Barriers to breaking bad news among medical and surgical ... to breaking bad news... Barriers to breaking bad news among medical and surgical residents Sonia Dosanjh,1 Judy Barnes1 & Mohit Bhandari2 Introduction Communicating bad news to patients

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Barriers to breaking bad news among medicaland surgical residentsSonia Dosanjh,1 Judy Barnes1 & Mohit Bhandari2Introduction Communicating `bad news' to patientsand their families can be difcult for physicians.Objective This qualitative study aimed to examineresidents' perceptions of barriers to delivering bad newsto patients and their family members.Design Two focus groups consisting of rst- and sec-ond-year medical and surgical residents were con-ducted to explore residents' perceptions of the badnews delivery process. The grounded theory approachwas used to identify common themes and concepts,which included: (1) guidelines to delivering bad news,(2) obstacles to delivering bad news and (3) residents'needs.Setting McMaster University, Hamilton, Ontario,Canada.Subjects First- and second-year residents.Results Residents were able to identify several guide-lines important to communicating the bad news topatients and their family members. However, residentsalso discussed the barriers that prevented these guide-lines from being implemented in day-to-day practice.Specically, lack of emotional support from healthprofessionals, available time as well as their own per-sonal fears about the delivery process prevented themfrom being effective in their roles. Residents relayed theneed for increased focus on communication skills andfrequent feedback with specic emphasis on the deliv-ery of bad news. The residents in our study also stressedthe importance of processing their own feelingsregarding the delivery process with staff.Conclusions Although most residents realize importantguidelines in the delivery of bad news, their own fears, ageneral lack of supervisory support and time constraintsform barriers to their effective interaction with patients.Keywords *Communication; education, medical;emotions; family; patient care, *psychological,standards; physicians, *standards.Medical Education 2001;35:197205IntroductionThere is a need for effective communication in healthcare. This is especially salient for patients facing afrightening diagnosis and an uncertain future forthemselves or for family members. Although manyhealth care professionals deliver `bad news' on a dailybasis, most feel uncomfortable and relatively unpre-pared for the interaction. In most circumstances, thedelivery of bad news is a life altering experience forpatients and families. Therefore, physicians at all stagesof their careers should endeavour to relay `bad news' topatients with the utmost sensitivity.Bad news has recently been dened in the medicalliterature as pertaining to situations where there iseither a feeling of no hope, a threat to a person's mentalor physical well being, a risk of upsetting an establishedlifestyle, or where a message is given which conveys toan individual fewer choices in his or her life.1There have been two studies, which have attemptedto address residents' perceptions of delivering badnews.2,3 These previous studies were based on quanti-tative research designs and used surveys to collect data.Residents were found in these studies to experiencediscomfort with psychosocial issues related to theconveyance of `bad' news. Moreover, few residents metpublished guidelines for doctorpatient interactionwhen they prepared patients for potentially threateningprocedures. While these studies revealed the residents'uneasiness in the delivery process, no additional infor-mation regarding the barriers to delivery was reported.Given the paucity of literature on residents' attitudesand relative `preparedness' towards the delivery of `bad1Department of Social Work, Wilfrid Laurier University, Waterloo,Ontario and 2Department of Orthopaedic Surgery, McMasterUniversity, Hamilton, Ontario, CanadaCorrespondence: Dr Mohit Bhandari, McMaster University MedicalCentre, Department of Clinical Epidemiology and Biostatistics, 1200Main Street West, Room 2C12, Hamilton, Ontario, Canada L8N 3Z5Communication skills Blackwell Science Ltd MEDICAL EDUCATION 2001;35:197205 197news', the purpose of this study was twofold: (1) toexamine further residents' perceptions on the deliveryof bad news with specic emphasis on institutional andpersonal barriers, and (2) to identify potential areas offocus in postgraduate medical training.We chose a qualitative research design, whichallowed for candid and in-depth responses fromthe residents. Moreover, a qualitative design permittedgreater time for the residents to express their beliefs oropinions. Additionally, a qualitative research approachensures completeness of the information retrievedrather than leaving out important (and sometimes vital)opinions or aspects of its subjects. The strength ofqualitative research enabled us to conduct focus groupsand permitted exibility to address other concerns orissues that had not been previously explored.MethodsSubjectsResidents from the McMaster University School ofMedicine, Hamilton, Ontario, Canada were interviewedregarding the delivery of bad news to their patients ortheir patients' families. To achieve `representativenessof concepts' from this phenomenon under study, pur-poseful sampling was used to select the residents.4 Inorder to assess whether curriculum changes concerningtraining in the delivery of bad news are required and atwhat point in this training should these changes beimplemented, the views of both rst year and secondyear residents from various subspecialties were sought.We initially interviewed 40 residents from varioussubspecialties at a single hospital site to identify thosewho were in their rst or second year of training. Ofthose interviewed, only 20 were eligible to participate inthe focus group. Five residents did not consent toparticipate in the focus group leaving a total of 15residents for the study.Two focus groups were conducted in an attempt toidentify trends and patterns in perceptions. The rstfocus group contained seven participants, repre-senting four medical disciplines: family medicine,internal medicine, general surgery and emergency.Four of the members were female; three were male.Four participants were rst-year residents and threewere second-year residents. The second focus groupwas composed of a total of four medical (two familymedicine and two internal medicine) and four surgi-cal residents of which four were rst-year residents(two surgical, one internal medicine and one familymedicine) and four were second-year residents. Fourof the residents in the second focus group werefemale.ProcedureResidents participated in a semi-structured, in-depthinterview lasting approximately 15 h. This interviewwas conducted in a private room located in a hospitalsetting. Two facilitators asked open-ended questionsregarding residents' views and experiences concerningthe delivery of bad news. A sample of prepared ques-tions asked were: `What is bad news?', `What sorts ofthings do you think patients and family memberswould consider as bad news?', `What are the thingsyou most need to learn about delivering bad news?',`Imagine you are the patient or family member Howwould you want the doctor to deliver the bad news?'and `What are your greatest fears about delivering badnews?'.Interviews were tape recorded and transcribed ver-batim. Two of the authors independently examined,coded and analysed the transcriptions in an attempt toreduce any bias. For reliability, comparisons were madebetween the two authors. Any discrepancies wereresolved through discussion.Data derived from the two focus groups was codedand the content analysed according to the canons andprocedures of the grounded theory approach to quali-tative research.4,5 Table 1 summarizes the canons ofthe grounded theory method. In this approach,`a grounded theory is one that is inductively derivedfrom the study of the phenomenon it represents. It isdiscovered, developed and provisionally veriedthrough systematic data collection and analysis of datapertaining to that phenomenon'.6The authors of this study used the analytic process ofcoding which is consistent with the grounded theorydesign. Three types of coding were employed. Initiallythe data, through the process of open coding, wasbroken down, named and categorized. Axial coding wasKey learning pointsMedical students are generally aware of theguidelines for delivering bad news.Personal as well as institutional barriers and dif-fering perceptions of bad news were identied asimportant barriers to breaking bad news.Residents reported their numerous role expecta-tions and indicated that specic training andhospital supports were needed. Blackwell Science Ltd MEDICAL EDUCATION 2001;35:197205Barriers to breaking bad news S Dosanjh et al.198then utilized to put the data back together in new ways.This was accomplished by making connections betweencategories and their subcategories. Lastly, by means ofselective coding, categories were integrated to form agrounded theory. Coding and content analysis of theinterview data was performed by two independentreviewers.Residents tended to provide personal narratives inresponse to specic questions; therefore, responseswere often not linked directly to the questions asked.For example, narratives regarding personal experiencesof delivering bad news were reported to the question,`What are your greatest fears about delivering badnews?'