Oregon Medical Students Learn How to Deliver Bad News, and Get Tested on It

For the first time, medical students are being evaluated on how they deliver bad news. By the time they receive their diploma, Oregon Health & Science University Medical School (OHSU)’s graduating class of 2018 will have passed a simulated patient encounter in which they delivered news about the passing of a loved one or admitted a medical mistake.

After years of interviewing patients and their families, Susan Tolle, MD, professor of medicine in the division of general internal medicine and geriatrics at OHSU, director of the OHSU Center for Ethics in Health Care, and the leading force behind the initiative, has learned and understood what can go wrong. A physician may stand at the doorway with their arms folded. They may also avert eye contact, use too much medical jargon where the loved one has trouble understanding what they are saying, or be too blunt and announce the death as they walk into the room.

“We’re hoping that we give these students the basic foundation they need,” said Tolle in an interview with The American Journal of Managed Care^®. “They still have at least 3 more years of training, so we’re not saying you’re a perfect product. We’re saying that you have a communications foundation on which to build, and you have some tools in your toolbox to keep building.”

While many medical schools teach communication skills, and have for decades, what makes OHSU’s program different is that it puts an increased focus on more ethical and professional communications by embedding them into the curriculum and testing if the students have mastered the skills at an appropriate medical student level. “We think we’re the first to attempt to set a bar for these kinds of communications skills,” said Tolle.

Students are tested on both how they verbalize the news and how their body language appears when they deliver the news. Checklist items include introducing themselves, finding a private place to speak, sitting down leaning forward with an open body position that looks welcome, and knowing when to stay silent so the person can take in the news before they continue speaking.

“I may not change what’s in your heart, but I can change what’s in your behavior,” said Tolle. “Your behavior is perceived by the patient. The patient will perceive getting bad news differently if I get you from the door frame, standing there telling you bad news, rather than sitting down with you and telling you the news. That alone will be perceived by the patient as more respectful and more empathetic.”

OHSU has a 2-story simulation center equipped with mock examining rooms, professional actors, and cameras. When it comes time for the exam, the medical student is filmed entering an examining room and conversing with the actor, delivering the news that a loved one has passed away or there has been a medical mistake. The student is then briefed on what they did well and what they need to work on. Although most of the students did well and passed, some struggled, according to Tolle. If a student doesn’t pass, OHSU faculty will privately work with them until they master the skills and can pass.

The training also has its benefits for physicians, Tolle said. She explained that this could potentially help alleviate physician stress and burnout if physicians are having more positive experiences in these difficult interactions. “This helps them take control of a scene that’s out of control,” said Tolle.