Accepted Manuscript

Title: Breaking Bad News to Patients with Cancer: A
Randomized Control Trial of a Brief Communication Skills
Training Module Incorporating the Stories and Preferences of
Actual Patients
Author: James Gorniewicz Michael Floyd Koyamangalath
Krishnan Thomas W. Bishop Fred Tudiver Forrest Lang

PEC 5504

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Patient Education and Counseling

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Please cite this article as: Gorniewicz James, Floyd Michael, Krishnan Koyamangalath,
Bishop Thomas W, Tudiver Fred, Lang Forrest.Breaking Bad News to Patients with
Cancer: A Randomized Control Trial of a Brief Communication Skills Training Module
Incorporating the Stories and Preferences of Actual Patients.Patient Education and
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Version: 10-8-16
Breaking Bad News to Patients with Cancer: A Randomized Control Trial of a Brief
Communication Skills Training Module Incorporating the Stories and Preferences of
Actual Patients.

James Gorniewicz, M.A.a
Michael Floyd, Ed.D.a
Koyamangalath Krishnan, M.D.b
Thomas W. Bishop, Psy.D.a
Fred Tudiver, M.D.a
Forrest Lang, M.D.a


Department of Family Medicine, East Tennessee State University, Johnson City, USA
Department of Internal Medicine, East Tennessee State University, Johnson City, USA

Corresponding author at: James Gorniewicz, East Tennessee State University, Department of
Family Medicine, PO Box 70621, Johnson City, TN 37614; Tel: 423-952-6486; E-mail:


37).034. education. p < . r=-. r=-.001. p=. attention to patient responses after BBN (CC. learner-centered. We created/tested a breaking bad news (BBN) communication skills training module.007.43).30). communication related to emotions (p=. objective structured clinical examination (OSCE). narrative.48).51). Practice Implications: Implementation of this brief individualized training module within health education programs could lead to improved communication skills and patient care.011.28). Abstract Objective: This study tested the effectiveness of a brief. r=-.004. determining patient’s readiness to proceed after BBN and communication preferences (p=.47. Conclusion: This brief BBN training module is an effective method of improving BBN communication skills among medical students and residents. performance scores of intervention group residents improved significantly regarding BBN (p=. stories.Version: 10-8-16 Highlights      We interviewed patients with cancer to learn about their communication experiences.001. Intervention group students and residents significantly improved their BBN skills.006. r=-. Results: Follow-up performance scores of intervention group students improved significantly regarding BBN (colon cancer (CC). common ground assessment. r=-. r=-. and addressing feelings (BC. The brief training module used video-recorded segments from our patient interviews. and global interview performance (p=. qualitative. r=-. p=. At CC follow-up assessment.001. breast cancer (BC). addressing feelings (p<. Methods: This randomized control study (N=66) compared intervention and control groups of students (n=28) and residents’ (n=38) objective structured clinical examination (OSCE) performance of communication skills using Common Ground Assessment and Breaking Bad News measures.74. r=-. r=-.041. cancer. p=. Keywords: breaking bad news.65).65). communication skills training. Health education programs could use this to improve communication and patient care. p=.003. BC. r=-. breaking bad news (BBN) communication skills training module using objective evaluation measures. r=-. empathy 2 .53). active listening (p=.001.

and poorer overall health outcomes [10]. Negative physician outcomes can include increased stress [11. and objective structured clinical examinations (OSCEs) [4. Training activities for BBN come in a variety of formats. Consequently. Where BBN training has been reported. while Girgis and Swanson-Fisher [20] provided consensus guidelines. OSCEs have been used in several studies [26-28]. randomized controlled studies evaluating the efficacy of BBN communication skills training have been conducted [25. and prognosis [9]. Recommendations involving challenging communication skills such as those found when delivering bad news were offered by Baile et al.16] made recommendations regarding communication skills in general practice.22-25]. skill-focused BBN training module using objective evaluation measures. Doctor-patient encounters involving breaking bad news (BBN) are important. Although they are difficult to create and expensive to implement. "any news that drastically and negatively alters the patient's view of his or her future.17-21]. It was the result of an interdisciplinary effort involving faculty from the East Tennessee State University (ETSU) Graduate Storytelling Program and the departments of Family and Internal Medicine. our study tested the effectiveness of a brief. these approaches can require up to forty hours [4.17].12]. video recorded. The Toronto and Kalamazoo Consensus Statements [15.29-32]. Negative patient outcomes can include stress and anxiety [8]. Initial studies concerning BBN relied largely on participant self-report of increased knowledge and/or confidence while giving bad news [26]. Recognizing these challenges to implementation and education. This module was developed using cancer stories from patients. 2.2]. transcribed verbatim. “Bad news” has been defined by Buckman [7] as. BBN training is often labor intensive and time consuming. When bad news is delivered poorly.Version: 10-8-16 1. miscommunication regarding diagnosis. instructional videos. 2. However. it can negatively impact both patient and physician. More recently. self-paced. Among these are lecture and small group discussion using role-play and/or standardized patients. and treatment failure. cancer recurrence. [17] who described a six-step protocol. and burnout [14]. came new communication challenges to both the patient and the treating physician [4-6]. conclusions regarding the expression of BBN communication skills were limited. therefore many medical schools provide few formal learning experiences [10. anxiety [13]. checked for 3 . physician-centered models of care evolved to an increased focus on autonomy and most physicians more fully informed their patients about their cancer diagnosis [3].” Examples of bad news include: cancer diagnosis. treatment. As cancer treatments improved in the late 1970’s. Introduction Historically patients with cancer were routinely left uninformed regarding their diagnosis [1. with this change.1 Intervention Methods Training materials for the BBN module were developed using qualitative methods for discovering a variety of challenging experiences reported among patients with cancer. Semistructured interviews were conducted. This was done largely with the belief that informing patients was harmful and caused undue stress.

