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Abstract
Background Delivering bad news to patients is one of the most challenging tasks in medical practice. Despite its great relevance to patients, relatives, and medical staff, there is a paucity of data pertaining to training, experience, expectations, and preferences of physicians and medical students on breaking bad news.
Methods We conducted an international survey in Germany, Switzerland, and Austria using an online questionnaire among physicians and medical students.
Results A total of 786 physicians and 303 medical students completed the survey. Physicians stated that 32.7% deliver bad news several times a week and 45.2% several times a month. Difficulties controlling their emotions (35.1%) and remaining professional (43.4%) were the greatest challenges for physicians. Delivering bad news is associated with feelings of anxiety, both among experienced physicians (median of 3.8 out of 10.0) and medical students (median of 5.3). Conveying bad news is a burden to physicians and consequently has a substantial impact on their job satisfaction. All participants reported the need for more communication training concerning this subject. Only 49.5% of medical students and 67.3% of physicians mentioned having learned adequate communication skills. Our data demonstrate that communication training decreases the level of anxiety and increases the feeling of self-confidence towards breaking bad news. Preferred educational tools were seminars with simulation (students: 71.4%, physicians: 49.5%), observing more senior faculty (students: 57.4%, physicians: 55.1%), and supervision and feedback sessions (students: 36.3%, physicians: 45.7%). The largest barriers regarding education on communication were limited time (students: 77.0%, physicians: 74.9%) and missing awareness of supervisors (students: 60.6%, physicians: 41.1%).
Conclusions Our study showed a great need for systematic training and education in breaking bad news among physicians and medical students. Hospitals, medical schools, and postgraduate training programs are strongly encouraged to fill this gap, and improve sustainable doctor–patient communication to overcome the psychological burden for physicians.
- Cross-Sectional Studies
- Quality of Life (PRO)/Palliative Care
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, an indication of whether changes were made, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Breaking bad news is an essential and impactful aspect of daily medical practice.
WHAT THIS STUDY ADDS
This study demonstrates that breaking bad news is a burden for physicians and is associated with feelings of anxiety among medical students and physicians. Communication training reduces anxiety and increases self-confidence; however, students and residents often lack (optimal) training.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Medical students and physicians emphasize the need for more education on this topic in medical school and residency training.
Introduction
Conveying bad news to patients is one of the most challenging and significant tasks in medical practice. The benefits of good physician communication skills have been indicated by studies demonstrating that physician communication is positively correlated with patient adherence,1 reduced emotional distress, and increased self-efficacy.2 The way that physicians deliver difficult and existential medical messages correlates with the level of patient motivation to continue treatment and affects therapeutic outcomes.3 Greater patient dissatisfaction and poorer patient outcomes have been associated with healthcare providers finding it difficult to deliver bad news.4 5 Furthermore, delivering bad news can be a great psychological burden for physicians.6
Step-by-step protocols such as the SPIKES model on how to optimally deliver bad news have been established7 and studies have revealed the educational effectiveness of communication training in this area.8 9 Communication training programs can thereby also substantially improve patient outcomes10 11 and adherence.1 In certain countries, medical students have access to communication training.12 This is, however, still not the case for the majority of medical students worldwide, as estimated by a recent international study showing that only 26.6% of medical students are offered education in this area during the course of their medical training.13 14 Offered communication courses mostly consist of simulation conversations with actors or fellow students, and it is not known whether the timing and setting of the currently offered education is optimal and offers medical students sufficient preparation in daily medical practice.
Moreover, despite its great significance for healthcare providers, patient well-being, and medical outcome, there is a lack of data concerning training in communication and training preferences of physicians and medical students in breaking bad news. Data are especially lacking with respect to this topic originating from European countries.
The aim of this study was to investigate experiences, the degree of training obtained, and desired future education of physicians and medical students on the topic of breaking bad news.
Methods
Between February and September 2020, we surveyed physicians and medical students in Germany, Switzerland, and Austria using an online questionnaire. The survey was conducted by the North-Eastern German Society for Gynecological Oncology (NOGGO eV) and was supported by the medical universities in Berlin (Germany), Basel (Switzerland), and Graz (Austria), the online medical knowledge platforms Amboss and Esanum, the major gynecologic oncologic societies Swiss-AGO and AGO-Österreich, the International Psycho-Oncology Society (IPOS), and the European Art Guild for Medicine and Culture.
