Breaking Bad Research Articles

Breaking bad news to cancer patients and their families: Attitudes toward death among Turkish physicians and their communication styles

Objectives: To investigate how Turkish oncologists’ attitudes toward death influence their emotional states, outlooks, and communication styles when breaking bad news to cancer patients and/or their families. Design: Cross-sectional study using self-completed questionnaires. Methods: The study sample consisted of 35 physicians working at an oncology department. Physicians completed a quantitative one-time survey developed by the authors and the Death Attitude Profile-Revised (DAP-R). Results: Thirty-one physicians completed the survey and the DAP-R. A mean of 13.39 ± 8.82 minutes was allocated for breaking bad news; 87.1% of the participants avoided using the word “cancer” and 42% avoided using the word “death”. The attitudes characterized by “death avoidance” and “fear of death” were found to be related to the emotional difficulty experienced by the physicians, and were also associated with less eye contact with the patient, and less attention paid to the language used while breaking bad news. Conclusions and implications: It is important for physicians to be aware of how their attitudes toward death affect their communication with patients during bad news. They should be provided in-service professional education, and therapeutic support.

Challenges of paediatric palliative care in the intensive care unit during the COVID-19 pandemic

The integration of paediatric palliative care into the Iranian health system is essential. The aim of this study was to identify the challenges of palliative care in the paediatric intensive care unit during COVID-19 through the experiences of healthcare providers. A qualitative study with content analysis approach was conducted. Fifteen physicians and nurses were selected by purposeful sampling. The semi-structured, in-depth interviews were applied in the data collection. Ten main categories were extracted from data analysis, including 'caring in COVID-19', 'communication and family centre care', 'breaking bad news', palliative care training', 'pain and symptom management', 'support of the child, family and clinical team', 'physical environment', 'guidelines', 'specialised staff' and 'home based palliative care'. Palliative care in the PICU faces several challenges, especially during COVID-19, but the clinical team are making every attempt to improve the comprehensive care of children and their families. Telehealth is important in COVID-19, and education is also a key component to improve palliative care in the PICU in Iran.

Religion and Spirituality in Oncology: An Exploratory Study of the Communication Experiences of Clinicians in Poland

Communication with patients regarding oncology-related aspects is a challenging experience and requires a high level of skill from the interlocutors. The aim of this study was to verify the influence of religion/spirituality in oncological settings from the health professionals’ perspectives in Poland. It assessed the role of religion/spirituality in patient-clinician communication, death or stress self-management, empathy, and breaking bad news skills. Data collection was carried out through a standardized self-administered questionnaire with varying scales. The study cohort consisted of 60 medical practitioners specializing in oncological radiotherapy treatments. It was observed that strategies used for coping with patients’ death, stress reduction, empathy, communication with patients and/or their relatives, or breaking bad news skills, may be gender-specific or may depend on the length of time employed, as well as experience in a cancer-related work environment. This study shows that spirituality and religiousness can support clinicians in managing challenging or negative emotions related to their work in cancer settings. Religiousness and spirituality can also serve as a potential therapeutic strategies for those exposed to patient suffering and death.

Walter White: From «Apply Yourself» to «Say my Name». Aspects of Political Theory in «Breaking Bad»

This text should be understood as an interdisciplinary inquiry into one of the most successful US TV series: Breaking Bad (BB). I use political theory analysis, plot analysis that one could understand as textual analysis of the story, and my interpretations of the series’ main characters. In the first chapter, I present a summary of the story of Walter White and how his decisions affect his family. In the second chapter, I analyse BB according to Thomas Hobbes’ Leviathan. What Hobbes meant with his famous saying that man is man’s wolf, thus a deadly reciprocal threat of all against all comes to life in Walter becoming a full-fledged criminal, murder and deception now the tools of his new chosen craft. Walter is breaking bad, ignoring societal norms and ethical values, pursuing relentlessly his plans of making money for his family, enjoying his new self as a powerful provider because that is what men do: they provide. The third chapter is dedicated to an analysis how Hannah Arendt’s definitions of power, strength, authority, violence and judgement can explain Walter’s change from Paulus to Saulus. In the conclusion, I shall present my thoughts about the series and answer the following research questions: first, why is the global public still so smitten with Walter White? Second, what can one learn from BB for our contemporary conditio humana in the 21st century? Third, is Walter White the master of his life, thus self-determined (Selbstbestimmung), or is he dominated by forces outside of his own free will (Fremdbestimmung)?