and confusion upon hearing that she had cancer during the “delivery phase” [37] of this encounter. This approach determined relationships between themes and provided exemplar quotes demonstrating the themes.17. Reliability and validity were maximized using four maneuvers: 1) interviews were transcribed verbatim. If the patient did not spontaneously mention something such as how the diagnosis was given. spirituality. and analyzed [33-34]. Viewing time averaged 60 minutes. The research team used these themes and quotes to develop the modules. "Please begin by sharing any stories or personal experiences that might help others to appreciate what it has been like for you to deal with cancer. Annotations were used to emphasize communication techniques. 3) palliative care and end-of-life care. These modules were designed to be brief (60 minutes) and to actively engage learners. 2) living through treatment. 3) at least two reviewers independently examined and analyzed the data before this was presented to the module development team. 4) spirituality. These reviewers compared and contrasted their independent coding and came to a consensus regarding the emerging themes. Each interview began with the statement. quiz questions were included every 5-10 minutes. and entered into NVivo 8 qualitative data analysis software [36]. decision-making. fear. Five main themes emerged: 1) breaking bad news. Each theme became the emphasis of a training module designed to improve communication skills with patients with cancer. one video clip presented a female patient who described feelings of shock. theme saturation was achieved after approximately 15 interviews. Key concepts and themes that emerged from the data were coded. interviewers asked 1) questions to clarify issues related to communication (e. then the interviewer would inquire.” After a patient shared their story. This intense emotional response limited her ability to process information. They also reinforced content themes. These clips were selected by their authors as being salient to the goals and learning objectives of respective training modules.g. This video clip highlighted the importance of pausing after delivering bad news in order to attend to a patient’s emotional response before sharing additional information. and 4) member checking occurred for a sub-sample of the interview participants and the research team met for further synthesis and interpretation of the themes. It was important from a pedagogic perspective that a representative variety of cancer types and exemplary quotes be obtained. For example. Interactivity between learners and modules was enhanced through video clips of patients.21] as well as selected video recordings of twenty-seven actual cancer patients who described challenging communications situations involving BBN. Accordingly. The BBN module incorporated recommendations found within the literature [4. Following guidelines suggested by Kuzel [35]. Quizzes asked learners to imagine how they would respond to a patient in a challenging communication situation: “How would you respond to this patient? What would you say and do?” Simulated patient interviews using actors portraying doctors and patients were included to help learners identify effective communication skills during doctor-patient interactions. end-of-life. empathic responses among learners. coded. 2) interviewers took field notes during interviews to improve accuracy of data interpretation. Transcripts were independently examined by at least two reviewers. Learners viewed the training module on a CD-ROM or website. and 5) family. 4 .g. In order to keep learners engaged. a total of 112 interviews were transcribed. etc.Version: 10-8-16 accuracy by the original interviewer. During this time she reported experiencing a “deafening silence”. and family in the introduction of various communication skills. physicians.20.) and 2) questions based on previous research and communication consensus reports (e. breaking bad news.). and evoked patient-centered.

Communication Related to Patient Emotions.42]. and group status (intervention or control). The CGAS (Figure 2) contains five summary scales (Overall Rapport. It assesses whether forewarnings are used as well as how the bad news is expressed. and preferences before providing additional medical information. including the involvement of family or other supportive persons. Raters were assigned OSCE video recordings after they reached an a priori accuracy of 90%. 2. Two 15-minute OSCE stations (breast cancer and colon cancer) were developed. Each OSCE lasted approximately 15 minutes (7 minutes of chart review and 8 minutes of female SP interview). Lang et al. After BBN Determines Patient Readiness to Proceed and Communication Preferences. 4. Preamble to Breaking Bad News (gauging patient knowledge and readiness). Breaking Bad News focuses on skills used while the bad news is delivered.40]. After BBN.3 OSCE Standardized Patients and Raters Standardized patient (SP) OSCE training was conducted by ETSU’s SP Coordinator. Each measure is composed of several checklist items (no=0. [39] 5 . emotions. Determines Patient Readiness to Proceed and Communication Preferences examines interview skills related to timing and the exploration and incorporation of patients’ communication preferences. Breaking Bad News. Three independent raters were recruited from this pool of SPs. a validated measure of general communication skills. thoughts. 2. Attention to Patient Responses after BBN. Overall Closing. Overall Deals with Feelings. Raters were blind to the participant’s level of education. It has demonstrated good reliability and validity with medical encounters found in general practice [38. The Preamble to Breaking Bad News measures the introduction portion of the interview in the context of a BBN visit.Version: 10-8-16 2. 3. Figure 1 displays the BBN Skills form. The five measures are: 1. SPs who delivered at least 90% of the OSCE clues accurately were assigned to the BBN OSCE. the OSCE interview sequence (baseline or follow-up).41. a checklist comprised of five measures.4 OSCE Evaluation Measures Communication skills were assessed using performance ratings in two OSCE scenarios. but before the interview transitions into the information-sharing stage.20. Two communication skills rating forms were used: the Breaking Bad News Skills rating form checklist (BBN Skills) which is a measure of specific BBN-related skills and the Common Ground Assessment Summary form (CGAS) [39].39]. This level of reliability is similar to those reported in previous studies [39. Attention to Patient Responses after BBN examines interviewer’s interactive behaviors related to patient’s prior experiences. It determines whether and how an interviewer might avoid difficult issues.2 Case Scenarios The widely used OSCE format was chosen because it allowed for the simulation of multiple doctor-patient meetings in a standardized setting. and Overall Global Interview). The OSCEs used in this study involved challenging scenarios found when delivering bad news with particular attention to communication skills recommended through consensus statements and guidelines specific to cancer [17. 2. yes=1) corresponding to the BBN training module learning objectives. and 5. Communication Related to Patient Emotions determines whether and how the interviewer addressed emotions expressed by the SP throughout the OSCE. Overall Active Listening.

The students assigned to the intervention arm of this study received the follow-up OSCE within seven days of their completion of BBN training module. They received each OSCE. A second group of participants was comprised of family medicine and internal medicine residents who completed the OSCEs as part of their usual academic exercises at the beginning of their first year of training. 5=exemplary). Although less than one percent of the data was missing. 3=competent/adequate. A volunteer group of health professional students who were paid $100 participated in this study. The direction of change between intervention and control groups was hypothesized to be positive for all measures. Differences in length of time between baseline OSCEs and follow-up OSCEs for students and residents were due to scheduling limitations within the residency programs and student availability. where this did occur. Residents assigned to the intervention group completed the training module one week after they completed the baseline OSCE and the follow-up OSCE within one month of the baseline OSCE. Change scores for each measure were determined by subtracting the baseline OSCE score from the follow-up OSCE score. spaced one month apart. 2. or nursing and had completed the Communications Skills for Health Professionals course. They were enrolled in the colleges of medicine.5 Research Participants and Procedure The ETSU Institutional Review Board approved this study. colon cancer). raters were instructed to score half-point increments between rating points described by the scale. missing data from within the BBN Skills measures were imputed using the formula: (sum score of scale / number of valid items in scale multiplied by the number of total expected items in scale). 2. Ideally. All patient participants provided their written consent to use their personal cancer stories and experiences that demonstrate effective and ineffective cancer communication as part of educational modules to educate doctors to communicate more effectively with cancer patients. OSCEs were rated using the CGAS and the BBN Skills Form. The training of students in the control group was delayed for two weeks.” The CGAS scales use a 5-point rating (1=needs improvement.6 Analysis The measures comprised within the BBN Skills Form were developed by summing the categorical checklist items within each of the scales. All 66 participants were randomly assigned to either an intervention group or a waiting list control group (Figure 3). Residents received the colon cancer scenario in both the baseline and follow-up OSCE. consistent with the expectations of the Toronto and Kalamazoo consensus statements. As a means of increasing precision. The students and residents provided their written consent to video-record OSCE sessions with a standardized patient. pharmacy. before receiving the training module. 2=marginal. Their prior experience with communications skills training was unknown. To control for a possible order effect. Training was delayed for residents assigned to the control group. Mann-Whitney U tests were employed to compare change scores found between the intervention and control groups. and to complete a training module and a quiz on communication effectiveness. students would have been assessed on schedule with residents (30 days between baseline and follow-up).Version: 10-8-16 reported that this measure provided “a reliable and valid assessment of patient-centered communications skills for everyday office visits. 4=very effective. students received a counterbalanced presentation of the OSCE (breast vs. so all statistical tests examining OSCE performance were one-tailed 6 .