. Consequently, responses to all the questionsasked during the interview were combined for purposeof these analyses.ResultsBy organizing associated concepts into unifyingsubcategories, the identication of categories and thediscovery of relationships between these categories, aframework of results was developed. This frameworkconsisted of three major categories, nine subcategoriesand 53 concepts (Tables 2, 3, 4).The rst major category contains informationregarding medical residents' perceptions surroundingthe proper guidelines for delivering bad news topatients and to patients' family members. The secondmajor category describes medical residents' viewsregarding obstacles, both personal and institutional, todelivering bad news appropriately. The third majorcategory contains issues pertaining to medical residents'needs in a hospital setting which ultimately effect thefacilitation of delivering bad news.Table 1 Summary of canons from the grounded theory approach1. Data collection and analysis are interrelated processes2. Concepts are basic units of analysis not the actual data per se.3. Categories must be developed and related.4. Sampling proceeds on theoretical grounds in terms ofconcepts, their properties, dimensions and variations.5. Analysis makes use of constant comparisons.6. Patterns and variations must be accounted for, that is, the datais examined for regularities and irregularities.7. Process must be built into the theory by: (1) breaking aphenomenon down into stages, phases or steps and (2) notingpurposeful actions/interactions.8. Writing theoretical memos is an integral part of doinggrounded theory research.9. Hypotheses about relationships among categories should bedeveloped and veried as much as possible during theresearch process.10. A grounded theorist need not work alone. Discussion withother researchers working on the same topic under study isencouraged.11. Broader structural conditions such as economic conditions,cultural values, political trends and social movements mustbe analysed, however, microscopic the research.2Table 2 Guidelines to delivering bad newsVerbal deliveryLanguageValidatingSomething tangibleEmpathyClarify roleSummaryNon-verbal deliveryFace to faceSitting downTimeSupportive measuresAssessing supportsJudging family's reactionsChoiceQuestionsFinding common groundPatient's comfortAccepting outcomeExhausting all optionsPro-active in treatmentTable 3 Barriers to bad news deliveryResidents' fearsMaking mistakesNot being preparedShame in asking for supportPersonal attachment to the newsAwkwardnessNervousStressTelephone deliveryConfrontationsBeing misunderstoodUnable to follow upDiscernments regarding bad newsProlonging life or deathBiasesStigmasUnusual circumstancesUncommon reactionsContinuum of lossPatient or family instinct(s)Institutional barriersLack of supportTime constraintsBarriers to breaking bad news S Dosanjh et al. 199 Blackwell Science Ltd MEDICAL EDUCATION 2001;35:197205Category 1: Guidelines for delivering bad newsOur rst category entitled `Guidelines for deliveringbad news' included the clinical tools or strategies resi-dents used in order to convey the difcult news(Table 2). The guidelines were broken down into threesubcategories which consisted of verbal delivery, non-verbal delivery and supportive measures.Verbal delivery The majority of the respondents wereaware of previously reported general guidelines ofdelivering bad news to patients and their patients'families.1 The residents stressed the importance oflanguage as a key element in effective delivery. Thelanguage used to the patient or family must be simpleand direct as one participant stated:`I always say die. I always say it bluntly. I never saypassed away because I had an episode where some-one did not understand what I was saying.'1A number of the residents agreed that using unclearlanguage resulted in confusion and misunderstandingfor the patient and their families. Additionally, tominimize confusion among caregivers and patients, theresidents indicated the importance of identifying theirroles and offering something tangible, such as resultsfrom tests, to the receivers of the news. Residents alsosupported showing patients and families empathy aresponse which could include normalizing or validatingthe impact of the news on the patient or family.Non-verbal delivery We found that residents agreed thatnon-verbal delivery, such as sitting down, face to facediscussion and adequate time were essential in con-veying bad news. These gestures complemented theverbal delivery of the news and were felt to reect anempathic response by the residents.Supportive measures Supportive measures were perhapsthe hardest of the guidelines to follow. Supportivemeasures are based on assessment and formulationskills. These measures required the residents to dealwith patients' or families' emotional needs after thenews has been delivered. Medical training has focusedon the skill in obtaining information rather than givinginformation to patients and families on how to copewith difcult information.7 It makes sense, therefore,that