Perspectives of Colombian medicine students about their formation on breaking bad news: A cross-sectional study

IntroductionMedical schools are responsible for breaking bad news training, which should be focused on the students; therefore, the purpose of this study is to identify undergraduate medical students’ perceptions regarding the best way to train them. MethodsCross-sectional anonymous survey applied between 438 >18-years-old Colombian medicine students. ResultsThe students feel unprepared to breaking bad news; even without formal training, they believe they are better at breaking bad news as they advance in their training due to their observation of other clinicians and their personal experiences. A higher proportion of male students consider themselves empathetic than female students, but advanced male students report more frequently that their empathic capacity has decreased throughout their career more frequently than female students of the same academic level. DiscussionThis information will allow the medical school to modify the curriculum to offer proper training to its students. ConclusionVery few students have received formal training regarding this topic, and most of them are interested in training.

The Effectiveness of Communication Skills Training on Nurses' Skills and Participation in the Breaking Bad News.

Background:Nurses have an important role in the process of providing information and helping patients prepare for and receive bad news and understand and cope with the bad news they have been given. This study was conducted to evaluate the effect of communication skills training on the level of skill and participation of nurses in breaking bad news.Materials and Methods:This semiexperimental study was performed on 60 nurses working in educational hospitals of Birjand, Iran in 2019. Convenience sampling was performed and the participants were randomly assigned to the two groups of intervention and control. For the experimental group, an integrated workshop on communication skills was held. Before and after the intervention, the Setting, Patient Perception, Invitation, Knowledge, Empathy, and Strategy (SPIKES) SPIKES questionnaire (breaking bad news skills) and the questionnaire of participation in breaking bad news were completed. The collected data were analyzed using descriptive and inferential statistics (independent t-test) in SPSS software.Results:The mean (SD) of breaking bad news skills after the intervention was 57.42 (10.13) in the control group and 65.12 (5.68) in the experimental group and the between-group difference was statistically significant (t59,41 = 3.93, p < 0.001). After the intervention, the mean (SD) of nurses' participation in delivering bad news was 21.17 (5.21) in the control group and 25.77 (4.96) in the experimental group and the between-group difference was statistically significant (t75,48 = 3.94, p < 0.001).Conclusions:It seems that to increase the ability of nurses in the process of breaking bad news, it is necessary to teach them communication skills.

Breaking bad news: Child welfare workers' informing parents of care order proceedings

AbstractRemoving children from parents through care orders is a highly intrusive intervention. This article explores how 12 experienced Norwegian child welfare workers perceive and cope with breaking bad news to parents of the decision for a care order initiative. A thematic analysis of qualitative in‐depth interviews revealed that the task of breaking bad news to parents includes several challenging aspects involving ethics, care and control that are influenced by relational and emotional aspects. Caseworkers felt obligated to convey the decision humanely and caretake children and parents, ensuring safety, determinacy and control. Caseworkers struggled to endure heightened emotions, handle the painful switch from helper to traitor and cope with an extreme though necessary intervention of child protection work. Care order meetings are complex and unpredictable and challenge child welfare workers professional and human capacity, as it represents considerable professional and personal demands. The article discusses the challenges of breaking bad news in the child protection profession compared with professions in the health care field. Moreover, discussing how caseworkers' coping strategies may impact their practice and highlights caseworkers' burden with the task, pointing to practical implications.

Communication skills preparedness for practice: Is there a key ingredient in undergraduate curricula design?

ObjectiveTo characterize medical interns’ experience regarding communication skills education and to explore potential associations with preparedness for practice. MethodsTwo hundred sixty-six medical interns answered an original questionnaire specifically developed to explore how well they feel their undergraduate training had prepared them in key aspects of medical communication. Instrument’s psychometric properties were tested. Medical schools’ curricula were considered and associations explored using non-parametric tests. ResultsThe questionnaire reliability was high, with Cronbach’s alphas ranging from 0.89 to 0.94 on all the factors. Core communication skills were highly rated. Perceived preparedness was lower in aspects concerning dealing with emotion, breaking bad news and communicating with speech impaired patients. Better preparedness was associated with a longitudinal integration of communication skills throughout the curriculum, simulation with standardized patients and real patient interviewing with feedback on communication skills. ConclusionsIntegrated programs, standing on a strong experimental component, particularly combining patient-simulation strategies with continuous supervision and learner centred feedback, were associated with higher preparedness. These results support the expansion of an educational model based on simulation strategies and structured longitudinally throughout the undergraduate medical curriculum. Practice implicationsThis study intends to inform educational background and to support further development of communication skills curricula.

