FACILITATOR’S GUIDE

For

Breaking Bad News using Role-Playing: A Multimedia Instructional Activity for Faculty/Facilitators Teaching Medical Trainees

developed by:

Michael J. Mintzer, M.D.Aileen Chen, MD, PhD

Tara Conway Copper, MDSara Filmalter, MD

Matthew S. Markert, MD, PhDTahira Mathen, MD

Natasha Parekh, MDShalu S. Patel, MD

Maria H. van Zuilen, PhD

August 2013

Facilitator’s Guide

This guide is the complete description of the session designed to help faculty/facilitators effectively and completely deliver the session from beginning to end.

Session Overview

This session is designed to teach medical students the basics for breaking bad news: getting the words out, and recognizing and controlling the personal emotional reaction. A short scenario is described to the entire group. One student is asked to be the “physician” and break the bad news to the “patient” who is played by another student. Each role-play is designed to last from 30 – 60 seconds. A facilitator asks students how they did and asks for reaction from the group. Each student “physician” will receive formative feedback and be asked to try the scenario again until it is done successfully. It is important that students play both the physician and the patient since we want students to recognize the emotion experienced on both sides of the conversation.

The faculty/facilitator will describe the session structure, the benefits of using role-playing simulations, the emotional impact that bad news has on physicians, patients and families, and learning to recognize and control these emotions.

The session uses 8 scenarios. The first two are non-clinical; the remaining ones are clinical, each successively having an increasingly serious impact on the patient’s clinical care. The two non-clinical scenarios have several purposes. First, they are ice breakers. They help initiate the learners to the technique without the threat of embarrassment for not knowing the medical illnesses or terms. Second, it allows the introduction of the extremes of emotion.

The first role-play is about a roof leak and the need to spend money to fix it. This is a problem requiring a “cognitive” solution: the homeowner will need to cut back on other expenses to solve the problem. The second role-play is about the break-up of a relationship. This is a problem requiring an “emotional” solution: the couple will have ongoing heartache for some time. This second role-play begins the process of learners feeling the intensity of emotion while breaking bad news. Not only are the students performing the role-play experiencing emotion; but also, those watching are also feeling emotion! The remaining role-playing scenarios are all clinical scenarios.

Role-playing is an effective instructional method for this teaching since there is a large component of emotional learning involved. There are several important characteristics about role-playing that need to be addressed with the student before beginning. First, it is a way to practice and develop difficult communication skills without putting patients at risk. Poorly communicated bad news can harm a patient in many ways, often emotionally. Second, during role-playing, we expect to see mistakes; and, since it is a simulation, learners can fix their mistakes and ultimately demonstrate success. As a facilitator, your role is to guarantee the success of the activity for students by keeping the role-plays short, by stopping the role-plays if a student is obviously stuck or distraught, and by using formative feedback and encouragement to help each student successfully complete the role-play – even if it takes several attempts. At the end of the session, each student “doctor” will have successfully delivered the bad news in 2 or 3 scenarios and will have had the bad news delivered to them as a patient a similar number of times.

One important caution: some students will find this session very difficult. Often times, the scenarios are similar to current or past life experiences that dredge up emotions students find themselves unable to manage. As a facilitator, be forthright about the emotion happening during the session. Give students a chance to “get ready;” give students permission to opt-out of a scenario they find particularly difficult. On rare occasions, a student may have to be allowed to leave the session. If a student needs to leave the session, take a moment to speak to the student privately and assure them that there will be no negative consequences to them for leaving. Tell students that education is not about injuring learners and that staying would cause them injury. A phrase like, “I prefer that you leave; we can complete the session another time,” is very reassuring to a distraught student. Call the student the next day to see how they are doing; always remember to call.

This session is designed to last 2 hours with 12 medical students. (For ease of recording, the module used 7 students).

Learning objectives

Using short scenarios, the student will:

  1. Appreciate the physician’s responsibilities regarding breaking bad news
  2. Understand the six-step protocol for breaking bad news
  3. Appreciate the impact receiving bad news can have on patients
  4. Develop communication skills for breaking bad news

Goals

For this session, the goals are straight forward

  1. Accept you responsibility for breaking the news
  2. Use a structured approach whenever possible – 6-step protocol adapted from Robert Buckman (see Appendix 1: Six Step Protocol for Breaking Bad News)
  3. Feel the emotion as a physician and patient
  4. Develop an advanced communication skill

Intended audience(s)

  1. Medical students
  2. Interns
  3. Other clinical providers who may need to deliver bad news

Instructor qualifications

The facilitator should be someone skilled in small group interactions and willing to facilitate role-playing experiences. It is important that the facilitator has skill and experience in delivering the bad news.