Effect sizes were calculated to determine the magnitude of the differences between baseline scores and follow-up scores.30).043.007.4 (Figure 3).28). Two students self-identified as Asian (7%) and two students Black (7%).041.001. Results 3. Determines Patient Readiness to Proceed and Communication Preferences (p = . yielded no significant differences based on age [t (34) = -. Twenty-one members of this group self-identified as Caucasian (55%). Attention to Patient Responses after BBN (p = . the Addressing Feelings scale was significantly higher in the intervention group on the breast cancer OSCE (p = . r = -.011.009]. 2 Hispanic (5%).05. 3. However. The resident group. Communication Related to Emotions (p = .48). The resident intervention group also had significantly higher scores on four of the five CGAS scales: Active Listening (p = . r = 7 . r = -. significant improvement was found on three of the BBN Form measures: Breaking Bad News (p = . On the colon cancer OSCE.89. p = .788] or gender [χ2 (1) = . As is typical of the demographic makeup of this region.2 Effects of BBN Training on Student and Resident OSCE Performance Most OCSE change scores of students were significantly higher for the intervention group as compared to the control group. r = -. Residents scored significantly higher than students on two of the ten measures: Preamble to Breaking Bad News (p <. most of the BBN Skills and CGAS scales were significantly higher for the intervention group than the control group.Version: 10-8-16 with an alpha level of .003.43). Using the CGAS.001] and were more likely to claim a non-Caucasian ethnic identifier [χ2 (1) = 6.732]. effect size r = .662]. residents were significantly older than students [t (62) = 3.001. No significant within group differences were detected based on student age [t (19.006. p = .65).191. 14 Asian (37%).015). these differences were not significant with students who completed the colon cancer OSCE. p = . r = -. r = -. Addressing Feelings with Patients (p < . most of this group self-identified as Caucasian (86%).37). significant improvement was found on two of the BBN Skills measures: Breaking Bad News (p = . Statistically significant differences were found in both the colon and the breast cancer OSCEs (Table 1). Although students who received the breast cancer OSCE had significantly higher scores than the control group on the Communication Related to Patient Emotions and Addressing Feelings with Patient scales. p = .12.27.111] or gender [χ2 (1) = .05.47) and Attention to Patient Responses after BBN (p < .034. Among residents.67. Table 2 provides a baseline assessment and comparison of students and residents using the BBN Skills rating measures and the Common Ground Assessment.004. Using the colon cancer OSCE. and 1 Native American (3%). r = -. r = -. 3. A comparison of the intervention and the control groups of the residents.34. and After BBN.74).001. On the breast cancer OSCE. The analyses were performed with SPSS version 21 for PC [43].1 Participant Demographic Data and Baseline Assessment The student group of 12 females and 16 males had an average age of 25. All statistical tests on demographic characteristics were two-tailed with an alpha level of .37) = 1.6. three of the five BBN Skills measures were significantly higher in the intervention group: Breaking Bad News (p = . p = . r = -.001) and Rapport (p = .53).33). p = . 20 males and 18 females had an average age of 29. r = -. and Communication Related to Patient Emotions (p = .

For example. checking for agreement understanding and feasibility. While improvement was demonstrated in most skill areas.65). 4. and closing the interview (identifying patient perspective. On the other hand. Residents did not significantly improve on a measure assessing attention to patient responses after breaking bad news. Because of additional training and maturation associated with life and clinical practice experiences. agreement.002. using the word “cancer” rather than vague terms like “growth” or tumor”. residents improved active listening skills. some differences were found between students and residents. many 8 . after training. health professional students who completed the BBN module were significantly more likely to wait or pause after the initial announcement that bad news was to follow and were more likely to explicitly ask about how the patient felt after bad news was delivered. Both sets of skills were related to patient emotions (Addressing Feelings scale) and Communication Related to Patient Emotions (asking about feelings. Cultural differences may also have played a role in preferences for communication approaches.1 Discussion This study evaluated the effectiveness of a brief (60 minute) BBN communication training module with students and residents. and using touch effectively). These included skills which occurred during the initial moments of breaking bad news. In addition to unknown differences between these OSCEs. While students significantly improved on the BBN and the Attention to Patient Responses scales using both the colon and breast cancer OSCE.Version: 10-8-16 . This may have been because residents did not attend a medical school where communication training was stressed. and establishing mutual responsibility). student performance improved on two sets of skills related on the breast cancer OSCE. assessing for preferred method of communication. Closing the Interview (p = . active listening. and feasibility. but not on the colon cancer OSCE. and to close the interview effectively by identifying patient perspectives. r = -.48). were more likely to address patient emotions. determining readiness to proceed. For example. Students who used the module were more likely to explore for possible underlying emotions expressed verbally and nonverbally by the OSCE patient. Communication skills of both student and resident intervention group participants significantly improved in a variety of areas. baseline communication skills of residents were anticipated to be higher than those of students. communication related to emotions. baseline scores for residents were higher than students on but two of ten measures (Preamble to BBN and Rapport). explaining impressions. r = . Discussion and Conclusion 4. attention to patient responses immediately after BBN. However.51). acknowledging feelings without specifically identifying the feeling. students may have felt greater empathy with standardized patients portraying breast cancer than for the standardized patients depicting colon cancer. explaining impressions. establishing mutual responsibility. Differences between residents and students may have been because many of the residents trained at foreign medical schools which provided little or no communication skills training. the provision of forewarnings before BBN. Indeed.001. and checking for understanding. because of age similarities or cancer’s relative frequency of occurrence. there were some differences based on the type of OSCE used. The effect sizes for these improvements ranged from medium to large. and Global Interview Performance (p = . there is the possibility that. suggesting that this brief BBN module can be an effective method for teaching students and residents. naming or hypothesizing feelings.

