- College of Medicine Medical Students
Your patient has cancer that’s spread to his liver. Or tests that show your patient’s HIV infection has progressed to full-blown AIDS. Or you have to explain to your patient that bloodwork shows her cheating spouse gave her gonorrhea.
Breaking bad news to patients is as much a science as it is an art, and a skill that must be practiced. So first-year students at the UCF College of Medicine recently worked with “standardized patients” – trained actors — to understand how to be empathetic and informative when breaking bad news about their patient’s health.
Such communication “is a real skill that requires practice,” said Assistant Professor Dr. Christie Bellew, who leads the Medical Interviewing module, which includes lessons on all types of patient communication. “We like to start them early so they have plenty of time to develop those skills, to prepare them for the clinical arena.”
Standardized patients are members of the community who sign up to play various roles in the medical school’s Clinical Skills and Simulation Center. Some roles require the actors to have particular symptoms like chest pain, severe headaches or dizziness. Other roles require them to illustrate psychosocial issues like addiction. In other scenarios, standardized patients help train medical students on how to deal with the emotional and behavioral sides of care – how to establish proper boundaries and how to communicate about painful topics, including death.
Before they practiced with actors, the students received instruction on the science of breaking bad news. Find out what the patient knows about their situation or illness, how informed they are about their condition, the students learned. Then ask permission to deliver results; don’t just blurt out the bad news. Dr. Bellew advised students to be clear and concise, but not blunt. “If you tell someone that they have cancer, you’ve just set a bomb off in their head,” she said. “They’re not going to hear anything you say after that. You want to give them a chance to absorb what they’ve heard, and then get their permission to go on.”
Some of the student’s scenarios involved potentially deadly diseases like lung cancer and Hepatitis C. First-year student Bob Thomson was paired with a standardized patient who was diagnosed with a lung tumor, despite being a young man in his mid-twenties who had never smoked. “One thing they teach us in medical school is that the disease doesn’t read the book,” he said of the rare diagnosis. “You learn all these facts, but once you get out there, it may not work the way you learned it.” Thompson said he understood his patient’s reaction of denial and disbelief, because that’s exactly how he would feel. “I would want my doctor to be honest and straightforward with me, but also genuinely sympathetic and caring,” he said. Thompson said he tried to offer that same combination of feelings to his patient. “It’s hard to pack that range of emotions into the simulation. I think that’s’ why we are practicing so early, so that we will make fewer mistakes when we start working with patients,” he said.
Standardized patient Jennifer Neal played the role of another lung cancer patient and said her acting diagnosis became almost real. “There were times when I said ‘what am I going to tell my husband?’ (during the simulation). You feel that situation as if it could happen to you,” Neal said. She added that some students she worked with felt similar emotions. Some reached out their hands in comfort. Others were visibly shaken. “When one student was telling me the news, she almost started to cry, herself,” Neal said. “It’s a simulation. But you could see the emotion on her face.”
Another scenario was not as life-and-death but was certainly painful. Standardized patient Frances Datz played Mrs. Taylor, a woman who finds out that her pastor husband is cheating on her after she she is diagnosed with a sexually transmitted disease. “I’m emotional, I’m angry, I’ve been betrayed finding out my marriage is falling apart, and what am I going to tell my kids?” Datz said of her scenario. “Some students respond to the emotion, while others want to tell me how they can give me medication and I’ll be OK. Their responses really determine how I continue to play out the part.”
As medical students Emily Dugan and Tyler Janz sat across from Datz, they explained in scientific terms her gonorrhea diagnosis. Their patient tried to rationalize, saying maybe she had been infected in a cruise ship sauna during vacation. Students had to be sensitive to her reaction, but also address the science — she could only have contracted the disease through sexual intercourse. “At any time, these actors can throw something different into the scenario—they may yell out or start crying,” Janz said. “I find myself having to pause and take some time to re-evaluate the situation.”
During one simulation, Dugan’s patient asked a question about the diagnosis the medical student wasn’t prepared for — “are you sure?” Dugan said she worried that saying “yes” would feel like she was breaking the bad news all over again. Dugan says she is becoming more comfortable as she gets more experience. “My patient was rocking in her chair, and I found myself doing it, too,” Dugan said. “My ‘aha’ moment was recognizing that weakness and having the space to learn from my mistakes.”
Students get the opportunity to call a “time-out” to ask a faculty member for guidance if they get stuck on a question or situation. After the simulation, students discuss their experience with faculty, and go over ways to improve. Janz says each scenario gives students a chance to become more comfortable relating to patients. “I feel like it’s become more natural throughout this year,” he said. “Just looking back, you can see how everybody has grown to have more of a natural conversation—as opposed to going through a list of questions you’re trying to get across.”