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Family physicians ability versus other specialty physicians in breaking bad

news skills to patient in Suez Canal University Hospital and family practice
centers

Sally Mohammed Moawed1, Ismail Mohammed Youssef, MD 2, Hanan Abass Elgammal, MD1
1
Department of Family medicine, Faculty of medicine, Suez Canal University.
2
Department of Neuro psychiatry , Faculty of medicine, Suez Canal University.

Abstract:
Objective: To assess family physicians ability to break bad news to the patient versus
the ability of physicians from other specialties in breaking bad news.
Patients and methods: A cross sectional study was carried out in family practice
centers and Suez canal university hospital that are affiliated to faculty of medicine
Suez canal university to compare the performance of family physicians in breaking
bad news skill versus the performance of physicians from other specialties in this skill
using a Breaking Bad News Assessment Schedule (BAS) which was a method of
evaluating how well a physician breaks bad news to the patient.
Results: the study found that the mean total skill score in the family physician group
(78±10.8) was statistically significantly higher than that of the other specialties group
(61±12.4) and the majority (91.7%) of the family physicians group were satisfied by
their ability to break bad news, compared to (43.3%) of the other specialties
physicians.
Conclusion: the study revealed that the total performance of breaking bad news in the
five areas and the mean of total score of breaking the bad news was higher in the
family physician group than in the other specialties group.
Keywords: breaking bad news, communication skills, terminal illness care.
Introduction and Rationale:
Bad news is defined as "any news that drastically and negatively alters the patient's
view of her or his future 1.
Bad news often is associated with a terminal illness such as cancer. However, bad
news can come in many forms: the diagnosis of a chronic illness (eg, diabetes
mellitus), disability, or loss of function (eg, impotence), a treatment plan that is
burdensome, painful, or costly; and even information that physicians may perceive as
neutral or benign 2 . In fact, many recent studies have found that most patients want to
know the truth about their illness 2.
Physicians frequently must break bad news to patients and their loved ones 3. How
bad news is presented may affect patients' comprehension of and adjustment to the
news as well as their satisfaction with their physician 4, 5. Historically, the emphasis on
the biomedical model in medical training places more value on technical proficiency
than on communication skills. Therefore, physicians may feel unprepared for the
intensity of breaking bad news, or they may unjustifiably feel that they have failed the
patient. The cumulative effect of these factors is physician uncertainty and
discomfort, and a resultant tendency to disengage from situations in which they are
called on to break bad news 6. Many physicians have had little or no formal training in
how to break bad news, and many perceive a lack of time in which to present the
news. Patients may have multiple physicians, making it unclear who should break the
bad news 7. From the previously mentioned review, we need to assess the ability of
both family physicians and other specialties in breaking bad news skill.
Subjects & Methods:
A cross sectional study was carried out to compare the performance of the family
physicians in breaking bad news skill versus the performance of the physicians from
other specialties in this skill. The study involved 120 physicians each group involved
60 physicians selected by using stratified random sample. The study was carried out
in the family medicine centers that were affiliated to the family medicine department
in the Suez Canal University and in the out patients clinics that were affiliated to
internal medicine department, pediatric department, oncology department and in the
obstetric &gynecology department in the Suez Canal university hospital. Physicians
from both genders and physicians with the following scientific degrees: M.B.B.Ch,
master degree and MD were included in the study. Ministry of health physicians was
excluded.
The tool used in this study was self administered questionnaire that was distributed to
the physicians involved in the study. It was completed by each physician as self
assessment.
The questionnaire was divided into two parts as following:
(1)First part was designed to investigate the socio demographic data of the physicians
and their job characteristics as following: Sex, Scientific degree, Years of experience,
Specialty, if the physicians were involved in breaking bad news to the patient and
any training courses in breaking bad news skill were received by physician during
his /her pre or post graduate education. (2)The second part was Breaking Bad News
Assessment Schedule (BAS) which was a method of evaluating how well a physician
breaks bad news to the patient.
It consists of 23 items divided into 5 subject areas. It was developed in Oxford,
England 8
Subject Areas:
1. -Setting stage: This section looks at whether the doctor facilitated an
initial rapport before breaking the bad news.
2. -Breaking the news: This section specifically focuses on
Whether the doctor was sensitive to the patient's perspective when he/ she
Delivered the news.
3. -Eliciting concerns: This section focuses on whether the doctor
actively attempted to gain a clear idea of the personal implications and
meaning of the news to the patient, and the concerns that it generated.
4. -Information giving: This sections looks at aspects other than giving
the news itself.
5. -General considerations: These points relate to the interview as a
whole.
According to the likert scale, the answer for each question was choosing one word
from five words.
These five words represent a gradual score that range from 1 to 5 in which 1 was
minimum score and 5 is maximum score.
Breaking bad news assessment score was calculated as a summation of answers of all
23 items in which minimum score was 23 and maximum score was 115.The adequacy
of performance was considered if the total score was above 60% (>69point).
Results:
Results showed similar distributions of gender and qualifications. The experience of
physicians in both groups was five years or more, with the mean being slightly higher
among family physicians. Concerning the frequency of breaking bad news to patients,
there was a slightly higher percentage among family physicians.

