Breaking bad news: how do doctors learn?

Categories: Education.

It’s an office that could be anywhere, except for the clinical examination bed in the corner, complete with curtained cubicle. The A4 sign blu-tacked to the door reads: “Room booked for breaking bad news all day.”

Six medical students sit listening. “They’re real. They cry, they shout,” the facilitator, a doctor, tells the circle in front of her. Nerves crackle in the air, a few people let out self-conscious laughs. The facilitator is referring to the two actors who have come to rehearse scenarios with the students, who are one year from being qualified doctors.

Understandably, they have a lot of concerns: about getting emotional, whether or not they should touch patients, saying the wrong thing, not saying the right thing, not saying anything at all. 

The scenarios are given out. The students’ eyes hurriedly scan down their sheets of paper. Cringes. Sharp intakes of breath. One scenario is based around telling a parent that their son has suspected schizophrenia. Another, that a person’s relative has unexpectedly died in hospital. One peers over his neighbour’s shoulder. “You got the short straw,” he says, shaking his head.

When the time comes, his neighbour heads for the door. “You might want to take in some tissues for this one,” the facilitator tells him. “Yeah, for me,” the young man replies. 

The rest of the group watch on a live video link, seated in plastic chairs in a half-moon in front of the screen. They touch their faces self-consciously, arms crossed protectively across their bodies. The speaker hisses.

In the room sit a couple. The woman fiddles with her handbag, refusing to accept the news. The man stares silently at his hands, fists clenched around his mobile phone. “Is that true, or just something you say?” he says aggressively to the young doctor. He’s just been told that his baby, born at just 26 weeks, has severe brain damage and is unlikely to survive. 

The students’ eyes dart to each other across the room. A shake of the head, a smile, a wince, sensing their colleague’s pain – pain they are all going to feel for themselves sooner or later.

The actor

Jay Worthy played four roles the day I observed him – and in all of them he received bad news. He’s been acting for nearly 30 years and it’s 20 years since his first training role-play, for a water company. But this day he was there for medical students, taking their turns to tell him the worst.

“They’ve got so many things running round their head, including their fear, and their plan that they had for it [the role-play],” he says of the students. But, of course, anyone giving bad news could be nervous, anxious, inexperienced or unsure.

His advice is to remember that a conversation goes both ways. “My feeling is that listening is the secret… Listen to what [the patients are] saying and try and not to listen to the prejudices in your head…” he says. “I think that’s the best a patient can hope for in a doctor.”

Worthy stresses that doctors need to be flexible. He says, for example, that if you stick rigidly to the idea of giving a verbal ‘warning shot’, an indication that bad news is on the way, then things can go wrong when the patient pre-empts you. 

“Pretty much all of the doctors I’ve ever been in a breaking bad news situation with want the best for the patient,” says Worthy. “Sometimes that means that they’re too gentle, and that affects the clarity of the message.”

He has seen many situations where students say, “It’s all going to be fine”. “But it’s not,” he says. “Ultimately it’s not going to be fine. It’s going to be different. Things come out of their mouths because they want to reassure.” 

How can role-playing help develop skills? He remembers one job he worked on with call centre staff. Some trainees struggled to put aside their negative personal feelings for particular callers. Sometimes they’d feel a ‘successful outcome’ was if they’d won the argument or put the phone down, rather than sorting out the problem with the caller’s mortgage. 

The call centre trainees developed a way to stop themselves from getting too personally involved – by role-playing the person they would like to have on the end of the phone if they were the one calling. People who were quick to be aggressive played somebody who wasn’t, for example. 

These characters weren’t an amateur-dramatics kind of concoction, says Worthy, just a slight separation between themselves and the person they could play, to stop them being affected by an aggressive person. “Obviously people who are about to have their homes repossessed are afraid and could be aggressive. It’s not personal,” he says. “It’s the same in the medical role-plays. My opinion is that the majority of negative stuff comes out of a fear of something.”

Worthy is not sure whether this technique would work for doctors, “but it’s a thought,” he says. “If you’re somebody who’s very affected by having to tell somebody this news, then maybe you play somebody who is less affected by it… play the character of somebody who is able to not cry when you’re giving information to people.”

This article has been adapted from ‘Breaking bad news‘, published by Mosaic.

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