Breaking Bad News Communication Module: Incorporating Evocative Stories From Patients Improves OSCE Performance East Tennessee State University Department of Family Medicine Cancer Stories Project Forrest Lang, MD James Gorniewicz, MA Michael Floyd, EdD

Background Video recorded interviews with –patients with cancer –physicians Training module based on stories from patients and physicians Measured impact of module on cancer communication OSCE performance

Methods: Interviews Patients 104 semi-structured interviews Purposeful sampling Cancer types: colon, breast, prostate, leukemia (AML and CML), cervical, thyroid, brain, etc. Physicians 20 semi-structured interviews Purposeful sampling Family medicine, surgery, oncology, and hospice

Methods: Interviews Patient Interviews –60-90 minutes –“Please begin by sharing any stories or personal experiences that might help others to appreciate what it has been like for you to have cancer. You can start wherever you’d like.”

Methods: Interviews Patient Interviews – Focused prompts Receiving bad news (primary and secondary) Emotions Family’s past experience with cancer Information preferences Decision-making preference and experiences Honesty/hope preferences and experiences Palliative care Clinical trials Spirituality and religion End-of-life care Hospice and death Recommendations

Methods: Interviews Physician Interviews –60-90 minutes –“Please tell us about your most challenging communication situations involving care of cancer patients and their families.”

Methods: Interviews Physician interviews –Focused prompts Breaking bad news Emotions Decision-making Honesty/hope Prognosis – timeline Family Spirituality and religion End-of-life care Recommendations

Methods: Interviews Audio transcribed verbatim Qualitative data analysis by two raters (IRR>.90). 552 thematic codes identified

Methods: Module Literature-based and experiential-based model for patient-centered cancer communication 25 video clips (<60 secs) from patients and physicians Simulated clinical scenarios Integrated written quiz to engage the learner (e.g. What would you say to this patient?) 1 hour to complete

Methods: Module Video Examples –Breaking bad news (shock)Breaking bad news (shock) –Jargon 1Jargon 1 –Jargon 2Jargon 2 –Don’t worryDon’t worry NOTE: Due to IRB restrictions, we are not allowed to upload patient interview videos to the STFM website. However, these videos are available for viewing by contacting James Gorniewicz He will send you a secure video link and/or a disc containing the clips.

Methods: OSCE Demographics N= Students (medical, nursing, and pharmacy) 64 Family Med Residents (PGY 1, 2, & 3) 3 Internal Med Residents (PGY 1 & 2) 7 Oncology Fellows (PGY 4 & 5) Gender Female = 45% Male = 55% Age Mean = 28 years (range 19-41) Ethnicity Caucasian = 62% Asian = 32% African American = 4% Hispanic = 1% Native American = 1%

Methods: OSCE Intervention Group Colon cancer OSCE 1 & Training Module Colon cancer OSCE 2 (30 days after OSCE 1) Analysis (Raters and Stats) Control Group Colon cancer OSCE 1 Colon cancer OSCE 2 & Training Module (30 days after OSCE 1) Analysis (Raters and Stats)

Methods: OSCEs Random assignment of learners to intervention or control group. 15 minute colon cancer OSCE scenario w/ standardized patient (baseline and follow-up) –7 minutes to review patient chart –8 minutes to conduct interview OSCE video recorded and judged by 1 of 3 raters (IRR>.90).

Results Qualitative feedback from learners: overall positive and spontaneous “It can sometimes be hard to know what to say when you have not been through the problems personally, so it is good to see examples. I really enjoyed seeing the videos with actual patients.” “It is hard to know how to handle situations like these with different patients, and knowing how a patient would like to be notified of the news is pertinent in building a relationship with them.”

Results Before breaking bad news to a patient… –[decrease] Distracting ice breaker or prolonged introduction with signs of patient becoming uneasy (p=.007) –Asks how the previous biopsy/diagnostic procedure went (p=.001) During breaking bad news… –Provides forewarning “The news is not good.” (p=.005)

Results After breaking bad news… –Use of clear language (no unexplained jargon) (p=.047) –[decreased] After stating “cancer”, immediately proceeds to providing additional information re: cancer, Tx, etc. (p=.004)

Results After breaking bad news (cont.) –Explicitly asks patient about her reactions to hearing bad news. (p=.001) –Preferences re: readiness to proceed (p=.001) –Information preferences – General (qualitative) vs. Specific (quantitative: charts, graphs, percentages) (p=.006)

Results After breaking bad news (cont.) –Responds non-verbally (silent pause, lean in, touch, etc.) to patient’s non-verbal expression. Encouraging a verbal response. (p=.028) –Explores personally charged verbal clues (p=.024)

Results Anytime during interview… –Asks about feelings “Would you like to talk about how you’re feeling?” or “How are you feeling?” (p=.000) –[decreased] Discourages expression of feelings “Don’t worry.” (p=.010) BEFORE: Pt: “I’m a little nervous today.” Dr: “Don’t be nervous. Just relax.” AFTER: Pt: “I’m a little nervous today.” Dr: “It’s okay to be nervous. What are you concerned about?”

Results Overall ratings… –Active listening for understanding of patient’s ideas, concerns, and expectations (p=.000) –Addressing feelings (p=.004) –Closing the interview (p=.002) –Global interview score (p=.000)

Summary Including stories in communication training modules appears to be an effective path to improving communication skills. Patient-driven, stand-alone modules demonstrate the potential to improve clinician performance in OSCE situations.

5 Training Modules 1.Breaking Bad News 2.Living Through Treatment: Gathering Info, Emotions, and Shared Decision-Making 3.Transitioning from Curable to Treatable to End-of-Life Care 4.Family 5.Spirituality and Religion

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