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Breaking bad news interdisciplinary training.ppt
- 1. Breaking Bad Newsto Families in Crisis: An Interdisciplinary Training Approach Utilizing Personal Values
- 2. Introductions School of BehavioralHealth, Department of Counseling and Counseling and Family Sciences • Jackie Williams-Reade, Ph.D., LMFT, Associate Professor • Elsie Lobo, M.S., MFTI, Doctoral Student • Abel Arvizu Whittemore, LMFT, Doctoral Student School of Medicine, Department of Pediatric Surgery • Joanne Baerg, M.D., Associate Professor
- 3. Learning Objectives At theconclusion of this session, the participant will be able to: • Design, implement, and evaluate a training program to enhance compassionate communication skills in breaking bad news to patients and family members. • Describe relevant concepts of adult learning theory, behavioral health and medical cultures, and family systems theory as they relate to the acquisition of communication skills. • Identify areas where behavioral health and medical professionals can collaborate in interdisciplinary training interventions in integrated healthcare settings.
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- 5. Learning Objectives forMedFTs »Understanding of interpersonal and cultural differences between medicine and family therapy »Explain the benefits of medical family therapy to medical care stakeholders
- 6. Learning Objectives forSurgical Residents »Communication skills: core competency » Specific skills: rarely taught »Barriers to adequate training: a lack of curricula, time, and supervisor skill. »Holmes: the process of making patient care routine shifts the patient from status as an individual with suffering to the object of the physician’s work. Holmes CL1, Miller H2,3, Regehr G4. (Almost) forgetting to care: an unanticipated source of empathy loss in clerkship. Med Educ. 2017 Jul;51(7):732-739. doi: 10.1111/medu.13344.
- 7. Surgical Residency Background »Goals and Objectives: The Accreditation Council for Graduate Medical Education requirement: competency in communication and professionalism. » A recognized paucity in curricula » New requirement for resident curricula in the empathic communication of bad news. » The APD for General Surgery contacted the MFT Director » A collaborative training was created
- 8. Factors Contributing tothe MFT and Medical Cultures: Professional Differences » Basis of Knowledge » Orientation ~ Paradigm ~ Philosophical Stance ~ Goals » Identity and Sovereignty » Care Provided ~ Client / Patient Focus ~ Orientation ~ Exposure to Clients / Patients while in Professional Training ~ Interventions ~ Time Frame of Action ~ View of Organizational Resources
- 9. Different, yet complementarycultures MFT: A culture that… »Allows for the tentativeness, “holding lightly” »Recognizes the client as expert »Values being relational »Values collaboration »Includes other core mental health professions »Acknowledges the systemic and complexity »Accommodates multiple clinical training paths / approaches »Is process oriented Medical: A culture that… »Is evidence, based, values objectivity »Recognizes well defined roles / specialties »Values individual expertise »Rewards solo practitioners »Stems from a well-established and cohesive guild »Aims for perfect outcomes »Extensively socializes its members into the profession »Is action / results oriented
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- 11. Compassion »Compassion – 2ndof our 7 values – JCHIEFS »Empathy – to feel what another is feeling, walk in their shoes »Sympathy – to feel for another’s pain, implies distance »Compassion – to be moved to action by another’s suffering »“Compassion… is the mandate that drives those of us in the healing professions to seek relief from suffering... But it must be tempered. We talk about the "wall" or "guard" that we watch develop, and even encourage, as we help students come to grips with pain and loss as a necessary part of becoming an effective professional.” ~Richard Hart, Notes from the President, March 2016
- 12. Breaking Bad News »BBNpoorly has negative impacts on patient satisfaction, treatment decision making, and patient–provider relationships (Reed, Kassis, Nagel, Verbeck, Mahan, & Shell, 2015). »The process of BBN also affects medical professionals, producing physiologic stress responses in both novice and experienced physicians (Meunier et al., 2013). »Goal: Teach residents how to be aware of and regulate their own stress response in order to live out value of providing compassionate, competent care
- 13. Simulation Overview Eight 2.5hour educational seminars 2 residents per session Behavioral health training clinic using 2-way mirror and audio feed system MedFTs as family members and trainers Pilot study of family systems-based BBN curriculum (that we created) based on Kolb’s learning theory May and June 2016
- 14. Family Systems Theory: Bowen’sTheory of Differentiation Main goal of Bowenian therapy is to reduce anxiety by ~ Differentiate between thinking and reacting/feeling ~ Being able to live true to one’s own values Emotional Fusion / Emotional Cutoff Residents’ felt like they would either get lost in the patient/family pain (fusion) or they had to shut down and distance (cutoff) Differentiation: A place in between - aware and able to regulate own emotions in order to provide compassionate, competent care