these residents struggled over this section.The residents appeared divided over the most dif-cult type of measure to implement. A couple of theresidents identied that judging and responding to thefamily's or patient's reaction was particularly difcult.As one respondent indicated:`Sometimes it's fearful because you already have afamily that you know is quite litigious or unap-proachable so you are always afraid in those situa-tions am I going to say something that's reallygoing to sets things off.'Other residents indicated that honouring thepatient's or the family's choice concerning treatmentwas troublesome and sometimes complicated:`I guess that's where you start towing the ne lines are they capable of making that choice or are theysuffering with depression or something else that reallyneeds tobe treatedandthat'swhere it reallygets tricky.'Other supportive measures included establishing thepatient's comfort, exhausting all resources or options,being proactive in treatment, and accepting the out-come of the prognosis or treatment.The guidelines that were offered by the focus groupwere consistent with some of the existing literatureconcerning difcult news delivery.1,8 The literature is,however, varied in terms of the best approach. This di-lemma resulted in some of the residents being confusedas to the best approach to take when conveying the news:`I guess that brings up to what are the best ways to dothis? I heard those who say you should just go and,you know, say so and so has just died rather thantrying to approach by saying that someone passedaway or died, whatever, but then I heard other peoplesay you should lead up to it.'Although the residents were aware of the guidelines,they experienced difculty in applying them in clinicalTable 4 Addressing resident's needsTrainingBest approachObservationReformExplore attitudes toward death and dyingHospital supportsMultidisciplinary teamTime to prepareTime to processResident's rolesMessengerExpertHeroMartyrAgent of changePrimary care providerTeam playerMachinistBarriers to breaking bad news S Dosanjh et al.200 Blackwell Science Ltd MEDICAL EDUCATION 2001;35:197205practice. According to the residents, the chaotic hos-pital environment, their own personal fears and thepatients' reactions hindered the implementation ofthese guidelines. These obstacles resulted in only par-tial adherence to the guidelines.Category 2: Obstacles to bad news deliveryThis major category includes what was identied in theanalysis of the data as the medical residents' viewsregarding obstacles that block the effective andcompassionate delivery of bad news in a hospital setting(Table 3). The personal and professional experience ofmedical residents regarding this phenomenon has sel-dom been addressed in the literature. Findings for thiscategory are divided into three subcategories: discern-ments regarding bad news, residents' fears and insti-tutional barriers.Discernments regarding bad news Residents notednumerous types of intrinsic factors that affected theappropriate delivery of bad news. Differing perceptionsbetween the resident and the patient or the patient'sfamily members, in regard to what constitutes badnews, had been cited as a factor by the residents in ourstudy. This supports the concept that the perception ofbad news is highly subjective and may differ greatlydepending on one's role in the communication either asthe bearer or the receiver of bad news.1Some level of emotional pain to the patient usuallyaccompanies the delivery of bad news. The durationand intensity of these emotions may vary however,depending on whether the resident and the patientagree about the nature of the bad news.1 Residents inour study suggested that their own biases, or the asso-ciated stigmas regarding particular illnesses, inuencedtheir perception of the news.`I sort of have a real problem with this. I think a lot ofus have our own biases on certain illness and oncertain conditions and states of patients.'A resident's personal bias might well leave him or herunprepared for a patient's or family member's reactionthat appears uncommon. Moreover, residents alsonoted that there is a continuum of loss (for example,broken leg vs. amputation or death) which effects theawfulness of the news. Bor et al. stress the importanceof physicians waiting for the patient to make a judge-ment as to whether the news is good or bad beforeforming their own opinions.9 Many of the residentsexpressed the idea that opinions between themselvesand their patients regarding bad news may differ;however, none of the residents mentioned suspendingjudgement until the patient's reaction had beenassessed. This is of prime importance since dire medicalpredictions and harmful attributions by physicians arestrong enough to affect not only the duration andintensity of emotions but also create anxiety, fear,depression and resignation in their