gms | German Medical Science

The concerns of patients suffering from life-threatening disease and end-of-life care aspects have gained increasing attention in public perception. In an ambulatory setting, mostly general practitioners and nurses are caring for the palliative patients in nursing homes, hospices and in the patient’s home [1]. Specialized ambulatory palliative, and hospice care teams are keeping a link between inpatient and ambulatory care. The number of inpatient-palliative institutions in Germany has increased during the last decade [http://www.wegweiser-hospiz-palliativmedizin.de/]. Seven medical faculties hold a chair in palliative medicine (Aachen, Bonn, Erlangen, Göttingen, Köln, Mainz, München; more will follow); they are assigned to organize the teaching of palliative topics locally as a new interdisciplinary field (Q13) at the latest for all students who leave medical school in summer 2013 [2], [3].

The curriculum of the German Association of Palliative Medicine [4] contains basics of palliative medicine, symptom-control, psychosocial aspects, ethical and judicial questions and topics such as teamwork and self-reflection. We also find educational objectives such as communication-skills, which should use 10% of the curricular time. The conceptualization and implementation of these courses are ambitious, because basic- and advanced communication skills need to be taught. In this context one competence that is particularly difficult to attain is breaking bad news to a patient [5].

Anglo-American and Scandiavian research has shown that communicative competences can be taught and learned also for breaking bad news and this can also be assessed in special formats [6], [7], [8]. Useful didactic methods are role-plays, simulated patients or analyzing real or edited video-tapes. The tradition of teaching „bad news“ exists only in a few German faculties, where we find these teaching units as part of “history-taking” or general “doctor-patient communication courses“(HEICUMED in Heidelberg, Erlangen. Köln), in model or reformed curricula (e.g. Berlin and Witten /Herdecke) as elective courses and projects, and finally some established courses that have existed for some years at faculties with a palliative tradition (Mainz, Bochum, München, Bonn) [9], [10], [11], [12], [13], [14], [15], [16].

Since the revision of Medical Licensure Act in 2004, communicative and social competences are more frequently realized in the curricula; in this journal, a longitudinal model curriculum for social and communicative competence addressing German medical faculties was published for the first time [17].

At some faculties we now have a good synergy: the increasing experiences with innovative didactic methods such as simulated patients, learning in small groups, role plays or including media facilitates the teaching- topics like breaking bad news as well. In Göttingen, parts of Q13 existed at different points of time in the curriculum as lectures and an optional 45 minute course [3]. Since the summer term of 2010 we are teaching an interdisciplinary seminar „breaking bad news“ for all students in the sixth year. As a guideline we used several elective courses from the departments of oncology, palliative medicine, and one existing compulsory course called “basic medical skills” (dept. of general practice and dept. of psychosomatic medicine), where students practice taking the case history and basics of communication skills. Within a longitudinal curriculum it seemed consistent, to build on these basics and continue with a new area: the breaking of bad news.

We here describe the development and contents of our new teaching concept.

Implementing the new course for 180 students as a compulsory course, we needed to spread the lessons across several departments. The following departments with previous experiences as described above met for planning the course:

• Dept. of Palliative Medicine
• Dept. of General Practice
• Dept. of Hematology/Oncology
• Dept. of Psychosomatic Medicine

Our teaching team consisted of medical doctors as well as psychologists.

The common goal was to involve the three learning levels knowledge, practical skills, and attitudes in the learning process. Beyond this, we were able to include the following learning objectives of the “Göttingen catalog of aims in learning”:

• Communication with patients at the end of life /caring for dying patients
• Informing patients before therapeutical and diagnostic procedures.

Our framework defined two 90-minute courses and 12-15 students per group. The course started first in winter term 2009/10 in its final form as a pilot course and is taught for all sixth-year-students since summer 2010.

In some cases two teachers were able to teach together in one group to allow a splitting-up into two smaller groups (role play).

Table 1 [Tab. 1] shows how we transferred the three learning levels into practice.

The configuration of details in the several groups was realized differently. The introduction into the topic was meant to activate the student’s affective level. We used a novel - (which was read aloud) or the first part of a movie. Both show a doctor communicating with a patient about an advanced carcinoma. We chose this subjective way of demonstrating a doctor-patient interaction to attune student’s feelings and attitudes. We developed questions, require a deeper reflection about the scenes:

• „Describe from the patient’s perspective, who just got the bad new, how you feel in this moment after the consultation”
• „Describe from an observers perspective the interaction between patient and doctor“
• „If you were the patient, what would have been your request in this situation?

The first lesson ends with a short theoretical input about the background, aims, and practical advice for the structuring of difficult conversations. Several modifications of didactic methods within the lesson intended and contribute to the student’s activity and attention.