Meanwhile, the difference in attending postgraduate courses in breaking bad news


was striking, with almost all family physicians having attended such courses,
compared to only 13.3% of physicians from other specialties.
Performance was higher in the family physician group in all five areas of assessment.
The differences were all statistically significant (p<0.00.1). The lowest area of
performance in the family physicians group was in eliciting concern (88.3%) while in
the other specialties group it was in the area of setting the stage (51.7%).
the means of the performance scores of breaking bad news between physicians in the
two groups demonstrates statistically significantly higher scores in the family
physicians group (p<0.00l). This was evident in all tested areas. The widest difference
between the two groups was in the area of setting the stage. Overall, the mean total
skill score in the family physician group (78±10.8) was statistically significantly
higher than that of the other specialties group (61±12.4).
The majority (91.7%) of the physicians in the family physicians group were satisfied,
compared to (43.3%) of the physicians in the other specialties group. The difference
was statistically significant (p<0.001).
There was statistically significant difference in the need for training courses in
breaking bad news between physicians in the two study groups (p=0.03). It is evident
that almost all physicians in the other specialties (98.3%) have expressed such a need,
compared to 86.7% of the family physicians. No statistically significant associations
could be detected with either satisfaction or need. The only family physician with
inadequate performance was dissatisfied with own performance, and expressed the
need for more training courses in this skill.
It is evident that all physicians from other specialties groups with inadequate
performance (100.0%) had not attended postgraduate courses in breaking bad news,
compared to 77.8% of those with adequate performance and this was statistically
significant. there was a statistically significant relation between adequacy of
performance and satisfaction with skill performance (p<0.001). About two thirds of
those with inadequate performance were satisfied (63.9%), compared to only 12.5%
of those with inadequate performance. Meanwhile, no statistically significant relation
could be detected between adequacy of performance and need for more training
courses in this skill.
Table 1 demonstrates statistically significant moderate positive correlations between
the scores of performance and physician's qualification, the experience years. This
was shown for both groups separately and combined. The strongest correlation was
between experience years and performance score among family physicians (r=0.69).
As regards the number of times of breaking bad news, it had a statistically significant
weak positive correlation with the scores of performance only in the family physicians
group (r=0.26).
Table 1. Correlation between scores of performance of breaking bad news and
physicians qualifications and work experience.

Total skill score


Family physicians Other Specialties Total Sample
(n=60) (n=60) (n=120)
Qualification (reference; MBBCh)@ 0.67** 0.49** 0.44**
Experience years 0.69** 0.55** 0.59**
No. of times of breaking news 0.26* 0.25 0.10
(reference: never)@
(*) Statistically significant of p<0.05 (**) statistically significant at P<0.01
(@) Spearman rank correlation

