DELIVERING BAD NEWS: COMMUNICATION
STYLES AMONG 1ST YEAR IM RESIDENTS
Carissa Pereda
Internal Medicine R3
End-of-life Communication:
Problems and Importance
• Patients report poor clinician-patient
communication as primary concern1 2
• Trainees report being uncomfortable and
untrained in end of life communication
• Trainees’ self-reported competence not
associated with patient/family assessments
• Trainees benefit from experiential trainings
Improving Clinician
Communication Skills Study
• Design: RCT of interdisciplinary communication
intervention– “CodeTalk”1
• Goal: to improve end-of-life communication skills
among MD, NP trainees
• Curriculum: experiential, adult learning
• Communication strategies (SPIKES, NURSE)
• Practice with simulated patients
• Evaluation:
• Outcomes: Patient, family, clinician surveys of trainee
communication skills
• Process: Pre- and post- intervention audiorecordings of
trainees with standardized patients
1
Curtis et al.
Study Goal: What Do Trainees Do?
• How do trainees respond to patients, prior to
workshop training?
– Recognizing diversity of communication styles
– Identifying/describing these styles/techniques
– Reproducibility with existing data?
• Standardized patient interviews with required
behaviors or “triggers”
–“I have to tell you, I’m really scared”
–“Is there any hope for a cure”
Methods and Materials
• Sample: pre-intervention audiotapes
(n=173)
• MUSC, n=60; UW, n= 113
• Trainees: 1st year IM residents
• Random selection of 50 pre-intervention recordings
• Standardized patient interviews
• “Cathy” with recurrent ovarian cancer
• “Thomas” with recurrent colon cancer
Interviews
• Resident task: Deliver results of a CT scan:
– Recurrent cancer (colon and ovarian) with
metastases
• Patient task: Stay in character!
– Provide 3 behaviors at any point during the
interview
• 20 second silence post bad news
• “I have to tell you, I’m really scared”
• “Is there any hope for a cure”
Analysis
• Goals:
– Identify and describe communication techniques
utilized by residents in response to target statements
– Develop a framework of “codes” to describe/evaluate
communication techniques
• Methods:
– Team (n=3) established codes from 5 audios
– Single investigator coded and compared subset of
audiotapes to assess trustworthiness (n=25)
– Trainees review subset (n=5-10) for validity
CODEBOOK
EMPNORM
CLININFO
Normalizes/reassures patient that
emotion is appropriate ("very
understandable/normal to be scared"
"you have a right to be scared")
Provides clinical information/medical
terminology to patient
DEFER
Defers conversation to oncology
DIRECT
Provides clear/direct explanation to
patient ("cure for cancer is not possible"
"there is hope for a cure")
Explores patient's emotion with open
ended inquiry into emotional
statements. (Tell me what is most
scary.)
EXPLORE
Is there any hope for a cure?
• I can’t be a 100%. Right
now it looks like your
disease would actually
be classified as stage 4.
I don’t know if you
know the stages of
cancer, but stage 4
would be the end stage,
meaning that it has
spread from the colon
to another part of the
body.
• I can’t really answer
that question. I wish I
could. I think it’s better
if you talk to the
oncologist. If they could
offer you surgery,
maybe there’s a small
chance for a cure. I
can’t comment on
exactly what your
prognosis is going to be.
I have to tell you, I’m really scared.
• Tell me more about
that. What is making
you feel scared?
• That’s very
understandable. It is
normal to be scared.
“The single biggest
problem with
communication is the
illusion that it has taken
place.”
-George Shaw
MANY THANKS:
-Research Team
-Randy Curtis
-Ruth Engelberg
-Erin Kross
-GOOGLE images
-Invaluable mountain of
prior research