patients.10Residents, as well as established physicians, tend tohave a strong orientation toward cure. Residents statedthat they felt the need to, `do something or feel like youare making a change or an effect' and to `save lives atany cost'. Others, however, were struggling with thedissonant views emerging from the eld of palliativecare. One such resident expressed it best by saying, thefamily of one of her patient's:`had it right when they came in and said, look, I thinkwe crossed that bridge here. We are no longerprolonging this individual's life but we are prolongingtheir death.'When physicians are faced with a situation that theycannot remedy, they often feel ineffective and power-less.8 These feelings may result in the physician limitingtheir relationship with the patient or the patient's familymembers to areas that they feel comfortable.8 Thisconcept of limiting the relationship between physicianand family members is reected in the thoughts of oneresident:`do you just walk in and say, okay they died and I amsorry and there is nothing else we can do and walkout?'Residents' fears Residents reported stress in dealing with,and responding to, patients' and their family members'reactions to bad news. This concept was frequentlynoted by residents in our study.`Not being prepared for the outcome afterwards. It is cleaning up afterwards and dealing with theirreactions which is most uncomfortable, I think.'According to the residents in our study, telephonedelivery of bad news made it especially difcult torespond to, and follow up with, patients' and familymembers' reactions. Additionally, residents alsoexpressed other fears such as being perceived by theirpatients and patient's family members as uncaring or asnot being empathic. This misunderstanding of affectwas reected in the comments of one the residents:`It is my fear that they won't think that I'm caringand that I'm not empathic enough.'Uneasiness with death and dying is cited in the litera-ture as being of concern for physicians. Only one residentexpressed views regarding this topic, which were:Barriers to breaking bad news S Dosanjh et al. 201 Blackwell Science Ltd MEDICAL EDUCATION 2001;35:197205`I mean we have to be comfortable with our ownconcepts around death and dying We have to lookat our own values around that.'Incidentally, immediately following this statement,the topic was abruptly changed, possibly indicatingdiscomfort with this subject matter. Awkwardness withdeath and dying can block the appropriate delivery ofbad news.Institutional barriers Institutional barriers are obstaclesin the hospital setting that block an appropriate deliveryand are structural and/or systemic in nature. Inade-quate amounts of time in various contexts was men-tioned most frequently in our study as an institutionalbarrier to the appropriate delivery of bad news. Thefollowing illustrates this concept.`Sometimes there isn't the time, they [patients] don'thave the luxury [of time] nor do we.'Inadequate amounts of time to prepare oneself, thecontent of the informing interview and the processing ofvarious emotions after the delivery of bad news werereported as signicant impediments by focus groupparticipants. Thiswas best summarized by a resident whosaid,`The way our system works we don't have time totake 10 [minutes] out and have a coffee and togrieve for the losses of our patients' regardless of howbrief the contact or what the setting is. But some-where along the line these things are in our experi-ence base and they need to be dealt with.'This lack of adequate time is more prominent inacute hospital settings where, often, life and deathdecisions need to be made instantaneously. Time forreection appears to be, however, an extravagance inboth the acute-care hospital setting and the chronic-care hospital setting.Not having adequate support from other members ofthe hospital institution was also repeatedly named as abarrier by the residents in our study. Residentsdescribed the need for support from their colleagues,from their supervisors and from other health-careprofessionals. Support from others was mentioned asbeing `important' both during the informing interviewand afterwards. Members of our focus groups suggestedthat, not only do patients' and family members needsupport, but the residents themselves as well.Institutional barriers not only affect the delivery ofbad news from the residents' perspectives but also havedire consequences for services offered to patients andtheir families. Residents noted that time is not availableto provide such needed services as, viewing thedeceased patients' body with family members.