A Review and Clinical Practice Guideline for Health Professionals Working With Indigenous and Culturally and Linguistically Diverse (CALD) Populations During COVID-19

Background: As the rates of infection and mortality from COVID-19 have been higher in minority groups, the communication of health information in a way that is understood and accepted is of particular importance.Aims: To provide health professionals with a clinical practice guideline for clear and culturally sensitive communication of health information about COVID-19 to people of Indigenous and culturally and linguistically diverse (CALD) backgrounds.Assessment of Guideline Options: The authors conducted a review of the literature on health communication, and the guidelines were developed with particular reference to the SPIKES protocol of “breaking bad news” in oncology and the use of the DSM-5 Cultural Formulation Interview (CFI).Actionable Recommendations: The guideline combines two approaches, the Cultural Formulation Interview, developed for DSM-5, and the SPIKES protocol used for delivering “bad news” in oncology. The combined CFI-SPIKES protocol is a six-step clinical practice guideline that includes the following: (1) Set up (S) the interview; (2) Determine how the patient perceives the problem (P) using the Cultural Formulation Interview (CFI) to elicit the patient's cultural perception of the problem; (3) Obtain an invitation (I) from the patient to receive a diagnosis; (4) Provide the patient knowledge (K) of diagnosis in a non-technical way; (5) Address the patient's emotional reaction (E) to diagnosis; and (6) Provide the patient a summary (S) of healthcare and treatment.Conclusions and Relevance: This article presents guidelines for assessing the cultural dimensions of patients' understanding of COVID-19 and delivering diagnostic and treatment recommendations in ways that are culturally safe and responsive, such as: (a) suspending the clinician's own cultural biases to understand the explanatory models and cultural values of their CALD or Indigenous patients; (b) encouraging the use of interpreters or cultural brokers to ensure that that the message is delivered in a way that the patient can understand; and (c) encouraging CALD or Indigenous patient to take an active part in the solution and treatment adherence, to minimize transmission of COVID-19 in CALD and Indigenous communities.

Teaching residents how to break bad news: piloting a resident-led curriculum and feedback task force as a proof-of-concept study

BackgroundBreaking bad news (BBN) is a critically important skill set for residents. Limited formal supervision and unpredictable timing of bad news delivery serve as barriers to the exchange of meaningful...

BREAKING BAD NEWS IN HEAD AND NECK CANCER PATIENTS

<h3>Background</h3> Breaking bad news is a distressing situation for both patients and physicians. Physician communication should contemplate patient preferences for an effective process. <h3>Objective</h3> To evaluate the communication process of breaking bad news in head and neck cancer patients according to their perception and satisfaction. <h3>Methods</h3> A total of 100 patients diagnosed with head and neck cancer were interviewed. An instrument based on the Breaking Bad News Assessment Schedule was applied to measure perception of the diagnostic information as well as patient satisfaction according to SPIKES protocol standards (Setting up, Perception, Invitation, Knowledge, Emotions, Strategy and Summary). Data were analyzed using Student <i>t</i> test and the chi-square test. <i>P</i> < .05 was considered statistically significant. <h3>Results</h3> Forty women and 60 men with an average age of 57.96 ± 14.84 years were interviewed. Satisfaction percentage was 85%. An excellent/good perception was reported in 87 patients. Physician sex, age, or healthcare sector variables were not associated with patient satisfaction and perception. Medical specialty was statistically related to the satisfaction and perception of patients. Best scores were obtained by oncologist surgeons and oral medicine practitioners (<i>P</i> = .001). <h3>Conclusions</h3> In general, cancer patients were satisfied with professionals' ability to provide adequate information using good communication skills. Physicians who occasionally manage cancer patients were not prepared to deliver the diagnosis. The provision of the truth as well as emotional support was highly appreciated by patients.