This study has several strengths. 2) incorporates 9 . core communications skills. However. items comprising the BBN Skills are largely based on suggestions from existing literature. Our training used minimal time (1 hour) and resources. role-playing. whereas most others [25. Secondly. The BBN module is learner-centered. One study [31] used a self-directed training similar to our own. On the other hand. where others used more (1. this study used but two OSCE cases. self-paced. Unique to our study is the successful implementation of a self-directed training module that 1) does not require expert feedback in order to improve communication skills.80. students volunteered and were not required to participate as part of their regular educational coursework. and have informally reported that communication skills were taught casually and episodically at the bedside during hospital rounds. This study has several limitations. may also have had special interest in this topic. Unlike residents. [39] found that five OSCEs achieved a high generalizability coefficient of .29.31-32] used a combination of lecture. small group learning. Our results are consistent with findings of other studies in the literature. however these authors are uncertain regarding specific previous communications skills training among residents. BBN Skills items are based on expert opinion. an approach that may have led to the development of more precise assessment measures. Additionally. consistent with previous studies [25.29-32]. the BBN Skills measures used in this study do possess a high degree of face validity and focus on observable BBN skills measured using a simple “yes or no” checklist. and consensus statement guidelines. due to time constraints.29-32] have noted significant improvement in aspects of communication related to empathy. Additionally.29-32]. Previously developed interventions [25. however their method incorporated feedback sessions. sample size limitations prevented the use of factor analysis.40 hours). thereby diversifying the student group and likely mitigating self-selection bias introduced by volunteers whose primary motivation was learning new communication skills.29-32]. Lang et al. whereas others tested medical residents or mid-career oncologists.3 hours . In addition. Effect-sizes of results are included. 45] between baseline and follow-up OSCEs. Generalizability of CGAS results may be limited. Another consideration is baseline score differences might have been associated with selection bias: the student group was comprised of volunteers who. Deatwyler and colleagues [30] reported overall improvement in BBN skills using a checklist rating form with items similar to our own rating form [Figure 1]. Some students may have participated due to an interest in learning additional communication skills. and designed for the training of advanced interviewing skills. It is a randomized control trial design which.Version: 10-8-16 residents in this study received their medical school education in foreign medical schools. students received a $100 payment which may have incentivized some individuals who would not have normally participated without it. recently completing a communication skills course. this study used objective performance measures: standardized patients and OSCEs. Our study tested students and residents. suggestions from existing literature. Students had just completed training on basic. Our study used a self-guided module. and feedback. used a standardized. Like similar studies [25. which permits interpretability regarding the magnitude of change [44. whereas. whereas ours did not. Table 3 compares methods and relevant findings from our study with several others [25. and consensus statement guidelines. reproducible. expert opinion. and brief (60 minute) training module that incorporated videorecorded stories from patients who shared their experiences specific to cancer as well as their preferences for communication with physicians. A third limitation is that selection bias may exist among students.

and family) developed through this grant. MA. BA. spirituality. Additional research could also study the transfer of skills into actual clinical communication with real patients as well as their effect on clinical patient outcomes. residency training. such as a small group led by a facilitator or a short lecture/discussion. such as the one described by Lienard [25] examining residents’ verbal content and quantity of speech. Perry Ann Butler.. It is unknown whether other settings. MPH. There is also a need for future research examining the effectiveness for each of the four other modules (living through treatment.2 Conclusion Our results demonstrate that students and residents who used this module significantly improved their communication skills based upon measures designed to assess skill acquisition in a variety of areas. could be highly illuminating. Robert Enck. Similarly. Joseph Sobol. Joel Richards. other research methodologies. Research Support: This research was supported by a grant from the National Cancer Institute (NIH. MD. Informed Consent and Patient Details: “I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story. 10 .Version: 10-8-16 memorable and emotionally resonant video-recorded stories from patients with cancer. Conflict of Interest: The authors declare no conflicts of interest.” Acknowledgements: The authors would like to gratefully acknowledge the following individuals for their insight and assistance during module development and/or assessment: Catherine McMaken. 4. Future research could examine the effectiveness of using this module in other educational training settings. BFA. would yield similar results. Smith. 3) requires less time and resources than other training methods. PhD. MD. Marjorie K. MA.3 Practice Implications Implementation of this brief training module within medical schools. Bruce Behringer. Harsha Vardhana. MA. and Bill Linn. and quality of life. and 4) is effective with student learners. palliative care/end-of-life care. 4. and/or continuing education programs could lead to improved communication skills. self-paced learning for training. R25CA111698). patient care. This study used individual.

Res. Communicating sad. Br. Oncol. M. G. J. Physician. Assoc. J. Burnout and psychiatric disorder among cancer clinicians. S. Oken. 1 (1970) 295-305. Am. P. Factors that influence cancer patients' anxiety following a medical consultation: impact of a communication skills training programme for physicians. J. Ford. What to tell cancer patients . R.H. Health Hum. Glober. "I'm sorry to tell you .J. Med. A. Med. T. Sanson-Fisher. 11 . Graham. J. Merckaert. Med. [8] S. Lancet 334 (1989) 564. J. Physician management of dying patients: an exploration. Ramirez. J. Ochitill. Delvaux. 175 (1961) 1120-8. [20] A. 58 (2005) 244-51. M. Integrating the Art and Science of Medical Practice: Innovations in Teaching Medical Communication Skills. Buckman. G. Admin. [4] L.Version: 10-8-16 References [1] D. Gregory. Ed. Psychiatry Med. Hojat.W. A.. A. J. Plumer. Langewitz.S." physicians' reports of breaking bad news. [15] M. Breaking bad news . Beale.P. V. Serv. Buckman. W.) 288 (1984) 1597-9... Boniver J. Farewell.K. Marchal. 71 (1995) 1263-9.F. W. et al. E. (Clin.a review of the literature. 17 (2006) 1450-8.M. R. Cull. Lewis. V. Marchand. [9] J. VandeKieft. S. Lancet 359 (2002) 650-6. Lancet 263 (2004) 312-9. Fallowfield. [10] G. Br. D. Duffy. N. Eberhardt.J. Acad. Giving sad and bad news. [6] A. Ptacek. L. Breaking bad news. Ptacek. Breaking bad news: consensus guidelines for medical practitioners. Efficacy of a cancer research UK communication skills training model for oncologists: a randomised controlled trial. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. H. R. Amer. J. Patient. [14] A. Steele.R. J.T. Assoc.T. R.. 76 (2001) 390-3. Morrow. Girgis. Couns.J.A. Leaning. Ptacek. Recipients' perspective on breaking bad news: how you put it really makes a difference. Med. et al. Cancer.M. [17] W. Can oncologists detect distress in their out-patients and how satisfied are they with their performance during bad news consultations? Br. Novack. Lipkin. Y. [11] L. bad. J. N.. D. Ten approaches for enhancing empathy in health and human services cultures. Med. Lenzi. J. Richards.a study of medical attitudes. Buckman. Maguire. Amer. 70 (1994) 767-70. Novack.L. Kudelka. Clin. Libert. [12] J. Medical students' fears about breaking bad news. Makoul. M. 31 (2009) 412. Stewart. 64 (2001) 1975-8. et al. Seibert. Amer. 13 (1995) 2449-56. Baile. Sykes. Jenkins. Assoc. Fam. Simpson. [7] R. J. [16] G.J. A. M. Ellison. Eves. [3] D. L. Jenkins. Oncologist 5 (2000) 302-11. Fallowfield. Smith.A sixstep protocol for delivering bad news: application to the patient with cancer. Changes in physicians' attitudes toward telling the cancer patient. Lancet 341 (1993) 476-8. R.L. Oncol. [18] C. SPIKES . Bennett. Fallowfield. Breaking bad news: why is it still so difficult? Br.A. R. Behav. 276 (1996) 496-502. [21] L. [2] H. 241 (1979) 897-900. Schmid Mast. Fallowfield. Kindlimann. D. Med. Saul.M. C. [5] M. Med. R. J. and difficult news in medicine. 36 (2004) S43-50. J. [19] M. Haq. Brody. Doctorpatient communication: the Toronto consensus statement. J. Educ. Friedman. Lienard. Ann. Med. Cancer. 24 (2001) 205-17. Fam. [13] N. I. 303 (1991) 1385-7. V.

