Helping medical students to acquire a deeper understanding of truth-telling

Figures & data

Table 1 Medical students’ concerns regarding breaking bad news

	Respondents (N=225)
	Before intervention (144)	After intervention (115)	Clinical rotations (95)
Communication concerns	125	78	60
Choosing words	67	38	27
Appropriate behaviour	58	35	17
Adapting to the patient	48	18	14
Supporting the patient	21	17	15
Empathy	14	7	11
Managing time	11	12	7
Lacking competence	13	9	7
Appropriate distance	17	8	2
Adapting to the situation	10	1	3
Maintaining the doctor–patient relationship	8	5	5
Managing the discussion	3	6	1
Knowing oneself well	1	1	0
Being victim of a misunderstanding	0	0	1
Family pressure	0	0	1
Emotional concerns	83	59	45
Facing the patient's emotions	55	41	30
Specific expressed emotions	24	12	5
Managing one's own emotions	17	19	17
Emotional distance and personal implication	17	9	11
Feeling powerless	7	6	7
Empathy is difficult	3	1	3
Emotions of patient's family	3	1	1
Being associated with the bad news	3	3	0
Feeling of injustice	1	0	0
Ethical concerns	71	32	34
Improving consequences for the patient	50	22	20
Truthfulness	20	6	7
Respecting the patient	11	4	8
Personal responsibility	11	3	4
Respecting autonomy	5	1	0
Doing one's best	4	4	1
Integrity	2	0	3
Not acting like a member of the family	1	0	0
Not remaining technical	0	0	2
Being fair	0	0	1
Practical concerns	18	12	14
Allowing treatment to take place	9	5	6
Not having enough experience	3	2	4
Obtaining long-term follow-up	2	2	0
Having time for the patient	1	3	4
Including the patient's family	3	0	0
Finding oneself in a difficult position	1	1	0
Announcing uncertainty is difficult	0	1	0

Table 2 Integrating values and goals through time

	Before intervention	After intervention	Clinical rotations
Communication concerns
Choosing words	Avoid direct wording	Being clear	Being balanced
	The fear of being too brutal by not using the appropriate words. (Respondent 8)	It's difficult to be able to transmit all the necessary information in difficult circumstances. (Respondent 204)	To not reassure the patient too much with false hopes. (Respondent 109)
Appropriate behaviour	Inexperience	Clumsiness	Support
	I feel that I do not have the necessary tools to give this information in the best possible way. (Respondent 18)	Being clumsy in my remarks and so harm the patient. (Respondent 20)	My first preoccupation is to be appropriate so that the patient feels supported. (Respondent 284)
Adapting to the patient	Predictive planning	Support in situ	Lifelong adaptation
	Knowing how they will react, how they will come to terms with the news at the time and most of all afterwards, when we – the doctor – are not there any more. (Respondent 231)	It's impossible to predict the reaction the patient will have (…). However, it is reassuring to know that we will do all we can to assist them in their distress. (Respondent 15)	I think it is easier (…) when we practice medicine for some years (…). It is never possible to predict a patient's reactions (so) we must be capable of adapting to him, his life experience, and his wishes. (Respondent 201)
Supporting the patient	The goal of comforting	The goal of comforting	Practical examples
	Being able to comfort the patient as much as possible, while giving her the time to come to terms with the information. (Respondent 215)	To alleviate her distress. (Respondent 209)	It is difficult to wait, we want to continue. But it's best to wait for the reaction and, if needed, to take out a handkerchief or offer a comforting shoulder. (Respondent 72)
Empathy	An emotion	A perception tool	A clinical skill
	So, I think it's really a selfish reason, because I may have too much empathy and it hurts me to have to announce bad news. (Respondent 257)	I do not know what attitude to have; I have a hard time feeling the patient's feelings. (Respondent 40)	Being able to ‘put yourself in the patient's skin’, to understand him. (Respondent 69)
Lacking competence	Lack of general knowledge	Lack of specific knowledge	Lack of embedded knowledge
	My main concern is not being able to deal with the reactions and questions of the person to whom we give bad news. (Respondent 27)	A very good (i.e., perfect) knowledge of the disease and situation is necessary so as not to be embarrassed by the patient's questions. (Respondent 208)	Not knowing the diagnosed pathology well enough and making errors in prognosis, quality of life, which could have bad consequences for the patient. (Respondent 65)
Managing time	Preparing the patient	Managing the encounter	Giving the patient time
	It is difficult to succeed as well as possible in preparing the patient to hear the bad news. (Respondent 214)	The fear of being too moved myself to manage the timing of the discussion. (Respondent 24)	Sometimes it is difficult to wait, because we want to carry on. But the best thing is to wait for the patient's reaction. (Respondent 72)
Maintaining the doctor–	The patient could leave	The doctor could harm the link	Dialogue could end
patient relationship	A risk of the patient severing the link, or loosing trust. (Respondent 82)	We have to manage the moment, not downplay the bad news, but try to do it well and not lose the contact with the patient. (Respondent 10)	Keep a relation of trust and not end the dialogue. (Respondent 104)
Emotional concerns
Facing the patient's	Understanding the patient's emotion	Helping the patient through the emotion	Staying in synch with the patient
emotions	I hope to understand their emotions a little in order to be able to help better with the bad news. (Respondent 7)	(Fear of) the patient's revolt, and not being able to calm or comfort him. (Respondent 77)	To not be in the right ‘state of mind’, for example to be happy for a personal event and not be able to remain grave. (Respondent 65)
Managing one's own	Setting one's emotions aside	Tuning one's own emotions down	Avoiding emotional contagion
emotions	To be unable to hide my own emotions in front of the patient. (Respondent 3)	It is very difficult to manage a situation like this one when you are submerged by your own emotions. (Respondent 208)	I fear entering into sympathy with the patient and becoming destabilized by my own emotions. (Respondent 206)
Emotional distance and	A step back	Being available	The ‘right’ distance
personal implication	(Fear) of taking the bad news personally and too much to heart, and not stepping back from these situations enough. (Respondent 15)	Knowing how to be present without overwhelming the patient. (Respondent 99)	To place enough distance from the patient while remaining human. (Respondent 205)
Ethical concerns
Improving consequences	Not making the situation worse	Avoiding bad consequences	Sustaining the patient
for the patient	To do it in the right manner, so that it does not make the bad news even more difficult than it already is. (Respondent 29)	The patient's reactions can be very violent, I'm thinking in particular of suicidal thoughts. (Respondent 287)	Encourage him despite it all (to fight, to keep going) without giving him false hopes. (Respondent 211)
Truthfulness	Hiding nothing	A truthful evaluation	A truthful evaluation
	Being capable of explaining as honestly and completely as possible. (Respondent 47)	Being understood from the start, without giving false hopes or presenting a situation more dramatic than the truth. (Respondent 9)	To not reassure the patient falsely, nor falsely increase his despair and fear. (Respondent 60)
Respecting the patient	Not imposing one's views	Adjusting to the patient	Adjusting to the whole patient
	I hope to respect the beliefs or culture of patients, without imposing mine in announcing bad news. (Respondent 7)	Responding with the right touch and tact to the questions asked by the patient. (Respondent 78)	(Fear of) not responding to his expectations as a whole person (culture, character, etc…). (Respondent 105)
	Some patients give us to understand that they do not want to know, others do the opposite. (Respondent 16)