534 ADVANCED COMMUNICATION SKILLS: TEACHING DURING A PANDEMIC

Abstract Introduction In the first wave of the COVID-19 pandemic, it was recognised there would be an increased demand on clinicians to provide patients and relatives with bad news. The national ban on hospital visiting rapidly changed the way in which this news would be delivered. In recognition of these new challenges, our team sought to design a teaching course that could be implemented quickly and cost effectively, with the aim of improving clinician’s confidence around these difficult skills. Methods A teaching programme was created using senior geriatric and palliative care clinicians as simulated patients, open to any grade and speciality. Learners were required to break bad news (BBN) without any visual feedback, to simulate skills required when using the telephone. Surveys were collected to determine self–assessed confidence across four domains (Table 1) before, immediately after and 4–20 weeks after the course. Participants were asked to rank their confidence for each skill on a 5 point scale with 1 being very unsure and 5 being very confident. Results Pre-teaching scores showed an average of 3 (neither confident nor unsure) across all domains. After the course all domains improved, most notably around discussing end of life (EoL) care and discussing information over the phone. Conclusion This project has highlighted a lack of confidence across all skill levels when it comes to BBN. This confidence is easily improved by a short, cost-effective teaching course. It remains to be seen if this improved confidence translates to better communication with relatives.

Video-mediated breaking bad news simulation.

Communication between clinicians, patients, and families is a core component of medical care that requires deliberate practice and feedback to improve. In March 2020, the COVID-19 pandemic caused a sudden transformation in communication practices because of new physical distancing requirements, necessitating physicians to communicate bad news via telephone and video-mediated communication (VMC). This study investigated students' experience with a simulation-based communications training for having difficult conversations using VMC. Thirty-eight fourth-year medical students preparing for their surgical residency participated in a simulated scenario where students discussed a new COVID-19 diagnosis with a standardised family member (SFM) of a sick patient via VMC. Learners were introduced to an established communications model (SPIKES) by an educational video. After the simulation, SFM and course facilitators guided a debrief and provided feedback. Learners completed surveys evaluating reactions to the training, preparedness to deliver bad news, and attitudes about telehealth. Twenty-three students completed evaluation surveys (response rate=61%). Few students had prior formal training (17%) or experience communicating bad news using telehealth (13%). Most respondents rated the session beneficial (96%) and felt they could express empathy using the VMC format (83%). However, only 57% felt ready to deliver bad news independently after the training and 52% reported it was more difficult to communicate without physical presence. Comments highlighted the need for additional practice. This pilot study demonstrated the value and feasibility of teaching medical students to break bad news using VMC as well as demonstrating the need for additional training.

To play or pause: Video-based or conventional lectures in medical classrooms

Objectives: Medical knowledge has increased by leaps and bounds over the past century, but our teaching-learning methods remain archaic, lecturing being one of the oldest. This study was conducted to assess the change in knowledge following a conventional lecture and that following a video-based lecture using a medical television (TV) serial. Material and Methods: The students were divided into two groups based on their registration numbers. To one group, a video-based lecture using appropriate clips from a medical TV serial was administered while the other group was taught the same topic using conventional teaching-learning method of a lecture. A pre-test and a post-test were conducted and the change in the results compared. Results: The mean pre-test scores were higher in the successively senior batches of students as compared to the junior batches in both groups. The post-test scores were significantly higher in both the conventional lecture and the video group. Surprisingly, the mean post-test scores in the conventional lecture group were significantly higher than that of video-based lecture group. Students preferred the video-based lecture more than the conventional lecture. Conclusion: Both teaching learning methods have their own advantages. The conventional lecture uses an outcome-oriented session while the video-based sessions do not. The soft skills like breaking bad news, doctor patient communication skills etc which we never teach in conventional lectures can be learnt using these video-based sessions. Thus, we need a blended approach here as well, utilising the strengths of each of the teaching learning methods so that our students can achieve the laid down competencies.

Let's sit down and talk: The art of breaking bad news

Physicians often are uncomfortable when communicating bad or difficult news. In the absence of much effective training, many doctors find that breaking bad news is one of the most difficult, demanding, and stressful tasks. A significantly negative relationship can form between the patient and their medical staff if poor communication is used. Most patients want the truth, but how bad news is delivered can substantially influence a patient's emotions, satisfaction, subsequent psychological adjustments, and attitudes toward treatment. Moreover, values in certain cultures can become barriers that can limit or pressure a physician in ethically approaching the patient. Disclosing bad news is a complex communicational task that requires time, compassion, and empathy. Although breaking bad news will never be easy, communicating well is a skill that can be learned. The SPIKES protocol provides a simple and easily learnable strategy for communicating bad news.