The questionnaire was developed after a list of relevant topics and potential questions was defined by a working group of gynecological oncologists, psycho-oncologists, medical students, and a statistician. Additional topics were derived from a related survey conducted by the American Society of Clinical Oncology (ASCO).7 The majority of questions were generated on the basis of suggestions by members of the working group. The working group was then consulted to test and optimize the question and answer options for the final questionnaire. This questionnaire comprised two separate versions aimed at medical students and physicians, respectively.
A pilot study to examine the reproducibility and comprehensibility of the questionnaire was carried out among 10 volunteer medical students and 10 volunteer physicians before commencement of the survey. Accordingly, the average time for completing the survey was 5 min for medical students and 10 minutes for physicians. Data recorded in the questionnaire included demographics, medical students’ and physicians’ clinical experience, and their training and educational preferences. The questionnaire comprised 21 items for medical students and 38 items for physicians (questions that pre-suppose experience with breaking bad news are not applicable to medical students, as they are generally not conveying bad news to patients by themselves). We included students attending any year of medical school in Germany, Switzerland, and Austria aged >18 years, as well as physicians from all medical specialties (both residents in training and consultant physicians), working in Germany, Switzerland, or Austria at the time of inclusion. The bad news at issue in this study can therefore be related to any medical specialty.
Participation in the survey was completely anonymous. Written consent for the survey was obtained from the Ethics Committee of the Charité University Hospital, Berlin, Germany. The full questionnaire can be viewed in the online supplemental appendix.
Supplemental material
Statistical Analysis
We reported all characteristics by frequencies and percentages. Analyses between different subgroups of participants were performed using the independent sample t-test, the Mann–Whitney U test for nonparametric data, and the chi-square test for categorical data. We examined and excluded confounding by gender and age in our linear regression model. We examined the effects of communication training by linear regression with explorative post-hoc pairwise comparisons by estimated marginal means. These analyses were adjusted for multiple testing, age, and gender, because gender interaction effects were observed. Differences were considered statistically significant at p<0.05. All analyses were performed with Statistical Package for Social Sciences (SPSS version 26.0, SPSS Inc., Chicago, IL, USA).
Results
A total of 1146 participants participated in the survey. We had to exclude 8 students and 46 physicians that were not eligible for evaluation due to incomplete answering. Three more students were excluded that did not meet our inclusion criteria (1 midwifery student, 1 physician assistant student, 1 healthcare management student). A total of 1089 participants were included in the final analysis, comprising 303 medical students and 786 physicians.
Demographic characteristics of respondents are shown in Table 1. The median age of medical students was 24 (range: 18–69) years and physicians 42 (range: 24–81) years. Overall, two-thirds of participants were female and 80.9% were attending medical school in Germany or had done so in the past (84.4%). Physicians were mostly employed in hospital care (n=463, 59%) or in a practice (n=283, 36%). We included both residents in training (n=334, 43%) and consultant physicians (n=408, 52%), including 201 (26%) gynecologists, 147 (19%) internal medicine specialists, and 144 (18%) general practitioners (Table 1).
Characteristics of survey participants
Breaking Bad News: the Physician Experience
In total, 32.7% of all physicians deliver bad news several times a week and 45.2% several times a month. These conversations usually take 10–20 min, although a majority (55.1%) would rather spend more than 20 min per patient. The participating physicians generally believe that the focus in breaking bad news should be less on empathizing with patients than on straightforwardly presenting them with the facts. However, when asked how often bad news conversations go as expected, they only rated this question a mean of 6.7 out of 10.0.
Physicians report that they find it most difficult to control emotions such as grief or compassion (35.1%) and to remain professional in providing adequate information and finding the balance between empathy and pity (43.4%). When delivering bad news, 70.4% of the physicians are generally alone with the patient; only 57.4% encourage patients to be accompanied by their relatives. The reason for the physician not being accompanied by another healthcare professional is not a lack of interest; rather it appears difficult to organize within the working day and the limited time available.