Materials

  1. A quiet classroom with ample space and few interruptions
  2. Ample space for comfortable seating for all participants
  3. Appropriate attire for a “patient” encounter
  4. Student (one for each student) and faculty/facilitator evaluation forms (see Appendix 2 and Appendix 3)

Preparation

Before coming to the sessions, students will study a structured method for delivering bad news (Buckman 6-step model, SPIKES, etc.). Literature articles and patient written articles can be useful when added as a pre-session reading requirement (e.g., Creagan reference). The facilitator will have reviewed the facilitator’s guide and the multimedia module in advance of the session.

Beginning the session

  • Begin by introducing yourself and have the students introduce themselves.
  • Ask if someone can state the learning objects of the session.
  • Review the learning objectives
  • Ask if anyone has ever had any role-playing experience before in education (see Appendix 4: 10-Tips for Facilitating Role-Playing Instructional Activity)
  • Discuss the benefits of role-playing
  • It is a “safe” environment for both the student and the “patient”
  • Mistakes are expected, without consequence
  • Formative feedback allows learning to occur immediately
  • Allows practice for “saying the words” and “feeling the emotion”
  • Review the reading
  • Ask the students to describe how they would like “bad news” given to them (environment, depth of discussion, who else might they want to be present, etc.). This allows students to reflect on their understanding of the structured models (SPIKES, Buckman 6-step, etc).
  • Review the structured model
  • The following is a sample opening statement: During today’s role-playing scenarios you will have some experience in using a structured model but not in great detail. Why? The scenarios are designed to be short so that you can learn to say the words and recognize the emotion. In addition, for each scenario, the environment is pre-set. Finally, we do not want to create additional complexity in the role-play.”
  • Role-playing rules
  • The goal is to break the bad news
  • The scenarios are very simple and there are no tricks. Feel free to “ad lib” but don’t add complexity to the case
  • When you are a patient – react to the news
  • When you are a doctor – you may not know what treatment to offer. Therefore, when you offer a plan to the “patient” simple say something like, “I will need to do a few more tests,” or “I will ask the specialist to see you for another opinion.” (That will be near the end of any of the role-playing sessions AND respond to the patient’s questions and feelings
  • Each role-play will take somewhere from 15 to 60 seconds! It will just seem like a lot more!
  • Each of you will have the opportunity to successfully deliver the bad news
  • Each of you will get feedback from your peers and some guidance from me
  • Ground rules
  • You are allowed to laugh and learn. In a highly emotional circumstance, sometimes laughing is a nervous habit – one that you will need to control. You might laugh at yourself. You will find yourself laughing with your peers.
  • This session is not designed to injure or upset you. This session will bring out emotion. A scenario might bring back the memory of a recent or past highly emotional experience; you may find yourself with tears in your eyes; and you may not be able to control it. If I see that you are upset I will ask you if you are OK. You ARE PERMITTED to “opt out” of a particularly emotional scenario. Each year in a class of 150 students, 2 or 3 cannot do the session because of a personally difficult current life experience.
  • Answer any questions students may have about the session.

Begin the Role-Playing

Scenario #1

  • Ask for two student volunteers
  • The first role-play is non-medical. Tell the entire group what the scenario is. [You will want to watch the reactions of the “observers” during each scenario and elicit their comments at the end.] One student will be a home owner with a roof leak; the second is a roofer who just finished inspecting the roof. BAD NEWS: the roofer tells the home owner it will cost $2400 to fix the roof.
  • This scenario is designed to break the ice and “equalize” the students. By using a non-medical example, any perceived differences in medical skills or knowledge among the students is eliminated. The students form a group of learners who start out as “equals.”
  • Ask on student to be the home owner and one the roofer. Ask the “roofer” to break the bad news. This is a very short scenario and should take no more than about 20 seconds. Stop the scenario, once the bad news is given OR if the roofer is beating around the bush and has not delivered the bad news after about 30 seconds.
  • Ask the roofer how they did. What would they do differently?
  • Ask the home owner how they felt. Did they get the bad news?
  • Ask the group what they thought. Did they feel like the bad news was delivered?
  • If there was any hesitancy or incompleteness in the roofer’s performance, give very specific formative feedback on how to improve. For example, if the roofer did not clearly break the bad news, suggest a statement such as, “After inspecting your roof, it will cost $2400 to fix it.”
  • After the first student successfully breaks the bad news, switch roles and ask the home owner to become the roofer. Perform the role-play again until the second student is successful. Use the students’ observations and your assessment to give formative feedback as you did for the first student
  • Take a second to review the structured model. In this scenario, the environment is set, what the person knows and wants to know is set, there does not need to be another person present, and the plan is understood by all – fix the roof!

