Breaking bad news in neurology: assessing training, perceptions, and preparedness among residency programs in Brazil

Lima, Thaiza Agostini Córdoba de; Bruno, Fernando Pereira; Gushken, Fernanda; Degani-Costa, Luiza Helena; Novaes, Natalia Pelizari

doi:10.31744/einstein_journal/2023AO0036

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ORIGINAL ARTICLE • einstein (São Paulo) 21 • 2023 • https://doi.org/10.31744/einstein_journal/2023AO0036 copy

Breaking bad news in neurology: assessing training, perceptions, and preparedness among residency programs in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

We aimed to evaluate how breaking bad news training was implemented in neurology residency programs in Brazil and to assess the perception and preparedness of trainees and program directors.

Methods

We performed a cross-sectional descriptive study. Neurology trainees and program directors were recruited from the Brazilian Academy of Neurology registry through convenience sampling. Participants answered a survey evaluating the breaking bad news training at their institution and their preparedness and perception towards the topic.

Results

We collected 172 responses from 47 neurology institutions from all five socio-demographic regions of Brazil. More than 77% of trainees were dissatisfied with their breaking bad news training, and around 92% of program directors believed their programs required substantial improvement. Approximately 31% of neurology trainees reported never having a lecture about communicating bad news, 66% reported never having a simulated training, and nearly 61% never received feedback regarding their communication abilities. Moreover, 59% of program directors acknowledged that feedback was not a standard practice and nearly 32% reported the absence of any specific training.

Conclusion

This study suggested that the breaking bad news training in neurology residencies across Brazil is deficient and highlighted challenges to achieve this core competency. Program directors and trainees recognized the importance of the topic, and program directors acknowledged that many factors hinder the ability to implement formal training. Given the relevance of such a skill to patient care, every effort should be made to provide structured training opportunities during residency.

Communication; Education; Internship and residency; Learning; Mentoring; Neurology; Surveys and questionnaires

Highlights

• Neurology trainees and program directors recognized a lack of structured breaking bad news training.

• Program directors reported that many factors hinder the implementation of breaking bad news education.

• Trainees felt capable of breaking bad news, but most did not have lectures, simulations, nor feedback.

• Trainees acknowledged negative feelings when breaking bad news, including sadness and helplessness.