M. 32 (2010) e381-90. Etienne.. 12 . Kubota. Pearce. [23] J.J. [25] A. pp. Daetwyler.. A. E. A. Sage Publications Inc. Palliat.M. D. G.). Ferguson. Crabtree. Lienard. Kupfer. Sampling in qualitative inquiry. pp. I. E. Y. 32 (2014) 2166-72.G. J. Rosenbaum. [37] A. Rosenbaum. second ed. Clin. Teach. Vollmann. J. [35] A. Shirai.. Sage Publications Inc.A. Konen. Couns. N. Y. W.A. Miller (Eds. [34] M. Kreiter.G. I. Immersion/crystallization.J. Libert. I. Ozdogan. N. Baile. 17994. Fujimori. M. et al. Qualitative Research and Evaluation Methods. Schildmann. Kuzel. second ed. [27] W. Petty. [24] Y. Med.E. eLearning to enhance physician patient communication: a pilot test of "doc. 27 (2012) 338-41. Communication skills training in oncology. 79 (2004) 107-17. Etienne. Patton. Cancer 86 (1999) 887-97. third ed. Myers.H. M. A. D. Lienard. Br. Doing Qualitative Research.F. PLoS One 5 (2010) e12426. Merckaert.. 1999. N. M. Sage Publications Inc. Med.. Miller (Eds. H. J. W. Chiappetta. S. J.. A. Novack. K. 2002. Etienne. Kamdar. Uchitomi. Transfer of communication skills to the workplace during clinical rounds: impact of a program for residents. Delvaux. 14 (2002) 144-9. A. Is it possible to improve residents breaking bad news skills? A randomised study assessing the efficacy of a communication skills training program. el-Jawahri. Effect of communication skills training program for oncologists based on patient preferences for communication when receiving bad news: a randomized controlled trial. C. Delvaux. Knudson. [31] I. "Breaking bad news": standardized patient intervention improves communication skills for hematology-oncology fellows and advanced practice nurses.. 24 (2009) 154-9. Thompson.C. [28] M. M. 33-45. J. Med.. NVivo 8 software. Crabtree. Y. [29] E. M. [26] M. [33] J.). Borkan.G. 1999. Delvaux. Libert. E. Acad. Libert. Teaching and evaluating breaking bad news: a pre-post evaluation study of a teaching intervention for medical students and a comparative analysis of different measurement instruments and raters. 13 (2010) 439-52. Senol. Br. Cancer 103 (2010) 171-7. 86 (2012) 210-9. USA. L. 2009. J. Is it possible to improve the breaking bad news skills of residents when a relative is present? A randomised study.F. Szmuilowicz. Med. in: B. Merckaert. Lienard. K. et al. Y. et al. Bragard.Version: 10-8-16 [22] A.E. [30] C. N. Cohen.. Patient Educ. Asai. Katsumata. USA. R.C. Glober.. Beale. Using standardized patient instructors to teach health promotion interviewing skills. Thousand Oaks. Bragard. Block. Thousand Oaks.J. USA. J. in: B.A. 28 (1996) 103-6.F. Oncol.P. L. [36] QRS International. K. Hutchins. Fam.P. N. Cancer Educ. Teaching medical students and residents skills for delivering bad news: a review of strategies. A. M. Cancer Educ.L. Bozcuk. Description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Sharp. S. Teach Learn Med.Q. et al. J. Greisinger. Kudelka. Gracely. Improving residents' end-of-life communication skills with a short retreat: a randomized controlled trial. Teaching delivery of bad news using experiential sessions with standardized patients. Burchardi. I. J. Bragard. [38] P. A. Cancer 109 (2013) 2507-14. Merckaert. I. Lobas. Eid. Effects and permanency of the training program "communication with cancer patients" on the opinions of students. [32] M. Thousand" and "WebEncounter" in teaching bad news delivery. Doing Qualitative Research. Y.

Evaluating communication skills in the OSCE format: reliability and generalizability. Rosenthal. McCord. Gen. [44] A. USA. R..J. Turnbull.H. Communication assessment using the common ground instrument: psychometric properties. Harvill. Kroboth. Hodges. 2012. L. Field. [45] R. Quality of standardised patient research reports in the medical education literature: review and recommendations. [42] B. Coulehan. Clifton. S. Med. SPSS Statistics for Windows. Bienenstock. W.. Hanusa. K. [41] F. J. Newbury Park. revised ed.H. 30 (1996) 38-43.S. A. McNaughton.N. N. [43] IBM Corporation. Educ. Sage Publications Inc. L. version 21. J. J. Intern. Szauter. 42 (2008) 350-8. Discovering Statistics Using SPSS. Sage Publications Inc. Parker. R.L. 1991. Anderson. D. Fam. [40] L.. Med. B. 7 (1992) 174-9. Perkowski. Med. Kapoor. 2009. 36 (2004) 189-98. Meta-Analytic Procedures for Social Research. Norman. USA. 13 . G. Lang.. F. Educ. third ed. Association of Standardized Patient Educators (ASPE). M. Med. Cohen. et al. Howley.Version: 10-8-16 [39] F. The inter-rater reliability and internal consistency of a clinical evaluation exercise. Thousand Oaks. Brown..