- 15. Pre-Simulation Briefing Provide asafe learning context: Normalize BBN is difficult Previous experiences and concerns with BBN Common worries: saying the wrong thing, want to do it perfectly, feeling too little or feeling too much, didn’t know how to fix the pain Values What values would you like to exude as a physician when breaking bad news? (common ones were compassion/empathy and competence) How can you bring those values to this encounter? SPIKES and case study
- 16. Simulation and Feedback– Kolb’s Four Stages of Experiential Learning Stage I: Concrete Experience = Simulation Stage II: Reflective Observation = “What did you do well?” “What was challenging?” Stage III: Abstract conceptualization = Discussed values and emotional response; asked them to identify emotional responses and work to exude their value more clearly Stage IV: Active experimentation = 2nd role play, reflection and encouragement
- 17. What do MFTshave to offer? SPIKES Framework Behavioral Health Clinicians Skills S – Setting the Stage Warm Introduction; Providing context; Physical positioning P – Perception Listening Skills; Attending to Diversity (context- gathering) I – Inform Bad News is Coming Provide a warning to prepare for bad news K- Knowledge Cadence and Tone of Voice; Being Straightforward Managing own anxiety Balance of providing information details Responding to family response E- Empathy Key phrases / Non-verbal / Silent Presence Managing emotions (self and other) Conveying empathy while maintaining self S- Summary and Strategy Closing conversation appropriately Maintain connection (Sternlieb, 2014)
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- 19. Simulation Outcomes 0 10 20 30 40 50 60 Resident Simulated Survivors Observers SPIKESEvaluation Results Role Play 1 Role Play 2
- 20. Item Pre-Sim. Mean (SD) (N=15) Post- Sim. Mean (SD) (N=15) P value Hedges’ g (effect size) 6-month post Mean (SD) (N=14) P value Hedge’s g (effect size) How would yourate your skill at delivering bad news to patients/families? 2.73 (.80) 3.43 (.82) .006* * -.80 (large) 3.36 (.50) .026* -1.27 (large) How prepared do you feel to deliver bad news to patients and families? 3.40 (.83) 3.87 (.83) .014* -.55 (med) 3.36 (.75) .435 -- How confident do you feel in delivering bad news to patients and families? 3.13 (.83) 3.73 (.96) .023* -.65 (med) 3.79 (.58) .040* -1.18 (large) Self-Reported Outcomes
- 21. Resident Evaluation ofSimulation Item Mean % responding “4-quite a bit” or “5-very much” The simulation provided a positive learning environment 4.6 93.3% The simulation has increased my confidence in breaking bad news 4.1 80.1% The simulation has increased my knowledge in breaking bad news 4.4 86.7% The scenarios were similar to situations that I have or most likely will encounter clinically 4.3 93.3% The scenarios were at an appropriate level of difficulty 4.5 93.3% The simulation has increased my ability in breaking bad news 4.4 93.3% The simulation should continue to be a part of the pediatric surgery residency 4.5 86.7%
- 22. What Residents Learned Skills •“howmuch tone of voice & touch play in conveying empathy and kindness •“Learned how to approach family members and how to keep calm when things don’t go as expected” •“I am trying to listen more and explain less” •“Varying your approach by reading the patient’s family” Self-Awareness •“I’m aware of how your own anxieties change the way you come across” •It was good to hear feedback about how my own reaction was perceived: what I intended was not always what was perceived. Outcomes •“...families respond much better to direct conversation and thank me for it” •“I am much more confident in my ability to be compassionate as well as direct and not ‘sugar coat things…”
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- 24. Baile, W. F.,Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES—a six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5, 302–311. http://dx.doi.org/10.1634/theoncologist. 5-4-302 Bowen, M. (1978). Family treatment in clinical practice. New York, NY: Jason Aronson. Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall. Lamba, S., Offin, M., & Nagurka, R. (2013). Casebased simulation: Crucial conversations around resuscitation of the critically- ill or injured patient. MedEdPORTAL, 9, 9367. Lamba, S., Tyrie, L. S., Bryczkowski, S., & Nagurka, R. (2016). Teaching surgery residents the skills to communicate difficult news to patient and family members: A literature review. Journal of Palliative Medicine, 19, 101–107. http://dx.doi.org/10 .1089/jpm.2015.0292 Meunier, J., Merckaert, I., Libert, Y., Delvaux, N., Etienne, A. M., Liénard, A., . . . Razavi, D. (2013). The effect of communication skills training on residents’ physiological arousal in a breaking bad news simulated task. Patient Education and Counseling, 93, 40–47. http://dx.doi.org/10.1016/j.pec .2013.04.020 Meyer, E. C., Sellers, D. E., Browning, D. M., McGuffie, K., Solomon, M. Z., & Truog, R. D. (2009). Difficult conversations: Improving communication skills and relational abilities in health care. Pediatric Critical Care