Received from the Section of General Internal Medicine and Clinical EpidemiologyVA Boston Heathcare System, Boston Division
B. Graeme Fincke
Evans Department of MedicineBoston University School of Medicine
the Center for Quality, Outcomes, and Economic ResearchEdith Nourse Rogers VA Medical Center
Boston University School of Public Health
the Department of MedicineBeth Israel Deaconess Medical Center
Gregory A. Johnson
the Section of General Internal MedicineBoston Medical Center
Cite this article as:
Orlander, J.D., Fincke, B.G., Hermanns, D. et al. J GEN INTERN MED (2002) 17: 825. doi:10.1046/j.1525-1497.2002.10915.x
CONTEXT: Communication of bad news to patients or families is a difficult task that requires skill and sensitivity. Little is known about doctors’ formative experiences in giving bad news, what guidance they receive, or what lessons they learn in the process.
OBJECTIVE: To learn the circumstances in which medical residents first delivered bad news to patients or families, the nature of their experience, and their opinions about how best to develop the needed skills.
DESIGN: Confidential mailed survey.
SETTING AND SUBJECTS: All medicine house officers at 2 urban, university-based residency programs in Boston.
MAIN OUTCOME MEASURES: Details of medical residents’ first clearly remembered experiences of giving bad news to a patient or family member; year in training; familiarity with the patient; information about any planning prior to, observation of, or discussion after their first experience; and the usefulness of such discussions. We also asked general questions about delivering bad news, such as how often this was done, as well as asking for opinions about actual and desired training.
RESULTS: One hundred twenty-nine of two hundred thirteen surveys (61%) were returned. Most (73%) trainees first delivered bad news while a medical student or intern. For this first experience, most (61%) knew the patient for just hours or days. Only 59% engaged in any planning for the encounter. An attending physician was present in 6 (5%) instances, and a more-senior trainee in 14 (11%) others. Sixty-five percent of subjects debriefed with at least 1 other person after the encounter, frequently with a lesser-trained physician or a member of their own family. Debriefing focused on the reaction of those who were given the bad news and the reaction of the trainee. When there were discussions with more-senior physicians, before or after the encounter, these were judged to be helpful approximately 80% of the time. Most subjects had given bad news between 5 and 20 times, yet 10% had never been observed doing so. Only 81 of 128 (63%) had ever observed an attending delivering bad news, but those who did found it helpful 96% of the time. On 7-point scales, subjects rated the importance of skills in delivering bad news highly, (mean 6.8), believed such skill can be improved (mean 6.6), and thought that more guidance should be offered to them during such activity (mean 5.8).
CONCLUSION: Medical students and residents frequently deliver bad news to patients and families. This responsibility begins early in training. In spite of their inexperience, many do not appear to receive adequate guidance or support during their earliest formative experiences.
doctor-patient communicationgraduate medical educationsurvey research