It was reported that communication with patients has a big impact on the physicians’ job satisfaction (median score 9.0 out of 10.0). The degree of self-confidence during these conversations is estimated to be a mean score of 6.3 out of 10.0. Also, physicians experience this aspect of their work as particularly burdensome (mean score of 5.4 out of 10.0). Female physicians did report a significantly higher mean score of burden due to conveying bad news than did their male colleagues (5.7 vs 4.9, p<0.001). The reported level of burden for physicians does not seem to be influenced by the hours of communication training they received nor by how often they currently have to deal with delivering bad news.
Playing sports and engaging in conversation with a partner or colleague mainly help to deal with this burden. Physicians state that they would be interested in reflective supervision sessions at work to evaluate difficult working scenarios with colleagues (median score of 7.0 out of 10.0). Only 7.1% are currently using this coping strategy.
Anxiety and the Need for Communication Training
When assessing the feeling of anxiety towards breaking bad news, medical students display a significantly higher mean score than physicians (5.3 vs 3.8 on a scale of 0 to 10, p<0.001) (Figure 1). In both groups, women report a significantly higher mean score of anxiety than men (4.5 vs 3.7, p<0.001). The need for communication training is acknowledged among all participants (mean score of 7.9 and 7.5 out of 10.0, respectively, for students and physicians) (Figure 2). In fact, only 49.5% of medical students and 67.3% of physicians mentioned having learned adequate communication skills. The majority of physicians did not spend any time on the topic during medical school or residency (39.1% and 43.3%, respectively); however, 44.4% did invest 1–10 hours in self-studying. The reported need for further communication training among physicians appeared independent of their estimated skills and knowledge on the subject and the frequency that they are currently dealing with bad news delivery.
Anxiety scores for medical students and physicians, depicted by gender.
Need for training for medical students and physicians.
The upcoming generation of doctors has spent more time during medical school on breaking bad news training, with 55.9% investing up to 10 hours on this topic. The largest barriers to undertaking communication education are primarily limited time (students: 77.0%, physicians: 74.9%), but also missing awareness of supervisors (students: 60.6%, physicians: 41.1%).
Positive Effect of Communication Training on Anxiety
We observed a positive effect of communication training on the level of anxiety towards breaking bad news among medical students. Whether this training took place during medical school or by self-studying, the anxiety scores all significantly decreased, by as much as 50% after spending >20 hours on education compared with none (Figure 3A). A similar statistically significant finding was detected among physicians for education during medical school, facultative training sessions, and self-studying, demonstrating a 50% lower feeling of anxiety after spending >20 hours of training on this topic (Figure 3B).
Anxiety scores relative to hours spent on communication training among medical students (A) and physicians (B).
The feeling of self-confidence during bad news conversations among physicians was significantly increased following the education obtained in medical school, facultative training, and self-studying (Figure 4). These associations were all statistically significant for participants who reported spending >20 hours on communication training versus no training and versus 1–10 hours of training.
Feeling of self-confidence among physicians, relative to hours spent on communication training.
Preferred Training Tools and Strategies
With respect to potential future communication training, physicians in training would prefer to learn by observing their superiors, whereas medical students prefer seminars with simulation patients (online supplemental table S1). Physicians and students believe that digital tools may help in preparing delivery of bad news (51.0% and 57.4%) and for educational purposes (50.4% and 57.8%). Physicians suggest incorporating communication training during the residency period, and medical students during medical school.
Supplemental material
Influence of Intercultural Differences
Most physicians (93.3%) claim to adjust the way they deliver bad news depending on the cultural background of their patients. They mainly try to consider potential intercultural differences in coping strategies to deal with emotions and disease. We observed that the majority of respondents feel that intercultural differences are not or are insufficiently represented during the current medical curriculum (physicians: 87.6%, students: 72.5%), and believe that there is a need to incorporate this topic more in the future (mean score of 6.7 and 7.1 out of 10.0 for physicians and students, respectively).
Discussion
Summary of Main Results
This large, international survey highlights the issues associated with delivering bad news in medical practice. The results demonstrate the extensive emotional and psychological burden on physicians with a substantial impact on their job satisfaction. Delivering bad news is clearly associated with negative feelings of anxiety, both among experienced physicians and medical students. All participants reported a great need for more communication training concerning this subject. Our data demonstrate that communication training decreases the level of anxiety experienced in connection with breaking bad news and increases self-confidence.