`Often times people want to go see their loved onesand make sure they are not breathing and don't havea pulse. Unfortunately, it doesn't work out thatway. Because of time, you got 40 other people wait-ing in your emergency room. Our system doesn'tnecessarily allow adequate or ideal care at themoment.'The defence mechanism of denial is used by mostpeople when initially given bad news, to alleviate whatappears to be senseless, unexpected pain and possibleloss. Many residents in our study were familiar with theprocess of denial experienced by patients and/or familymembers. Immediate life or death decision making plusheavy caseloads which impede residents' from allowingpatients and/or family members adequate time toabsorb their reality, were cited as factors interferingwith the normal process of denial.Category 3: Addressing residents' needsOur nal category of addressing residents' needsemphasizes the tools residents require in order to pro-vide quality health services (Table 4). We wanted toacknowledge the needs of residents that are oftenignored within hierarchical hospital structures. Thefocus of the discussion pertained to changes in training,hospital supports and the different roles residents arerequired to play.Changes to training During the focus groups, the resi-dents were able to come up with clear suggestions thatwould improve their news delivery within a hospitalsetting. The majority of the residents concluded thattraining needed to emphasize the most appropriatemanner in which to deliver news depended on thecontext of the situation. This training should focus onthe similarities and differences of bad news deliverybetween chronic and acute care settings. The residentsalso suggested that direct observation of staff physicianswas helpful but that there needed to be more oppor-tunities to process their interaction, ask questions andreceive staff feedback after the news had been delivered.In addition, some of the residents stressed the import-ance of exploring attitudes toward death and dying intheir training. Many of them believed that this explor-ation would allow them to examine their own biases.Hospital supports The residents noted the signicance ofhospital supports to their training. Hospital supportsare those services, provided within a hospital, thatBarriers to breaking bad news S Dosanjh et al.202 Blackwell Science Ltd MEDICAL EDUCATION 2001;35:197205residents might access for emotional support. Theresidents in our study advocated for a multidisciplinaryteam approach to conveying difcult news. In a studyconducted by Lord et al., 70% of clients preferred thatsocial workers be present when the doctor breaks badnews.11 Residents concluded that team medicinebenets them and their patients. This team approachwould allow the residents more time to prepare andprocess their own emotions regarding the situation oftheir patients and patients' families.`That's why I really think it is important, at least forme it's important, to have another caregiver, whetherit be a nurse or a social worker, who can hear thesame words you are saying and who is not emotion-ally tied to the situation so they are processingmentally everything that has been said and they canfollow it up'`I think they could certainly serve both our needs interms of the anxiety issue, especially in the emer-gency setting.'Roles Residents play a variety of roles when they deliverbad news. Some of the residents were very clear of theirroles as the messengers:`I think part of the key is recognizing that you are themessenger and often times we are going to get shot.'This resident articulated the consequence of this roleduring news delivery. Other residents experienced thepressure of having to play the roles of either the expertsor heroes. The reality of the situation suggests thatresidents cannot save all their patients nor have all theinformation for the families. This former is not alwaysan easy compromise. The most common role the resi-dents described was one of a machinist.`All of the sudden we are telling the family and sowe tell the family and the next thing you know we'rewalking out and picking up the next chart and going.But where's our process in that? When do we come toresolution? It's so easy to feel awkward, like wait, Ijust told somebody that he's dead now, hi I amDr what brings you to the hospital today?'The hospital structure allowed little time for theresidents to process information. As a result, residentscontinued seeing patients as if they were on an as-sembly line of some sort. The residents in our studywere interested in being perceived as members of ateam. The role of team player would then reduce someof the isolation they experience when they break badnews.DiscussionIntuitively people know that health has to do withwholeness. Patients and their family members wantphysicians who care about them as whole beings notonly when they are well but, more importantly, whenthey are ill. Residents from our study want to be per-ceived as caring and empathic by their patients andpatients' family members. Our three major categoriesyielded some interesting results that may help