“How are you feeling?” Must successfully elicit what feelings are present. Communication Related to Patient Emotions a. c. (If postpones further discussion until family or patient is ready mark N/A. “Don’t worry…Be a fighter”…”Be strong” [reverse scored] [Yes/No] 5. Checks the patient’s readiness to receive the results. b. prognosis. f. percentages) [Yes/No] d. d. e.” [reverse scored] [Yes/No] Uses non-specific lay terms (mass. Preference for type of information – General (qualitative) vs. Discloses prognosis (either General or Specific) [Yes/No] f.”) [Yes/No] e. Percentages. tumor) instead of the word. [Yes/No] 4. Provides forewarning [Yes/No] Expresses personal regrets [Yes/No] Makes a positive personal statement [Yes/No] Makes statement using the term “cancer” [Yes/No] Uses ambiguous or obscuring modifier such as “highly suspicious. “how it went.Version: 10-8-16 Figure 1 Breaking Bad News Skills Rating Form Checklist (BBN Skills) 1.) [Yes/No] 14 . [Yes/No] g. After stating “cancer”. Explores personally charged verbal clues [Yes/No] e. 2. Premature inquiry regarding patient attributions about cause of symptoms.” [reverse scored] [Yes/No] 3. (reverse scored) [Yes/No] h. Distracting leads such as lengthy ice-breakers or “beating around the bush” (reverse scored) [Yes/No] a. and or TX. immediately proceeds to providing additional information re: cancer details. etc. tables. if needed [Yes/No] c. d. Attention to Patient Responses after BBN a. c. b. Breaking Bad News a. Asks about preference for prognosis timeline (General vs. d.) [Yes/No] f. how much. “cancer. Specific (graphs.” [reverse scored] [Yes/No] b. months)[Yes/No] e. growth. Not just.” “may represent. Asks about readiness to proceed [Yes/No] b. c. Asks about feelings [Yes/No] Acknowledges patient feeling without specifically naming it [Yes/No] Names/restates/hypothesizes or acknowledges a specific feeling [Yes/No] Touches patient supportively [Yes/No] Discourages expressions of feelings. treatment. workup. e. and in what amount of detail the patient prefers. b. Asks about experience and/or knowledge regarding cancer. Responds non-verbally to non-verbal expression [Yes/No] d. After BBN Determines Patient Readiness to Proceed and Communication Preferences a. Asks about preference to involve family member. Provides medical recommendations direction (the next step will be…on diagnosis. Explicitly asks about patient reactions [Yes/No] c. Preamble to Breaking Bad News (gauging patient knowledge and readiness) Refers to current “tumor related” or “procedure-related” symptoms [Yes/No] Checks with how the biopsy-diagnostic procedure went [Yes/No] Addresses family involvement [Yes/No] Checks what the patient has been told/knows about the results (“How told” is specific and different from exploring. Checks /explores/addresses feelings (must either initiate a dialogue about feelings or explores deeper a feeling statement made by patient.

Active Listening for Full Understanding of Ideas. #1 Initial Anxious #2 Worst Possible . Rapport (Number of Occurrences) No 1 2 3 4 5 O O O O O O O O O O O O O O O O O O Nonverbal Rating Scale Body position and Eye contact Voice Qualities Explicit “Positive Speak” Comments about Pt. 4 O 5 O NA O (Rating Scale) 1 O 2 O 3 O Overall Active Listening 15 . and expectations.meaning (Number of Occurrences) 0 O 1 O 2 O 3 O 4 O Asks (or affirms) about patients’ ideas. Concerns. and Expectations No O O O Yes O O O N/A O O O PT’s clues or statements needing follow up. strengths Explicit caring/commitment (Be there) Negative talk (implied or explicit) -2 -1 0 +1 Strong Negative Negative Neutral Positive +2 O O O O O O O O O O Strong Positive (Rating Scale) 1 O 2 O 3 O 4 O 5 O NA O Overall Rapport 2. concerns.meaning #3 Worst Possible .Version: 10-8-16 Figure 2 Common Ground Assessment 1.

2 = Thorough (Rating Scale) 1 2 3 4 5 NA Overall Closing O O O O O O ____________________________________________ 5. 1= Partially. 1 = Yes/No. 3 = Notably Explains Impressions (Dx. 3 = Notably effective Checks for agreement/feasibility No = None. 2 = Adequately. 2 = Effective Checks for understanding No = None. 1 = Minimal. Closing the Interview (Rating Scale) No O 1 O 2 O 3 O N/A O O O O O O O O O O O O O O O O O O Identifies patient’s perspective (What patient knows.Sigh (Number of Occurrences) 0 O 1 O 2 O 3 O 4 O 4 O 5 O Acknowledges -Explore other feelings. SPECIFY BELOW (Rating Scale) 1 O 2 O 3 O NA Overall Deals with Feelings O ______________________________________ 4. 2 = Effective. expectations) and builds INDIVDIDUAL plan accordingly: No = Little or not at all.Version: 10-8-16 3. #1 Anxious # 1 #2 Anxious # 2 #3 Worst thing-empathic response #4-. options): No = Strikingly ineffective. concerns.. 1 = Partial. Tx. 2 = Teach back Establishes mutual responsibility No = None. Addressing Feelings with Patient No O O O O Yes O O O O N/A O O O O PT’s stated or implied feelings needing follow up. Global Interview Performance (Rating Scale) 1 O 2 O 3 O 4 O 5 O NA O Overall Global Interview 16 . 1= Somewhat ineffective.

Version: 10-8-16 Figure 3.39) Age by group M (SD) 23. Data Collection Timeline and Demographics Timeline: Data Collection and Intervention Time Residents Time Day 1 1) Colon Cancer baseline OSCE (all residents) Day 1 1.80) total total 12 (43) 16 (57) 28 (100) 17 .9 (7.76) 29.02) 26.07) 29.4 (4.17) 25. BBN training module (control group only) Approx 31 days after baseline OSCE) 3) Colon Cancer follow-up OSCE (all residents) Within 7 days of follow-up OSCE 4) BBN training module (control group only) Students Demographics Residents (N = 38) Students (N = 28) Female Male Colon Cancer OSCE n (%) intervention control group group 10 (56) 8 (44) 10 (50) 10 (50) 18 (47) 20 (53) 38 (100) Female Male Colon and Breast OSCEs n (%) intervention control group group 7 (58) 5 (42) 8 (50) 8 (50) Caucasian Asian Hispanic Native American 12 (57) 8 (57) 0 (0) 0 (0) 9 (43) 6 (43) 2 (100) 1 (100) 21 (55) 14 (37) 2 (5) 1 (3) 38 (100) Caucasian Asian Black 12 (50) 2 (100) 1 (50) 12 (50) 0 (0) 1 (50) 24 (86) 2 (7) 2 (7) 28 (100) Family Med (R1) Internal Med (R1) 18 (51) 2 (67) 17(49) 1 (33) 35 (92) 3 (8) 38 (100) Med students (M1) Pharmacy students Nursing students 9 (50) 3 (43) 3 (100) 9 (50) 4 (57) 0 (0) 18 (64) 7 (25) 3 (11) 28 (100) Age by group M (SD) 29. Colon CA and Breast CA baseline OSCEs (all students) Within 7 days of baseline OSCE 2) BBN training module (intervention group only) Within 7 days of baseline OSCEs 2. BBN training module (intervention group only) 14 days after baseline OSCE 3.6 (4.8 (4.4 (5. Colon CA and Breast CA followup OSCEs (all students) Within 7 days of follow-up OSCEs 4.5(3.