Questionnaire 1 - Residents and Recently Certified Neurologists (part 1 of 2)	n (%)
Sex
Male	46 (42.20)
Female	63 (57.80)
Age, average	30.4
Do you feel capable of communicating bad news?
Yes	92 (84.40)
No	17 (15.60)
Are you satisfied with the training on the communication of bad news in your residency program?
Completely satisfied	25 (22.94)
Partially satisfied	61 (55.96)
Not satisfied	23 (21.10)
Do you consider the training on the communication of bad news to be important?
Yes	109 (100.00)
No	0 (0.00)
How many times have you had a lecture on the communication of bad news?
Never	34 (31.19)
Once	40 (36.70)
At least twice	35 (32.11)
How many times have you participated in simulations (role-playing with actors or residents)?
Never	72 (66.06)
Once	22 (20.18)
At least twice	15 (13.76)
During residency, how many times did you experience real situations involving the communication of bad news?
Never	2 (1.83)
Once	0 (0.00)
At least twice	107 (98.17)
During residency, how many times did you receive feedback on your performance of bad news communication?
Never	66 (60.55)
Once	18 (16.51)
At least twice	25 (22.94)
Do you know the SPIKES protocol?
Yes	64 (58.72)
No	45 (41.28)
Questionnaire 1 - Residents and Recently Certified Neurologists (part 2 of 2)	n (%)
Think of the last instance of communication of bad news that you participated in: Was a particular technique used when delivering bad news?
Yes	50 (45.87)
No	59 (54.13)
Where in the hospital was the news given?
Bedside	9 (8.26)
Hall	29 (26.61)
Reserved room	71 (65.14)
What are your feelings when delivering bad news?
No bad feelings, I am already used to this situation	19 (17.43)
Insecurity	23 (21.10)
Fear	10 (9.17)
Anguish	28 (25.69)
Helplessness	36 (33.03)
Sadness	53 (48.62)
Pity	22 (20.18)
Anger/Rage	1 (0.92)
Frustration	21 (19.27)
Choose the factors that hinder your ability to communicate bad news:	n=106
It is hard to find the appropriate words	36 (33.96)
The conversations are emotionally charged in a way that is hard for me	20 (18.87)
These are conversations one cannot prepare for	24 (22.64)
It is hard to balance honesty with the family while trying to salvage their hopes	60 (56.60)
The education level of the family	36 (33.96)
The religious beliefs of the family	19 (17.92)
How do you usually prepare before communicating bad news?	n=108
I mentalize a script to express the ideas	77 (71.30)
I write a list of primary points that need to be communicated	4 (3.70)
I discuss with the faculty	15 (13.89)
I discuss with another resident	7 (6.48)
I revise protocols proposed by the literature	4 (3.70)
I do not prepare; my activities in the residency are so demanding that I do not have time for any type of specific preparation	25 (23.15)
Do you ask about the patient’s perspectives or points of view?
Yes	91 (83.49)
No	18 (16.51)
Do you attempt to use plain language, allowing for clear and objective explanations?
Yes	108 (99.08)
No	1 (0.92)
Do you offer the information gradually, allowing it to be retained (approach possible diagnosis, therapeutic plan, and prognosis separately)?
Yes	98 (89.91)
No	11 (10.09)
Do you ask if the patient has any questions after your explanation?
Yes	109 (100.00)
No	0 (0.00)
Do you repeat and summarize the primary points that were explained?
Yes	79 (72.48)
No	30 (27.52)

Questionnaire 2 - Program Directors	n (%)
1. Institution
2. What type of training is used for the communication of bad news in your residency program?
Formal lectures	6 (9.52)
Simulation of real scenarios	4 (6.35)
Observation of real situations	24 (38.10)
Active participation in real situations, with supervision	36 (57.14)
Active participation in real situations, without supervision	10 (15.87)
There is no specific training	20 (31.75)
3. Do the residents in your program usually receive feedback on their ability to communicate bad news?
Yes	26 (41.27)
No	37 (58.73)
4. Would you like to provide more activities in your program to improve your residents’ training on bad news communication?
No, because they already have the adequate training	2 (3.17)
No, because I do not consider it a relevant topic	1 (1.59)
No, because I first want to promote changes in other areas of the residency that I find more important	2 (3.17)
Yes, I find the topic important, and I think it requires improvement	58 (92.06)
5. Which factors hinder the implementation of more activities with the objective of training in the communication of bad news?
Time availability of the residents	21 (33.33)
Time availability of the professors	24 (38.10)
The interest of the residents	15 (23.81)
The interest of the faculty	18 (28.57)
There is no factor	15 (23.81)
Other	6 (9.52)
5a. What other factors hinder the implementation of more activities for training in the communication of bad news?
“Lack of interest of our institution to promote discussion on this topic”
“Lack of specific training”
“Lack of institutional interest and trained personnel for offering the training”
“Lack of training of the faculty on this subject”
“There is a need for theoretical fundaments, with trained personnel to teach it”
“Lack of real cases to practice communication of bad news”
6. Do you consider the training on the communication of bad news to be important?
Yes	61 (96.83)
No	2 (3.17)

Instituto Israelita de Ensino e Pesquisa Albert Einstein Avenida Albert Einstein, 627/701 , 05651-901 São Paulo - SP, Tel.: (55 11) 2151 0904 - São Paulo - SP - Brazil
E-mail: revista@einstein.br

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[1] Corresponding author: Fernando Pereira Bruno, MD, MPH 60 Prospect Ave, room 205, Middletown, NY, USA Zip code: 10940, Middletown, NY, USA Phone: +1 845 648 1232 E-mail: fernando.bruno@touro.edu