In order to identify the independent predictors of the score of performance of the skill
of breaking bad news, multiple linear regression analysis was done. The best fitting
model is presented in Table 2. It is evident that being a family physician, with longer
experience years, having broken bad news to patients more frequently, and having
attended postgraduate courses in breaking bad news were the statistically significant
independent positive predictors of the performance score. The strongest predictor, as
indicated by the standardized beta coefficient was the experience years, followed by
being a family physician. The model collectively explains 62% of the variation in the
performance score, as indicated by the value of r-square.
Table 2. Best fitting multiple linear regression model for the scores of performance of
breaking bad news
Beta coefficient
p-value
Unstandardized Standard Error Standardized
Constant 67.62 5.48 <0.001*
Group (reference: other
10.56 2.65 0.37 <0.001*
specialty physician)
Experience years 1.02 0.14 0.44 <0.001*
No. of times of breaking news
4.76 1.66 0.17 0.005*
(reference: never)
Attended postgraduate courses
in breaking bad news to patients 6.29 2.77 0.22 0.025*
(reference: no)
r-square: 0.62
Model ANOVA: F-47.39, p<0.001
Variables excluded by model: sex, qualification, attendance of undergraduate courses in breaking bad
news, satisfaction with performance.
Discussion:
The result of current study showed that the total performance of breaking bad news
(98%) and the mean of the total skill score of performance in family physicians group
(78±10.8) were higher than the total performance of breaking bad news (60%) and the
mean of the total skill score of performance in the other specialties physicians group
(61±12.4). This result may be due to emphasis on the principles of family medicine,
including the importance of patient-centered interviewing, basic communication
techniques and providing continuity care to patients makes the family physician in an
ideal position to compassionately, yet clearly, convey devastating news. Having
already developed a sense of mutual trust, the family physician is often in the position
to break such news 9. Also, using the bio-psycho-social approach in the family
medicine that stress on the psychological issues and social issues and their effect on
the health make the family physicians in better position for breaking bad news.
The lower performance of other specialties physicians in the present study could be
explained by the study that was done by Sonia Dosanjh, Judy Barnes and Mohit
Bhandar 10. This study aimed to examine residents' perceptions of barriers to
delivering bad news to patients. The residents discussed the barriers that prevent
breaking bad news guidelines from being implemented in day-to-day practice such as
lack of emotional support from health professionals, available time as well as their
own personal fears about the delivery process prevented them from being effective in
their roles. Residents relayed the need for increased focus on communication skills
and frequent feedback with specific emphasis on the delivery of bad news.
Although most residents realize important guidelines in the delivery of bad news,
their own fears, a general lack of supervisory support and time constraints form
barriers to their effective interaction with patients .So the lower performance of
breaking bad news in the other specialties physicians in this study may be due to
hospital based day to day practice, lack of available time, lack of communication
skills, lack of professional support and personal fear from being engaged in such
situations.
In the current study, it was found that the weakest area of performance with the
lowest score in the family physicians group was in the eliciting the concern (88.3%).
This was in agreement with a recent survey of oncologists showed that handling
emotions was by far the most difficult element in breaking bad news 11
Another study conducted at San Diego County, California was not in agreement
with the present regarding the difficulty in eliciting concern. The study measures
surgeons’ attitudes toward self-perceived competence, importance, need for training
in the communication skills. Most respondents rated their competence high except in
the skills relating to giving the patient bad news. They found all skills important and
indicated a need for training in them. Younger surgeons rated their competence and
the importance significantly lower in the skills relating to giving the patient bad news
12
. These variables between the present study and California study may be due to
difference in the tools of assessment of competences used in both studies and different
setting of breaking bad news. Also, difference in specialty and culture may play a
role in this variability.
In the current study the weakest areas of performance in the other specialties group
were in setting the stage (51.7%) then in giving bad news (58.3%) then in eliciting
concern (60%).this was in agreement with a review of empirical work done by Elwyn
et al, 13 that shows that physicians lack skill in telling bad news and dealing with their
patients’ feelings (13, 14, 15, 16).
Anther study done by Ford and Fallowfield, was in agreement with the current study
regarding weak performance and difficulty in eliciting patient concerns. The study
found in a content analysis of doctor–patient interactions that oncologists of a large
teaching hospital in London delivered patients all the relevant information concerning
their diagnosis, treatment options and prognosis, but abstained from discussing
patients’ emotions or well being 17.
Also, weak performance in giving bad news and difficulty in eliciting patient
concerns that was found in the current study could be explained by a study that was
done by Cantwell and Ramirez, 18.It found that many junior house officers in two
hospitals in London felt they lacked adequate skills in psychological issues and never
inquired about the emotional adjustment of a dying patient. Their major reasons for
not addressing death with their patients were lack of time, wishing to avoid awkward
questions and inadequate skill. So the weak performance in giving bad news and
difficulty in eliciting patient concerns that was found in the other specialties group in