82(.22) 1.74 -.04 .40(1.47 -.18 67.53 -.74(1.25(.63 .56) 3.50 81.57(1.72) 2.00 39.46) .04(.45 -1.81(.85 11.48 -.98(1.60 15.76) 3.27 -.50 -1.80) 2.06 1.53 -.48) 2.99) 3.123 2.58 -.24) 3.86) 4.40(.59) 4.392 .39 15.50 11.50 71.27 . Closing the Interview 5.90(. Communication Related to Patient Emotions 5.56) 3.26 14.66) 2.31(.361 .75(.12) 3.31 -.00 12. Communication Related to Patient Emotions 5.86) .80(.65 13. Determines Patient Readiness to Proceed and Communication Preferences Breast . Attention to Patient Responses After BBN 4.54(.64) 2.48 -3.63) 3.92 -.00 24.00 2.15 9.65(.90 15.17) 2.00 -.1.32) 2.11 .179 .38(.72) 3.10(.53(.11 -.26 .08 .29(1.14(1.65(.24 . Global Interview Performance BBN Colon Cancer OSCE for Residents (N = 38) Control Group Intervention Group Mann-Whitney test 18 .19 -.96) 2.00 8.23(1.12 14.54(1.80 16.003** .33 -.21 .87(. Addressing Feelings with Patient 4.66) 3.23 . Intervention U Z r p (effectsize) change score change scores mean rank 12.80(.69 12.43(1.00 10.043* .43 .50 16.71 17.61 13.095 .42) -.23 11.17 2.98(.04 .83) 3.63) 2.45 .88 12.24 -.00 12.00 60.24 .85(.66) 3.069 .13(.95) 3.70 15.47) 2.55) 3.54 -.00 70.00 64.00 -. Closing the Interview 5.39) 2.05 -.64(.96 14.38(1.50 -.78 -3.40 19.22) .30 13.083 2.77(.33 -2.56) 3.55) .90(1.25(.60(.08(.92(.00 67.Common Ground Assessment Scales 1.45) 2.30 17.10(1.095 .43 -1.02(1.92(.50 62. Determines Patient Readiness to Proceed and Communication Preferences Colon .92 7.73(. Global Interview Performance Breast .25 -.07(.58) 3.16 -.163 .11 .31(.89) 3.73(1.47) 2.099 .001*** .46(.65 -.99) 3.53(.785 -1.58) 2.50 .40(.62) .64 15.61) 2.04(.88(. After BBN.15 . Rapport 2. Preamble to Breaking Bad News 2.77) 2.15 13.27(.15 -.12 15.43(.50(.69(.35(.47) 3.22 .62 (.56) 2.00 60.27) 2.23(.50 84.53 .49 -.27 .07(.38(1.61(1.53 . Preamble to Breaking Bad News 2. Breaking Bad News 3.40) 3.22) 2.77) 2.371 .93 16.74) 3.56) 3.53) .001** .07 -.19) 2.57) 3.97) 2.31 11.BBN Skills Rating Form 1.06 -.50 79.BBN Skills Rating Form 1. Rapport 2. Addressing Feelings with Patient 4.92) 2.057 Colon .01) 4.42) 3.29 -2. Active Listening 3.48) 3.42 10.37 1. BBN OSCE Results for Students and Residents BBN Colon Cancer and Breast Cancer OSCEs for Students (N = 28) Rating Scale Control Group n = 13 baseline follow-up M (SD) M (SD) Intervention Group n = 15 baseline follow-up M (SD) M (SD) change score Change Scores Mean rank 2.36 -1.41 1.64) 2.89(.58(.60 16.31(.66) 3.Common Ground Assessment Scales 1.83) 3.50 46.92 -1.42) 3.11) 3.39 -.27(1.40 16.13(.16 -.00 38.65 2. After BBN.Version: 10-8-16 Table 1.80(.43 14.69(.73(.10(.66) 2.14) 3.66) 2.86) 4.96(.05) 1.325 .68) 2.66) 2.25 -.93 18.30 .11 .06 1.85(.31 .73 78.19 82.20(.00 61.216 .55) Mann-Whitney test Change Scores: Control vs.17(1.08 19.99 -1.50 -.85(.92(1.16 -.81 .61) 2.50(.28 .006** .57(.55) 3.54 11.19 2.72 -1.09 -.81 2.17 -.58 13.92 2.67(1.23) 2.35) 2.52) 2.27 2.007** <.69) 2.23(1.55) 2. Breaking Bad News 3.73) 2.50 91.62(.66) 3.32(. Attention to Patient Responses After BBN 4.35 13.31 -2. Active Listening 3.

17 -.056 .35 26.94) 3.31 -1.30 -. Closing the Interview 5.31 (.12) 4.59) 3.11 16.15 3.92 16.37 -.45) 3.55 22.48 (.50 (.12 -. After BBN.00 (.33 1.60) 3.50 119. Breaking Bad News 3.28 .30 .06 .34) 2.50 -1.50) 2.041* 16.001*** .71) .73 (. Rapport 2.93 20.153 .001** Colon .12 -.47) 2.00) 2.48 -. Preamble to Breaking Bad News 2.60 -2.71) 2. Intervention U Z r p (effectsize) 21.68 .79 (. Attention to Patient Responses After BBN 4.27) .56) 2.72 .38 .011** <.50 78.25 .44 (.Version: 10-8-16 Rating Scale n = 18 baseline M (SD) follow-up M (SD) change score Change Scores Mean rank n = 20 baseline M (SD) follow-up M (SD) change score change scores mean rank 2. Active Listening 3.08 (.56(1.74 -.92 (.11) 2.06 -.74(1.67 -.05 -.46 (1.05.71 -.85(.70) 3.66) 3.32) . 19 .00 91.58 128.94 (.65 -.14) 2.51 .034** .52) 2.23 (.79) .75 22.04 (1.10 23.03 22.48 146.82) 2.31 -3.35) 3.17 13.73 24. Addressing Feelings with Patient 4.55 (.02 -2.61 15.00 75.61(1.002** .08 Change Scores: Control vs.86 (1.17) 3.30 .97 (.68 .66 .77) 3.004** .01 (1.35) 2.39 14.80 (.BBN Skills Rating Form 1.99 -2.63(.94 (.28 (1.45) 3.80) 3.64) 2.26) 3.86 3.378 .19 3.61(1. Communication Related to Patient Emotions 5.65) 2.40) 3.05 .83 17.89 (.001.26 -.63 (. All tests were one-tailed.80 (.94(1.18 (.00 103.00 .24) 3.00 48.10 23.Common Ground Assessment Scales 1.95 .58 18.14 (.50 -1.00 120.98 -3. Global Interview Performance Note: *p <.44 13.11) 3.61 (.80 (. Determines Patient Readiness to Proceed and Communication Preferences Colon .88) 2.49) 2.83 -1.28 (. **p <.97) 3.14 (.01.89) 2.55 (.85) 2.22 12.42(1. ***p <.10) 3.95 (.43 -.58) 3.06 (.50 169.80 23.

