news was higher in the family physician group than in the other specialties group. References: 1- Buckman R (1999): Breaking bad news: why is it so difficult? BMJ 1999; 288:1597-9. 2-VandeKieft GK (2001): Breaking bad news. Am Fam Physician; 64(12):1975-8. 3- Baile WF, Buckman R, Lenzi G, Glober E, Beale A and Kudelka A P(2000): SPIKES—A six-step protocol for delivering bad news: application to the patient with cancer, Oncologist 5 ,pp. 302–311. 4- Frankel RM, Morse DS and Suchman A (1991): Can I really improve my listening skills with only 15 minutes to see my patients? HMO Practice; 5:114-20. 5-Girgis A and Sanson-Fisher R.W (1998): Breaking bad news, current best evidence for clinicians. Behavioral Medicine; 24:5 3-9.
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Original Research 6- O'Hara D (2000): Tendering the truth. Am Med News; 43:25-6. 7- Markel H (2002): Cleopatra's syndrome: blaming the bearer of bad news. J AmA; 26:11-23 8- Miller SJ, Hope T and Talbot DC (2000): The development of a structured rating schedule (the BAS) to assess skills in breaking bad news. Br J Cancer, 80: 792-800. 9- Buckman Rand Kason Y (1992): How to break bad news: a guide for health care professionals. Baltimore, MD: Johns Hopkins University Press: 65-97. 10- Sonia D, Judy B and Mohit B (2001): Barriers to breaking bad news among medical and surgical residents. Medical Education 35 (3), 197–205 11- Baile WF, Kudelka AP, Beale EA, Glober GA, Myers EG and Greisinger AJ(1999): Communication skills training in oncology. Description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer; 86:88797. 12- Michael J S, Beth C, Daniel I, Sack BA and Maurine Goerhing (2006): Surgeons’ Attitudes about Communicating With Patients and Their Families. Science direct, current surgery Volume 63, Issue 3 , May-June, Pages 213-218 13- Elwyn G H, Joshi D, Dare M, Deighan and Kameen F (2001): Unprepared and anxious about “breaking bad news”: a report of two communication skills workshops for GP registrars. Educ. Gen. Practice. 12, pp. 34–40. 14- Maguire P and Faulkner A (1988): Communicating with cancer patients: Handling bad news and difficult questions. BMJ 297: 907-909. 15- Maguire P (1999): Improving communication with cancer patients. European Journal of Cancer, 35, 14151422. 16- Ptacek JT, Fries EA, Eberhardt T l and Ptacek J J (1999): Breaking bad news to patients: physicians’ perceptions of the process. Support Care Cancer 7, pp. 113–120. 17- Ford S. and L.S. Fallowfield (1996): Doctor–patient interactions in oncology. Soc. Sci. Med. 42, pp. 1511–1519. 18- Cantwell B.M. and AJ Ramirez (1997): Doctor–patient communication: a
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study of junior house officers, Med Educ 3, pp. 17–21. 19- Eggly SN, Afonso G, Rojas M, Baker L, Cardozo and. Robertson R S(1997): An assessment of residents’ competence in the delivery of bad news to patients. Acad. Med. 72, pp. 397–399. 20- Sise MJ, Sise CB, Sack DI and Goerhing M (2007): Surgeons’ Attitudes about Communicating With Patients and Their Families. Current Surgery Volume 63, Issue 3, May-June, Pages 213-218 21- Morton J, Blok GA, Reidi J, Van Dalen J and Morley M (2000): The
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Original Research European Donor Hospital Education Programme (EDHEP): enhancing communication skills with bereaved relatives. Anaesthesia and Intensive Care 28, 184–190. 22- Berg AO and Allan ML (2001): Breaking Bad News: The Many Roles of the Family Physician the New U.S. Preventive Services Task Force. American Academy of Family Physician; 2(3):81-99.
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TABLES
Table 1. Correlation between scores of performance of breaking bad physicians qualifications and work experience.
Qualification (reference; MBBCh)@ Experience years No. of times of breaking news (reference: never)@
Total skill score Family physicians (n=60) 0.67** 0.69** 0.26*
(*) Statistically significant of p<0.05 (@) Spearman rank correlation
Other Specialties (n=60) 0.49** 0.55** 0.25
news and
Total Sample (n=120) 0.44** 0.59** 0.10
(**) statistically significant at P<0.01
Table 2. Best fitting multiple linear regression model for the scores of performance of breaking bad news Beta coefficient Unstandardized 67.62
Standard Error 5.48
Standardized
p-value
Constant <0.001* Group (reference: other 10.56 2.65 0.37 <0.001* specialty physician) Experience years 1.02 0.14 0.44 <0.001* No. of times of breaking news 4.76 1.66 0.17 0.005* (reference: never) Attended postgraduate courses in breaking bad news to patients 6.29 2.77 0.22 0.025* (reference: no) r-square: 0.62 Model ANOVA: F-47.39, p<0.001 Variables excluded by model: sex, qualification, attendance of undergraduate courses in breaking bad news, satisfaction with performance.
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