Twelve tips to manage a breaking bad news process: Using S-P-w-ICE-S – A revised version of the SPIKES protocol

Breaking bad news (BBN) is a difficult task that requires multiple professional competencies. The way it is managed has implications for all involved in the encounter: the patient, family members, and the news provider. Existing guidelines were developed mainly at the turn of the millennium and require updating based on identification of daily clinical needs and pedagogical challenges while teaching the current protocols. Furthermore, there is a need to provide an overview of BBN encounters as a process, rather than a subdivided event, to help practitioners adopt an approach that might serve them in their daily routines. This twelve tips article summarizes research and practical experience for handling BBN encounters, from their preparation, through delivering the news while attending patients and family members' needs, toward documenting the news, and critically reflecting on the interaction. The tips are structured and explained to serve both practitioners and medical educators.

Breaking bad news in the oncologic population: Residents' perspective.

e24113 Background: Delivering bad news to patients is a delicate but required skill for doctors as part of patient care. There has been evidence that good communication from health care providers can improve patients' compliance to treatment as well as be beneficial emotionally. While many studies have been done in regards to patients' perceptions of receiving bad news, there are limited studies looking at a physicians' perspective, and even more so concerning residents' perceptions. In community hospitals, many patients are diagnosed with cancer, and resident physicians are often responsible for informing the patients and their families regarding the diagnosis. The manner in which the news is delivered is important, however it is unclear how much training is provided to residents before they are required to break bad news to patients. The lack of training can often result in improper delivery and poor patient care. Methods: We surveyed Internal Medicine and General Surgery residents at Mercy Catholic Medical Center, a conglomeration of two community teaching hospitals in Philadelphia, about prior training, confidence level, attitudes, and need for further education on delivering bad news to oncologic patients using a survey created after extensive research. The factors associated with confidence level were analyzed using paired T-test and ANOVA methods. Results: A total of 65 residents (72%) participated. No statistical significance was seen between American versus foreign medical graduates, MD vs. DO residents, or among those in different specialties when assessing their confidence in delivering bad news. Though only 62% of participants reported having had prior training in delivering bad news, residents with previous training (p1) or who have had to deliver bad news previously (p2) reported higher confidence when it came to delivering a new diagnosis of cancer (p1 0.03, p2 0.001), delivering news regarding the progression of cancer (p1 0.03, p2 0.02), delivering news regarding the recurrence of cancer (p1 0.04, p2 0.002), and delivering news regarding end-stage cancer with little to no treatment options left (p1 0.04, p2 0.003). 100% of participants thought communicating bad news is an important skill for a physician, and 92% of participants thought further education would help prepare them for similar scenarios in the future. Simulated patient scenarios (64%), grand rounds lectures/presentations (59%), and feedback from faculty after actual patient scenarios (57%) were the most requested whereas pamphlets/brochures (17%) and online training courses (20%) were less popular. Conclusions: Our study highlights the importance of prior training or exposure among residents in being able to deliver bad news to patients effectively. We propose that implementing further training in the form of simulated scenarios and lectures can improve residents' confidence at delivering bad news and result in a better physician-patient relationship.

A study of Chinese medical students\u2019 communication pattern in delivering bad news: an ethnographic discourse analysis approach