After BBN.55 -1.001. Rapport 2.65 -.100 .57) 2.68 30.50 371.89 3.57 34.45) 2.35 3. Communication Related to Patient Emotions 5.01. Determines Patient Readiness to Proceed and Communication Preferences 3.001*** 2.86 252.97 35.063 . Breaking Bad News 3.99) 2.50 (. Attention to Patient Responses After BBN 4.11) 3.67) 26.828 . Global Interview Performance Note: *p <.90) 1.08 .38) 28.04) 2.84 (.59 31. Rating Scale Students N = 28 Baseline scores M (SD) Mean rank Residents N = 38 Baseline scores M (SD) Mean rank U Z r (effect-size) p 1.67 (. All tests were two-tailed using Mann-Whitney U test.50 -3.89 (0. **p <.55) 37.86 -1.65 33.Common Ground Assessment Scales 1.690 -.05 35.92 (1.57) 2.47 335.00 427.72 (.97) 39.25 35.83 (0.51 34. Comparison between Student Group and Resident Group Baseline Scores on BBN Rating Form Scales and Common Ground Assessment (CGAS).44 -1.015* .68) 2.384 .83 27.45 <.72 (.09) 35.46 (0.07 (.20 -1. ***p <.50 462.97 (.10 30.52) 3.53) 2.30 -.31 -. Preamble to Breaking Bad News 2.90) 2.20 -.43) 2.66 379.BBN OSCE Rating Form Scales Colon . 20 .63) 23.50 497.15 29.00 401.16 (1.491 2.198 Colon .871 -.11 -. Active Listening 3.23 -.93 (1.41 37. Addressing Feelings with Patient 4.00 419.50 449.11 (0.229 .16 .74 29.121 .02 (1.66 -.00 -1.37 (0.60 (1.19 -.03 -.91 (.67 (.00 -2.58) 2.67 32.16 (.15 -.217 -.69) 2.Version: 10-8-16 Table 2. Closing the Interview 5.05.52 3.

001.72) Medical Responding to emotion . (2010) Lecture and small groups w/ roleplaying and feedback Total hours [29] Szmuilowicz. Closing the Interview (p = .001. Krishnan. r = -.4] (p = .65) 3.74) Breast cancer OSCE: 1. r = -. Breaking Bad News (p = . Attention to Patient Responses after BBN (p < .43) 3. r = -. RR = 1. Communication Related to Emotions (p = . Communication Related to Patient Emotions (p = . Active Listening (p = . Tudiver.) Gorniewicz. Bishop. Libert.003. RR = 0.overall score [2-4] (p = .74) Less information transmission (p = .65) 5. Summary Comparison of BBN Communication Skills Training Incorporating OSCEs and Randomized Control Design. nursing. r = -. RR = .041. Merckaert.33) 4.51) [25) Lienard.47) 2.043.03) 21 . RR = 4.017.001.Version: 10-8-16 Table 3. Breaking Bad News (p = . After BBN.53) 2.002. Global Interview Performance (p = . Authors Training Method Participants Highlights of Significant Results (Note: Areas of overlap between improvements in communication skills demonstrated in our study and other studies are italicized. r = -.28) 6. and pharmacy) and Medical Residents (family medicine and internal medicine) Student group Colon cancer OSCE: 1. r = -. Bracketed numbers after skill items correspond to similar skills assessed by our measures.48) Empathy [2. r = -. effect size r = -.79) Open directive questions [6] (p = .37) 7.001. Breaking Bad News (p = .30) 4.003. Determines Patient Readiness to Proceed and Communication Preferences (p = .48) Medical Resident group Colon cancer OSCE 1.006.001. Floyd. r = -. RR = 5. r = -. el- time: Medical Residents 40 Lecture and small Open question [6] (p < . Addressing Feelings with Patients (p < . Attention to Patient Responses after BBN (p = .001. et al. r = -.004. r = -. Addressing Feelings with Patient (p = . r = -.50) Fewer medical words [1] (p < . and Lang (2016) Self-directed PowerPoint-based training module incorporating cancer patient videos (1 hour) Total time: 1 hour Students (medical.

66) 1. online BBN module (1 hour) + WebEncounter OSCE (10 minutes) w/ feedback (10 minutes) Total time: hours [31] Merckaert.04) Shorter “post-delivery phase” (p < . al (2014) time: BBN skills checklist summary score [1-7] (p = .14) Decrease in use of medical words by residents [1] (p < . Libert. Asai. et.4] (p < . et. et.83) Longer “pre-delivery phase” (p < .93) 40 Orientation/icebreaker (30 minutes) + lecture w/ videos Oncologists (10 years experience average) of on Not beginning bad news without preamble [1] (p < .001.011) Checking questions [7] (p = . RR = 0.Version: 10-8-16 Jawahri. RR =2. RR =1. RR =1.3 Lecture and small groups. Lienard. roleplaying and feedback (30 hours) + stress management training (10 hours) Total hours Medical Residents Decrease in procedural information utterance by residents (p < . al (2010) groups w/ playing feedback role and Residents (internal medicine PGY 2) Total time: 5 hours [30] Daetwyler.018) Medical Residents (oncology.045) Providing reassurance and addressing patient’s emotions with empathic 22 .58) Open directive questions [6] (p < .7] (p = .001) Checking to see that patient understands bad news [2. et.001. and others) Supportive utterances: acknowledgement [2.001. Gracely. RR = 0. gynecology. RR = 0. RR = 3. Shirai.001.001.81) Checking questions [7] (p = .034.008) Communicating clearly main points of bad news [1] (p = . al (2013) [32] Fujimori. al (2010) doc. Cohen.047.

024) Checking to see whether talk is fast paced (p = .011) Remaining silent out of concern for patient’s feelings [2] (p = .005) Accepting patient’s expression of emotions [3] (p < .005) Providing information on services and support (p = .005) Considering how to deliver bad news (p = .001) Asking how much patient knows about his or her illness before breaking bad news (p = .001) Using words that soothe patient [2-4] (p = .Version: 10-8-16 (1 hour) + small group role plays w/ discussion (8 hours) + summary session (30 minutes) Total hours time: 10 Responses [2-4.001) Setting up supportive environment for interview (p = .012) 23 .002) Explaining second opinion (p = .6] (p = .002) Greeting patient cordially (p <.