Medicine, 10, 352– 359. http://dx.doi.org/10.1097/PCC.0b013e 3181a3183a Peterson, E. B., Porter, M. B., & Calhoun, A. W. (2012). A simulation-based curriculum to address relational crises in medicine. Journal of Graduate Medical Education, 4, 351–356. http://dx.doi.org/ 10.4300/JGME-D-11-00204 Reed, S., Kassis, K., Nagel, R., Verbeck, N., Mahan, J. D., & Shell, R. (2015). Breaking bad news is a teachable skill in pediatric residents: A feasibility study of an educational intervention. Patient Education and Counseling, 98, 748–752. http://dx.doi .org/10.1016/j.pec.2015.02.015 White, S. J., Stubbe, M. H., Dew, K. P., Macdonald, L. M., Dowell, A. C., & Gardner, R. (2013). Understanding communication between surgeon and patient in outpatient consultations. ANZ Journal of Surgery, 83, 307–311. http://dx.doi.org/10.1111/ ans.12126 Bibliography / References
- 25. Post-session evaluation » -What expertise do professionals in your discipline have that can help to enhance another profession? - What are important components of Kolb's learning theory that should be included in designing a curriculum that reflects your response to the first question above.
Editor's Notes
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- #5 How the project came about
- #15 We purposefully chose an unexpected traumatic death scenario due to the realistic yet unique challenges presented to residents as they often have no prior relationship with the family members, who are typically confused and in shock. This scenario allowed us to evoke anxiety in the residents so we could observe their response and help them improve their self-management through the application of Bowen’s differentiation of self (Bowen, 1978). Differentiation refers to people’s ability to manage their emotional reactivity and remain thoughtful and guided by their values even when their stress or anxiety is high. To operationalize this family systems theory, we guided residents through a reflection on their professional values and concerns about BBN. Then, after each role-play scenario, in addition to providing general feedback for improving skills of compassion (e.g., tone of voice, pacing, and language), we also addressed ways residents could emotionally self-regulate achieve differentiation) in the face of conveying difficult information to upset family members. We emphasized how self-regulation could help their communication align more closely with their chosen values. Fusion/lack of differentiation – individual choices set aside to achieve harmony in relationship Expressed through intense responsibility for other’s reactions or emotional cutoff from the tension Differentiation is the capacity of the individual to function autonomously by making self directed choices, while remaining emotionally connected to the intensity of a significant relationship system (Kerr and Bowen, 1988). Dr. Bowen describes differentiation as the ability to be in emotional contact with others yet still autonomous in one’s emotional function. Students will learn about the two different aspects of this concept namely the “differentiation of self” (i.e. the ability to distinguish between the “thinking” system and the “feeling” system) Fusion describes each person's reactions within a relationship, rather than the overall structure of family relationships (like enmeshment). Hence, anxiously cutting off the relationship is as much a sign of fusion as intense submissiveness. A person in a fused relationship reacts immediately (as if with a reflex, knee jerk response) to the perceived demands of another person, without being able to think through the choices or talk over relationship matters directly with the other person. Energy is invested in taking things personally (ensuring the emotional comfort of another), or in distancing oneself (ensuring one's own). The greater a family's tendency to fuse, the less flexibility it will have in adapting to stress. Bowen maintains that the speculative nature of estimating a level of differentiation is compounded by factors such as stress levels, individual differences in reactivity to different stressors, and the degree of contact individuals have with their extended family. A person’s emotional system, according to Bowen, includes survival mechanisms that humans share with other species, such as instinct, reproduction and the involuntary operations of the autonomic nervous system, that is, the activity of the limbic or fight/flight system (Bowen, p. 70; Kerr & Bowen, pp. 35 & 92, referring to the work of Maclean, 1978, p. 339). Bowen theorised that the degree to which a person is able to remain thoughtful and manage their emotional reactivity is indicative of the person’s level of emotional maturity. A person with a welldefined or more ‘solid’ or ‘separate’ self, has a higher level of differentiation and is guided into action by their values and principles, even when their stress or anxiety is high. Differentiation is also associated with the Bowen concept of the I Position, which reflects the degree to which individuals have a clearly defined sense of self, stick to their convictions, and take action based on those convictions even in the face of criticism from others (Bowen, 1978; Johnson, Buboltz, & Seemann, 2003).