the current study may be due to general lack of competence at delivering bad news
and a poor “patient-centered” interviewing style that was also found among residents
of general internal medicine at Wayne State University, who delivered a diagnosis of
lung cancer to a simulated patient 19.
In the current study there was statistical significance in the difference of the level of
physician’s satisfaction between two study groups. The level of satisfaction among
family physicians (91.7%) was higher than the level of satisfaction of other specialties
physicians (43.3%).
The higher level of satisfaction in the family physicians group may be due to their
adequate level of knowledge about communication skills, availability of several
guidelines on how to break bad news to the patient and stressing on the bio-psycho-
social approach in their consultation.
Also in the current study, there was no statistical significance between adequacy of
performance and level of satisfaction in the family physician group. This result may
be referred to the application of continuous professional development program in the
family practice which made the physicians searching for higher level of performance
that can affect their satisfaction. On the other hand, there was statistically significant
relation between the level of physician’s satisfaction and adequacy of performance in
the other specialties group. Lack of knowledge about communication skills, stressing
on biomedical model and stress experienced by physicians during the process of
breaking bad news may explain the lower level of satisfaction among other specialties
physicians group.
The result of current study regarding the difference in satisfaction level may be due to
the stress experienced by the physicians during the process of breaking bad news
despite adequate performance or following recent guidelines or recommendation. This
explanation presented in the investigation done by Ptacek J.T et al 16, the goal of this
investigation was to gain a better understanding of the processes associated with
communicating bad news to patients. The majority of physicians reported following
most of the published recommendations for delivering bad news. However, the
number of recommendations followed was not correlated with self-reported stress and
effectiveness in news delivery. Overall, physicians reported that the transaction was
moderately stressful for them, that the stress lasted beyond the recalled transaction,
and that they were effective in delivering the news in a way that reduced patient
distress. The fact that many of the physicians reported that their stress lasted beyond
the transaction itself and result in low level of satisfaction suggests that training in the
delivery of bad news should include guidance on cognitive and behavioral coping
strategies to help physicians deal with their own discomfort and raise their satisfaction
level.
In the present study, it was found that the majority of the study groups need training
in breaking bad news communication skills. (86.7%) of the physicians in the family
physicians group and (98.3%) of the physicians in the other specialties group
expressed their need for training in this skill. This result was in agreement with the
study done by Sise and his colleagues, 20, demonstrated that surgical specialists
perceived a high rating of importance for a set of skills related to giving the bad news
to the patients and interactions with patients. They also expressed a belief in the need
for training in these skills. A similar relationship between age and the rating of
importance was found for the skill of listening to patients and family’s anxieties. All
age groups felt it was either fairly or extremely important (between 86% and 92%).
Extreme importance was more commonly chosen by those in age groups 40 to 49 and
50 to 59 years. The belief in a need for training in the 12 skills was supported by a
significant majority of all age groups.
In the current study the most statistically significant relation was between adequacy
of performance and attending postgraduate courses in breaking bad news in other
specialties physicians group. The same was observed by the European Donor Hospital
Education Program (1995) which was a part of a randomized controlled study to
assess the effects of workshop attendance on the competence of intensive-care-unit
doctors in breaking bad news. For ten experimental and ten controls doctor the
researchers reported positive changes in the communication skills of doctors after the
course 21.
Finally, the multiple linear regression model for the scores of performance that was
performed in this study showed that being a family physician was strong predictor for
high score and consequently adequate performance. Communication of bad news is an
essential skill for any family physicians. As a result, family physicians are in an ideal
position to help physicians from other specialties in correction of breaking bad news
skill and to help patients with a terminal disease face their illness with compassion
and dignity 22.
Limitations of the study:
Since it is a self-assessed questionnaire, may be there are problems with bias, such as
prestige bias.
The data are self reports by physicians; no attempts were made to assess the actual
behaviors by physician in giving bad news to patients as it can be done by direct
observation. Thus, respondents may over report that they engaged in such steps more
than they actually did, and may have not performed some of the steps in a competent
fashion. These possibilities only serve to emphasize the need for more educational
interventions for physicians in this important area of communication.
The study did not assess the performance in different types of bad news. How
physicians communicate bad news may be dependent upon the clinical situation and
their familiarity with the medical condition.
Finally, this study did not attempt to assess patients' opinions about how bad news is
communicated to them or impact of the way of breaking bad news on patient
satisfaction.
Conclusion:
The study revealed that the total performance of breaking bad news in the five areas
and the mean of total score of breaking the bad news was higher in the family
physician group than in the other specialties group.
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