The central component of the second lesson is the role play, which is performed after a short repetition of the most important aspects of the first lesson. We conduct the role play intentionally without simulated patients, to allow students the opportunity to participate in the patient-perspective as authentically as possible [18], [19]. It is important that the patient-role-script does not tax the students to much: age, disease, and the general life situation should be in some way removed to enable the students to keep an inner distance from the role [20]. After finishing the role- play we „debrief“ the students to avoid mental stress for the student who just played the patient.

Both role-plays are designed as a serial: first the consultation demands to look at technical aspects of diagnostic procedures in a case of suspicion of a malignant disease and realizing and handling the patient’s anxiety. The second consultation contains breaking the bad news to the patient and scheduling the following treatment and attendance (see Table 2 [Tab. 2]).

First in the small group and later in the whole group we have a short feedback-round to discuss our experiences.

For the second role-play students are allowed to choose if they want to play the same doctor resp. patient role again or if two fellow students should play (see Table 3 [Tab. 3]).

At the end of the role-playing, the whole group reflects if the communicative aspects that were summarized at the beginning were realized during the role play.

The following sequel of the-role play is possible and is already realized in other circumstances (qualification course with GPs in palliative care)

• A third consultation (one year later) with the attending oncologist includes the communication about the incurable metastatic disease and the implication for a remaining lifetime.
• A fourth consultation takes places in the situation of tumor progress despite chemotherapy with the consequence of planning a symptom- controlling therapy and palliative medicine.
• A last sequence could be the message about the patient’s death to the spouse, e.g. as a written exercise or with help of mind-mapping.

The sequence of consultations is meant to demonstrate a shifting of the character of doctor-patient communication in these cases: technical (diagnostic, organizational) and medical aspects are important at first but later fade into the background, however questions about remaining lifetime, the end of life and the subjective feelings (of patient and family) become more imminent.

In Göttingen we conduct a standardized optional online-evaluation concerning all clinical modules, where we ask about the organizational and didactic quality of the teaching units. The evaluation of our new course took place once after the pilot-phase in summer 2010 with a participation of only 35% of the students. We obtained good results with regard to the relevance of the topic and the motivation and attitudes of the teacher.

During the oral feedback at the end of the second lesson students showed great acceptance of the seminar. They also showed gratitude that this important topic is now „finally“ taught. Students criticized that breaking bad news was taught only at the end of their medical degree and wished to have more time. The movie in particular was highlighted as a vivid and discreet introduction into the topic.

Our new compulsory course „breaking bad news“, which was interdisciplinary developed and taught, was able to be realized according to the new guidelines for Q 13 for all students in the sixth year. We imparted cognitive knowledge, exercised skills, and stimulated and reflected the student‘s attitudes. The combination of methods within a teaching unit gives room for self-reflection, cognitive activity, and practical exercising, seems to be inspiring for students.

While we only offer one such course during the whole medical degree, the point in time seems to be advantageous: the students find themselves directly before the beginning of the „practical year“, were they presumably will be confronted with this topic. Other studies showed that exercises in communication skills have the best effect if they are realized promptly [20].

Two courses of 90 minutes are only capable to sensitize students and give them a first opportunity for practicing this complex subject. Breaking bad news is one of the most difficult problems for medical professionals, but should be practiced - with increasing complexity - already with students [21], [22].

The use of media such as film in medical teaching has some tradition in Canada and the USA [23], [24] and seems to be very appropriate for teaching topics like death and dying. "Cinemeducation is an effective tool that can enhance teaching as it provides a dynamic and humanistic depiction of clinical situations to audiences, captures their attention, and engages them in the emotional experience." [25]. The approach with help of arts like cinema or novels is able to focus the student’s attention and to show new, individual aspects [26].

Personal time and effort to prepare for courses is necessary, but the small-group format is a fundamental component of our teaching concept and probably responsible for the satisfaction of students and teachers both.

Topics that were taught should also be tested: in line with the conception of assessment of Q13, we presently set a written test (MC) concerning the theory of communication, e.g. breaking bad news. We are planning a clinical OSCE at the end of the sixth year containing a station with “breaking bad news” to a simulated patient.

In terms a spiral learning (repeated lessons on a progressively higher level) a repeated teaching of these topics during the whole medical study is desirable: beginning with easy consultations that highlight basics of communication (students in their first and second year), one could raise the degree of difficulty up to lessons during the practical year. Real experienced cases could be reflected and difficult situations could be analyzed with the help of role-plays or simulated patients. Thus the medical degree course would be able to live up the expectation of building the students professional attitude and personality.

The authors declare that they have no competing interests.