Can training improve doctors’ skills in breaking bad or difficult news? Our review

Breaking bad or difficult news in healthcare settings is challenging. What is the best way to tell someone they have cancer? How do you find words to say their treatment hasn’t worked? When I first became interested in this topic, I found a large body of literature had explored these questions. Studies suggested that the way difficult news is delivered has a lasting impact on patients’ subsequent symptoms of depression (Mager & Andrykowski, 2002), and that these events can have a negative impact on healthcare professionals themselves, increasing their stress levels (Shaw et al., 2013).

Despite this, one thing was still unclear: can this situation be improved? Can we train healthcare professionals to be better at delivering difficult news? This question seemed so big, so obvious, that my co-author Dr Maria Panagioti and I were sure it would have been answered before. We were surprised; while several individual studies had tested an intervention to break bad news, no one had yet systematically reviewed these studies and analysed the data together using meta-analysis. Meta-analysis combines results from multiple studies, providing better evidence about whether an intervention works and how effective it is than individual studies can provide. At first I was frustrated, why had no one done this yet? My frustration was quickly replaced with a sense of anticipation: if no one else had done it, there was an opening to do this ourselves! We got to work.

The search process
We decided to focus our review on doctors. We searched databases for potentially relevant studies and identified 2,270 records altogether. We filtered these by reading their abstracts, leaving 71 studies for more careful inspection. After reading the full texts of these, we excluded a further 53, leaving 17 studies for inclusion. The studies we included were from a range of countries, including the United States, Hong Kong and Israel. They were also from a range of healthcare settings, including palliative care, obstetrics and primary care.

Does training improve doctors’ skills in breaking bad or difficult news?
Altogether, the studies provided data from 1322 participants to answer our main question. The results of the meta-analyses were clear: interventions improved doctors’ abilities in breaking bad news with a large effect size. This effect wasn’t explained by sources that can bias results (such as the included studies being low in quality). Interestingly, interventions were most effective when they used an established framework for news delivery, known as ‘SPIKES’ (Baile et al., 2000). SPIKES outlines clear steps that doctors should follow when delivering bad or difficult news, such as delivering a ‘warning shot’ before breaking the news itself.

Could training help doctors too?
We asked a second question of the data, which was whether interventions can improve doctors’ confidence in delivering difficult news. Again, the results were clear: interventions improved doctors’ confidence in news delivery with a medium effect size. This suggests that difficult news delivery training may be one way to help reduce the stress levels of healthcare professionals who are regularly involved in these events, which is important considering current high rates of burnout in the healthcare workforce (see my previous blog on healthcare staff burnout here).

What now?
It is now clear that physicians can indeed be trained to deliver difficult news, and this training both improves their skills in difficult news delivery and also their confidence. What is less clear is whether such interventions can improve the experience of patients receiving this news. We only identified one study which looked at this. This study was based in Japanese cancer services (Fujimori et al., 2014). It found that when physicians were trained in breaking bad news, their patients reported significantly lower depression and anxiety symptoms later on, although the effect size was small. Further research into patient experience is warranted.

A need for further research in obstetric settings
One area future research on news delivery should focus on is obstetrics. The challenges in this setting are particularly complicated, as expectant parents may have no reason to think there is anything out of the ordinary with their pregnancy. Furthermore, if a healthcare professional has identified that a baby has a disability, it can be hard to know the extent of this before birth or how it will affect their lives. Our own research suggests that some parents still have a terrible experience at this time, which leaves a strong emotional imprint (Johnson et al., 2018; for my blog on this see here). Future research is needed to understand how healthcare practitioners working in obstetrics can be better trained and supported to deliver difficult news.

To read the review discussed in this blog, see here.

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