Results in the Context of Published Literature
Within our survey, physicians reported that delivering bad news to patients is a burdensome task. This is reflected by the fact that physicians found it most difficult to control their emotions and remain professional, and by their relatively high anxiety scores. The burden of breaking bad news is widely supported by other studies where this aspect is often defined as a stressful task.7 15–17 Actual stress responses have been demonstrated during breaking bad news simulations by rapid heart rate and heart rate variability peaks, especially among physicians who were inexperienced and/or fatigued.18
We also observed that communication with patients has a large impact on physician job satisfaction. Despite the level of discomfort connected with this topic, both medical students and physicians claim that breaking bad news and dealing with conversations about incurable disease and death have very little influence on their choice of (desired) medical specialty (median score of 1.0 and 2.0 out of 10.0 for physicians and students, respectively).
Although we could demonstrate that medical students today have spent more time during their studies on learning how to communicate bad news to patients, the overall opinion among our participants is that there is still a great need for communication training on this topic. Throughout many different countries, this observation is widely supported by others.16 19–21 Recently, Alshami et al demonstrated that only 30% of medical staff in 40 different countries worldwide received training in this field.14 Especially in Asia and Europe, healthcare providers reported no previous formal training.14 In Germany, Simmenroth-Nayda et al described that in the year 2011 students declared a need for more and earlier training in breaking bad news than was offered in their curriculum.22
For physicians, our results are supported by the findings of another survey study, which reported that 43% of physicians had received training in delivering bad news (vs 40.2% in the present study).23 In 2000, Baile et al reported that fewer than 10% of physicians had received formal training on delivering bad news.7 Consistent with the evident desire for more training possibilities, our physicians scored relatively low (6.3 out of 10.0) when assessing their level of self-confidence during these conversations. This is in agreement with other findings, where only 53% of respondents consider themselves capable of breaking bad news, 39% to be fair, and 8% poor.7
One observation from our study was the level of anxiety among students and physicians. Fortunately, even after relatively little time investment, a positive effect of various types of communication training on feelings of anxiety and self-confidence was observed. It has been reported that for patients and relatives too, feelings of anxiety are positively impacted when they are cared for by physicians who have had communication training.24 Moreover, training has been proven to improve physician capability of monitoring distress in patients.25 Training and educational programs for patients and relatives could even improve patient empowerment.26
Our data demonstrate that physicians prefer to incorporate communication training during residency, and medical students during medical school. In order to be most effective, we and others suggest offering these courses repeatedly during both medical school and residency training.9 22 The relevance of recurring communication training is also underpinned by our observation that the perceived need for additional communication training was independent of physicians’ estimated communication skills and their level of experience.
The high anxiety scores among medical students and the poor assessment of their own communication skills may be related to a lack of experience, but perhaps the currently offered teaching methods are not accurate. Students prefer to participate in seminars with simulation patients, as has been suggested by others.19 27 Various learning methods have been analyzed in the literature, and it has been shown that role modeling, demonstration, and bedside teaching are all highly rated by learners. It would appear especially valuable to incorporate observation possibilities, feedback opportunities, and repeated practice opportunities.9
Physicians in training would rather learn from their superiors, as was also demonstrated in another survey conducted among pediatric residents.19 We and others suggest that one optimal method of education for residents in training is the possibility to repeatedly perform difficult patient contact under supervised guidance, followed by personalized evaluation.19 Furthermore, we suggest that digital tools may be used for educational purposes and in preparing bad news conversations. Digital tools could be of particular benefit in countries or universities that do not have the financial resources to easily incorporate expensive communication training into their medical curricula. Based on our findings, our final recommendation is to include the increasingly important aspect of intercultural differences in training programs.