residentswhen delivering bad news. We recommend the need forthe removal of barriers, a shift in paradigm and medicalcurriculum reform as three key components for theempathic delivery of bad news.Removal of barriersThis study has shown that residents are aware of thegeneral guidelines to delivering bad news but theyexperienced difculty when applying them in practice.We identied two studies, which focused upon sur-geons' interactional skills with patients.2,3 In the rststudy, 21 surgical residents were rated on their ability tobreak bad news and discuss potentially life-threateningsurgical procedures with patients.2 Of those 21 resi-dents involved in the study, none were able to dealappropriately with psychosocial issues relating topatient care. Moreover, when the news about a pa-tient's prognosis was bad, only 10% of residents gavesupport to the patients. In a second study, 143 surgeonswere surveyed regarding their skills in patient commu-nication.3 While only 133% of surgeons reported a lackof condence in breaking bad news to patients abouttheir diagnosis or prognosis, a signicantly higherproportion of surgeons (596%) felt uncomfortable withbereavement counselling. The results of these studiessupport our ndings regarding the difculty residentsexperience with having to implement supportive mea-sures. At the same time, however, these studies wereunable to address the barriers that prevented the resi-dents from following the guidelines. The barriers, bothpersonal and institutional, that residents face createinconsistency with implementing the guidelines. Addi-tionally, these barriers prevented residents from havingtheir own learning and emotional needs met.Residents cited time constraints and lack of supportfrom other health professionals as being the two mainfactors in terms of institutional barriers. These factorsaffect an appropriate delivery of bad news and theyinterfere with other consumer-focused services such as,lending assistance while family members' view the de-ceased patient. Moreover, these institutional barriersfeed into the residents' personal barriers. For instance,Barriers to breaking bad news S Dosanjh et al. 203 Blackwell Science Ltd MEDICAL EDUCATION 2001;35:197205both time constraints and lack of support from collea-gues does not allow the residents to process their ownemotional attachments to their patients or patients'families. Additionally, without processing their feelingsor actions, residents may feel anxious if they have todeliver similar news again. This situation plays on theirlack of condence, which was another personal barriercited by the residents.In Canada, $80 billion per year is spent on healthcare. Canadians, however, are increasingly critical ofperceived defects in the health care system. Removinginstitutional barriers and increasing health care fundingmay allow health care professionals to provide service,and to deliver it in a compassionate and empathicmanner.A paradigm shiftConsiderable attention has been given to the contentand the context of the informing interview. Only twostudies cited in the literature, however, concern them-selves with the importance of the affective manner bywhich physicians convey bad news.1,7Emphasis in conventional western medical training isplaced on the biochemical paradigm. Using this para-digm, healers treat defects, pathologies and disabilitiesin a very mechanistic manner. The body is seen as acompilation of parts and, when ill, is treated by a parts`specialist', the physician. This mechanic role wasreected in the comments voiced by the residents in ourstudy. Canadians, in record numbers, are seekingalternatives to conventional medical treatment. Onepossible suggestion given for this trend is the holisticapproach to healing that many alternative treatmentsprofess. A holistic approach is concerned with the body,mind and spirit. It is dehumanizing to treat patients asbody parts void of any humanness.Delivering bad news is not a technical skill where ascript is learned by the residents. Bad news deliveryshould include an emotional connection or response.Instead, residents may distance themselves from theirpatients or their patient's family members, to protectthemselves from the anticipated emotional pain ofothers. Residents may also emotionally and physicallydistance themselves to avoid the manifestation of thatemotional pain. Spending as little time as possible withangry or distraught patients' or family members' maypossibly be a protection mechanism for residents. If,however, residents were supported by other staff, per-haps they would allow themselves to connect more withtheir patients and patients' families.Residents in our study favoured a multidisciplinaryteam approach to delivering bad news. This teammedicine approach not only works with the patientsand their families but also serves as an emotional sup-port for health professionals. This