Distributed May 3, 2003
News Service Contact: Scott Turner
Residents often feel unprepared to break bad news to kids and parents
Medical residents have not had enough education or experience in sharing bad news with younger patients and their families, suggests a new study by researchers at Brown Medical School and Dartmouth Medical School. Their research appears in the May-June issue of Ambulatory Pediatrics.
PROVIDENCE, R.I. — 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 new 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,” said lead author Catherine Dubé of the Brown Medical School. “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.”
Dubé was one of five authors of the study. She teaches clinical interviewing skills to first-year medical students at Brown. The research appears in the May-June issue of Ambulatory Pediatrics.
The findings are based on self-assessments of 184 medical residents entering programs in pediatrics, internal medicine and family medicine – specialties most likely to diagnose and treat young people. The residents noted their previous training time with adult patients and with pediatric and adolescent patients, and ranked their comfort levels in sharing bad news with each.
In the study, residents were also 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 discussing serious illness with adult and elderly patients.
Twelve percent of residents reported no formal training in pediatric communications skills, and 11 percent had no training for adolescents. More than half reported they 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 patients.
“Residents feel less prepared for and receive less training in general communications skills, particularly skills required for delivering bad news, in pediatric clinical interactions compared to interactions with adult patients,” wrote the authors.
Most 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 they will experience going through a diagnostic procedure,” Dubé said. “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.”
Dubé suggests strengthening communications skills training in the pediatric clerkship in medical school, which all medical students must take. During pediatric clerkships, some physicians may exclude students from serious cases. That practice should be curbed, she said. In addition, Dubé recommends that all residencies create as many opportunities as possible for new doctors to develop communication skills 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,” said Dubé. “I don’t think a patient and family would be upset by the presence of an empathic medical student.”
Residents in the study were affiliated with either Brown Medical School, which funded the research, or Dartmouth Medical School. Dubé can be reached at Catherine_Dube@brown.edu or (401) 793-8317.