Even after optimizing communication training, breaking bad news is bound to remain a demanding part of medical care. The level of burden among physicians was, for instance, not reduced by the hours of communication training they received nor by their level of experience. Better time management seems to be one essential additional factor. Our data suggest that physicians would rather have more time in which to deliver difficult news to patients. If more time was available, they would also have another colleague or healthcare professional in attendance and allow relatives to be present, both potential factors in improving the bad news conversation setting. Our respondents also suggest implementing reflective supervision sessions for physicians, and coaching residents in training in a personalized manner. We would also encourage providing education in stress coping strategies for physicians, since it has been reported that stress related to breaking bad news persists beyond the specific conversation itself.15
Strengths and Weaknesses
This is one of the largest international surveys examining the subject of breaking bad news among both medical students and physicians. We were able to obtain a solid overview of the current perceptions about this essential aspect of medical practice within all German-speaking European countries. In addition to the existing literature, we are the first group to compile a list of recommendations to improve education and training in these communication skills. Although in our study there is an overrepresentation of physicians in gynecology, internal medicine, and general practice, we did include a wide range of different medical specialties.
While also performed in Austria and Switzerland, this study displays an overrepresentation of participants who currently work or study medicine in Germany. For this reason, the study was underpowered to examine differences within the three participating countries. Although we can not directly translate our results to other countries, we believe that our observations are also relevant and applicable to other countries with similar medical curricula. Another limitation of our study is the presence of potential selection bias due to the large proportion of eligible participants who were sent a notification and link to our survey but did not complete it. A sensitivity analysis for this subgroup was not feasible, as these subjects were not defined or retraceable. One could imagine, however, that subjects who were interested in this topic would be more likely to participate in the survey than subjects who had no interest in it. Optimally, we would have used a validated questionnaire. Confounding due to age and gender was excluded, but preferably more participant characteristics would have been available to check for residual confounding. Lastly, the cross-sectional design of the study does not allow for adequate assessment of causality of any observed associations.
Implications for Practice and Future Research
We propose to conduct a prospective study to analyze the (long-term) effectiveness and potential benefits of the proposed educational interventions and other recommendations. For such a study it will be desirable to examine potential effects from both the physicians’ and the patients’ perspective.
Conclusions
We have demonstrated that breaking bad news is associated with feelings of anxiety and is perceived as a burdensome task. Our study participants expressed the need for structured support on this topic and the desire to improve communication skills. We showed that communication training can decrease the level of anxiety associated with delivering bad news and increase self-confidence. Hospitals, authorities, medical schools, and postgraduate training programs are strongly encouraged to fill this gap by offering recurring communication training, (reflective) supervision, guidance in stress coping mechanisms, and optimizing time management. This will likely have a positive effect on the job satisfaction of (future) physicians and consequently improve patient care.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval for the survey was granted by the Ethics Committee of the Charité University Hospital, Berlin, Germany.
Acknowledgments
The authors thank Ms Seyma Boz for her support in the digitalization of the survey, Mr Dario Zocholl for his contribution to the statistical analysis, and Prof. Dr Kirsten Mahlke for her contribution to the initial concept of this project. They also thank the North-Eastern German Society of Gynaecological Oncology for its contribution to the funding of this study, and all participating physicians and medical students for providing such relevant survey data.
References
Footnotes
Contributors EMH participated in the design and distribution of the survey, collection of data, responsible for the statistical analysis of data, and wrote all versions of the manuscript. APS was involved in the collection of data and contributed to the final version of the manuscript. JB was involved in the distribution of the survey and contributed to the final version of the manuscript. KP was involved in the collection of data and contributed to the final version of the manuscript. EP was involved in the design of the survey, contributed to the distribution of the survey, and contributed to the final version of the manuscript. VH was involved in the design of the survey, contributed to the distribution of the survey, and contributed to the final version of the manuscript. ER was involved in the design of the survey, collection of data, and contributed to the final version of the manuscript. DD was involved in the design of the survey, collection of data, and contributed to the final version of the manuscript. GO-Ö was involved in the distribution of the survey, collection of data, and contributed to the final version of the manuscript. OC was involved in the distribution of the survey, collection of data, and contributed to the final version of the manuscript. JS was responsible for all aspects of the study, the design of the survey, distribution of the survey, interpretation of the statistical analysis and contributed to all versions of the manuscript. All authors approved the final version of the manuscript.
Funding This work was funded by the North-Eastern German Society for Gynecological Oncology (NOGGO eV), Berlin, Germany.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.