Scenario #2

  • This is a non-medical scenario. This couple has been dating for 3-4 years and she has finally come to the conclusion that the relationship is over. BAD NEWS: tell him you are breaking up. [This scenario often gets comments from the crowd – enjoy them!]
  • Ask for 2 different students to do the next role-play. [You may want to choose the “couple” in order to create the highest emotional impact.]
  • Give her 30 – 60 seconds to break the bad news. As you did before, stop the role-play after the bad news is delivered (and you get to see or hear his response) or if she is unsuccessful. Ask her how she did; ask him how he felt; ask the observers what they heard and felt. Ask the student to try again if she was unsuccessful or awkward the first time.
  • Repeat the role-play to give the male student the opportunity to break up.
  • Compare this scenario with the first. In the first scenario, although there could be emotion such as frustration, the news is really a “dollars and cents” issue. In the second, the news is 100% emotion. Ask the students WHAT they felt when they broke the bad news. Ask the observers what they felt.
  • Ask the students if they noticed any differences in style between the way the woman and the way the man broke up. [This is not a critique of man vs. woman. It is recognition that style (or process) can be different, yet equally effective.] How did empathy come across?
  • Make the point that emotion is ALWAYS present when you break bad news. Learning to recognize it in yourself and control it is part of the skill of breaking bad news.

Scenario #3 through #8 (use the cases from the module or develop similar cases better suited to your curriculum. See Appendix 1: Module Play Time and Description, in the Breaking Bad News using Role-Playing: A Multimedia Instructional Activity for Faculty/Facilitators Teaching Medical Trainees session description).

  • The remaining scenarios are all clinical. Scenario #3 requires students to tell a well adult during an outpatient annual check-up that they have high blood pressure that needs to be treated. In each subsequent scenario, the bad news gets more and more difficult until the final scenario when a “physician” tells a “parent” that his/her child has died.
  • Use the same technique after each role-play. The students for each scenario should perform the role-play until the bad news has been successfully delivered. Give formative feedback based on comments from students and your own assessment.
  • Remember – guarantee success! Keep the role-plays short and focused on the delivered news and control of emotions. If a student cannot perform a specific role-play, they should not be forced to do so.

Debriefing

  • At the end of the session ask students if they feel “exhausted.” Emphasize that at the beginning of the session they were not skilled in delivering bad news. Now, merely 2 hours later, they have all delivered bad news successfully, unambiguously, even news about death and dying. They have each learned to feel the emotions that are ALWAYS part of breaking bad news and they have begun to learn to recognize and control these emotions. Emphasize that breaking bad news is not time consuming. In each scenario, the bad news could be successfully delivered in less than 60 seconds, often in about 30 seconds.

Evaluation

The last item is to ask students to complete the session evaluation form,anonymously. Remind them that this instructional activity for future students can be improved based on their evaluation and construction comments. All students complete one and place their response in a single envelop. In addition, each faculty/facilitator completes a faculty evaluation form and includes it in the same envelop. The faculty/facilitator will return the evaluations to the course coordinator or director.

Acknowledgement

The authors wish to acknowledge the efforts of Lisa Granville, MD; Pat Caralis, MD, and Maria H. (Rose) van Zuilen, PhD in creating the original facilitator’s guide adapted for this session.

Appendices

Appendix 1: Six Step Protocol for Breaking Bad News (Adapted from Robert Buckman)

Step 1. Getting started

  • Create a conducive environment.
  • Allow adequate time and avoid interruptions (e.g., turn off beeper).
  • Select a private quiet setting, where both physician and patient can be comfortably seated.
  • Sit close enough to the patient to touch if appropriate.
  • Determine who else the patient would like to be present.
  • Start with a question like, "How are you feeling right now?" to indicate to the patient that this conversation will be a two-way affair.

Step 2. Finding out how much the patient knows.