support would allowresidents an opportunity to process their own reactionsto the news delivery. In addition, a team approachwould also reduce the number of roles the residentswould play, thus allowing them greater opportunity todevelop some of their communication skills by learningfrom other disciplines. Team medicine is an asset inreducing both the personal and institutional barriersthat residents experience in bad news delivery. More-over, once the barriers have been removed, residentsare then able to follow the guidelines, including theimplementation of supportive measures, in a moreeffective manner. The end result of this process isquality service for the patients.Medical curricula reformTraditional medical education, as reected in thenarratives of the residents in this study, is ineffective inteaching clinical communication. There is extensivevariability in the quality and intensity of the coursesoffered.12 Traditionally, under the apprenticeshipmodel, complex clinical skills have been acquired byobservation of seniors and by practise, not alwaysobserved by seniors, followed by feedback.13 Some-times, in the interest of time, residents are not providedwith feedback. Furthermore, the approaches by seniorsto delivering difcult news may vary greatly, leading tomore confusion for the residents concerning the bestapproach.Findings from this study indicate that residentswant to learn how to be benecial clinical commu-nicators. A former study has indicated that, in orderto be a benecial clinical communicator, physiciansmust master a specic body of knowledge, skills andattitudes.14 Knowledge of psychiatry as it relates tomedicine, and the structure and functions of medicalinterviewing are suggested as relevant areas whereresidents should acquire skills. The authors of thisstudy would also include knowledge of the issuessurrounding death and dying as another requiredarea. Simpson et al. suggest that skills needed withinthe interview are those of data gathering, forming andmaintaining relationships, dealing with difcult issuesand imparting information, as well as therapeuticskills and strategies.14 Findings from this presentstudy lend strength to these postulates. Simpson et al.also suggest that a belief in the importance of abiopsychosocial perspective and an unconditionallypositive regard for patients are also required ifphysicians are to be benecial clinical communica-Barriers to breaking bad news S Dosanjh et al.204 Blackwell Science Ltd MEDICAL EDUCATION 2001;35:197205tors.14 We feel that the residents should accept thatdeath is an integral part of life and not some foe thatcan always be conquered.Murray et al. have stressed the importance of evalu-ation of which teaching methods enhance studentlearning in different settings.15 This point is criticalin regard to the different learning needs for residents inacute vs. chronic care settings. Residents needs have tobe placed on the agenda of learning to deliver bad news.In conclusion, residents identied several importantbarriers to breaking bad news including personal fears,differing perceptions of bad news, and institutionalbarriers. These barriers may be overcome with in-creased skills training for residents, a stronger supportnetwork of peers and supervisors, and fewer constraintsof time when delivering the news.AcknowledgementsWe are grateful to those rst- and second-year surgicaland medical residents who participated in each of thetwo focus groups.Contributors2SD carried out data analysis, conducted focus groupsand contributed to the preparation of the manuscriptand transcription. JB carried out data analysis,conducted focus groups and contributed to the pre-paration of the manuscript. MB developed the studyprotocol, carried out data analysis and helped withpreparation of the manuscript.FundingNo funds were received in preparation of this manu-script. Dr Bhandari's salary was provided, in part, byan R.K Fraser Foundation Research Scholarship.Dr Bhandari is a Fellow of the Clinical Scientist Pro-gram, Department of Clinical Epidemiology andBiostatistics, McMaster University, Hamilton, Ontario,Canada.References1 Ptacek JT, Eberhardt T. Breaking bad news: a review of theliterature. JAMA 1996;276:496502.2 Eden OB, Black I, MacKinlay GA, Emery AE. Communica-tion with parents of children with cancer. Palliat Med1994;8:10514.3 Falloweld LJ, Clarke AW. Delivering bad news in gas-troenterology. Am J Gastroenterol 1994;89:4739.4 Corbin J, Strauss A. Grounded theory research: procedures,canons and evaluative criteria. Qualitative Sociol1990;13:11521.5 Glasser B, Strauss A. The Discovery of Grounded Theory.Aldine, Chicago: Raven Press, 1967;1271.36 Strauss A, Corbin J. Basics of Qualitative Research. California:Sage Publications, 1990;1258.47 Krahn G, Hallum A, Kime C. Are there good ways to give`Bad News'? 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