Delivering bad news troubles med students - Diagnosis

Incoming medical residents who are about to treat children and teens for the first time believe they are ill-equipped and poorly trained to deliver bad news to young people and their families. A Brown University, Providence, R.I., study recommends additional medical school and residency training in "breaking news of serious diagnoses with patients of different ages."

"Residents just do not get enough medical school education or experience in sharing bad news with younger patients and their families," argues lead author Catherine Dube, who teaches clinical interviewing skills to first-year medical students. "They don't have strategies planned on how to do it, and they need more formal training in those skills. If you haven't observed the breaking of bad news to a young person and their family and you haven't tried it, it is going to be very difficult to do."

The findings are based on self-assessments of 184 medical residents entering programs in pediatrics, internal medicine, and family practice--specialties most likely to diagnose and treat young people. The residents noted their previous training time with adult, pediatric, and adolescent patients, and ranked their comfort levels in sharing bad news with each. Residents were presented with several "bad news" scenarios, such as informing a 70-year-old woman that she has terminal cancer or telling the parents of a 14-year-old that their child has a brain tumor. Respondents anticipated their greatest discomfort discussing serious illness in younger patients and the least discomfort in speaking about that topic to adult and elderly patients.

Twelve percent of residents reported no formal training in pediatric communication skills, and 11% had none for adolescents. More than half surveyed had never observed a pediatric or adolescent "bad news" interaction. In contrast respondents estimated that their training time with adult patients was greater than any other age category and rated that training as the most sufficient About half had personally informed a patient or family of a serious diagnosis, most often concerning middle aged or elderly individuals.

The majority of medical school communications training involves adult patients. It is a simpler model compared to speaking with children or teens at various levels of development in an examining room with at least one parent or guardian. "A five-year-old may not understand science but will understand an explanation of how they will feel and what the will experience going through a diagnostic procedure," Dube contends. "Procedures need to be discussed with children. Children need to be calmed. Even if something is not serious, a doctor must gain a child's trust. And doctors need to listen to the subjective information from a child, who is the only one who can explain how much something can hurt."

Dube suggests strengthening communication skills training in the pediatric clerkship in medical school, which is mandatory for students. During pediatric clerkships, some physicians may exclude students from serious cases. That practice should be curbed, she asserts. In addition, Dube recommends that all residencies create as many opportunities as possible for new doctors to develop the skills necessary for breaking bad news to children, teens, and loved ones. "As long as students are well-supervised, they should be allowed to participate in serious cases. I don't think a patient and family would be upset by the presence of an empathic medical student."

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