BackgroundBreaking bad news is inevitable for prospective doctors, it is important for medical students to learn how to humanely communicate devastating news to patients. This study explores the discourse strategies used by Chinese medical students when conducting critical conversations via role-play scenarios.MethodsFifty Year-6 medical students attending the ‘Serious Illness Communication Module’ were recruited from a local medical school in Hong Kong. They were asked to participate voluntarily in two role-play scenarios requiring them to break bad news to a simulated patient in Cantonese. The verbal interactions were video-recorded and analysed using an ethnographic discourse approach to unpack the quality of the observed interaction sequences and identify the discourse strategies strategically used by the medical students to overcome any communication breakdowns (e.g. linguistic expressions conveying diagnoses) and show empathy to patients.ResultsSix discourse strategies for delivering bad news were identified in the Chinese context: (1) placing great emphasis on patients’ emotional needs; (2) informing patients with a balanced focus on medical and emotional needs; (3) directing patients’ attention to treatment options; (4) acknowledging concerns about dying patients’ physical discomfort and wishes; (5) directing bad news disclosure to patients; and (6) addressing the family expectations of patients. The majority of the Chinese medical students in this study used a patient-oriented approach to cater to the patients’ emotional and physical needs. They also often informed and acknowledged the patients’ family members.ConclusionsWhen delivering bad news, medical students should be equipped with discourse strategies that effectively balance interpersonal communication with the communication of medical expertise, which is integral to ensuring patients’ participation, their understanding and satisfaction with their clinicians. This is in accordance with the existing communication frameworks for critical conversation and demonstrates awareness of the needs in the Chinese context. However, some students demonstrated poor sensitivity to non-verbal cues, such as tone, manners and attitude. Thus, more training using a culturally appropriate model of communication for critical conversation should be promoted.

Using Objective Structured Clinical Exams (OSCE) to Teach Neurology Residents to Disclose Prognosis after Hypoxic Ischemic Brain Injury

BackgroundNeurologists need to be adept at disclosing prognosis and breaking bad news. Objective structured clinical examinations (OSCE) allow trainees to practice these skills. MethodsIn 2017, in conjunction with the NYU School of Medicine Simulation Center, neurology faculty designed an OSCE case in which a resident had to inform a standardized patient (SP) her father had severe global hypoxic ischemic injury. The residents were surveyed on the experience using a Likert scale from 1 (worst) to 5 (best). The SP completed a behavioral anchored checklist and marked items as “not done,” “partly done,” or “well done”. Results57 third and fourth year neurology residents completed the case from 2018 to 2020, 54 (95%) of whom completed the post-OSCE survey. Residents reported feeling moderately prepared for the simulation (mean Likert score 3.7/5), and thought their performance was average (3.4/5). Overall, they found the case to be very helpful (4.6/5). The residents performed well in the realms of maintaining professionalism (64% rated “well done”), developing a relationship (62% rated “well done”), and information gathering (61% rated “well done”). There was room for improvement in the realms of providing education and presenting the bad news (39% and 37% rated “partly/not done,” respectively). ConclusionsOSCE cases can be used to teach neurology trainees how to discuss prognosis and break bad news. Feedback about this simulation was positive, though its efficacy has yet to be evaluated and could be a future direction of study.

Adapting Existing Resources for Serious Illness Communication Skills Training for Internal Medicine Residents.

Goals of care discussions are a vital component of patient care, but Internal Medicine residents receive limited training in these skills. Existing curricula often require simulated patients or faculty development, limiting implementation in many residency programs. Thus, we developed and implemented a curriculum leveraging existing educational resources with the goal of improving resident attitudes and confidence in conducting goals of care discussions in training settings. We developed cases and a detailed faculty guide for small-group discussion with three exercises to standardize the learner experience and minimize the need for faculty development. Exercises introduced established communication skill frameworks including SPIKES (setting, perception, invitation, knowledge, empathy, summary) and REMAP (reframe, emotion, map, align, propose a plan) for how to break bad news, respond to strong emotions, and conduct a goals of care discussion. Participants were 163 Internal Medicine postgraduate year 1, -2, and -3 residents at a large urban academic institution, where residency-wide curriculum is delivered in weekly half-day didactic sessions during the course of 5 weeks. Primary outcomes were resident self-reported confidence with goals of care communication skills. A total of 109 (response rate 67%) of residents reported improvement in overall confidence in goals of care discussion skills (3.6 ± 0.9 vs 4.1 ± 0.6, P < 0.001), responding to emotions (3.5 ± 0.9 vs 3.9 ± 0.6, P = 0.004), making care recommendations (3.5 ± 1.0 vs 3.9 ± 0.7, P < 0.001), and quickly conducting a code status discussion (3.6 ± 1.0 vs 4.0 ± 0.7, P < 0.001). Residents also expressed an increased desire for supervision and feedback to further develop these skills. This goals of care communication curriculum improves resident confidence and requires minimal resources. It may be ideal for programs that have limited access to simulated patients and/or faculty trained in communication skill simulation, but desire enhanced education on this important aspect of patient-doctor communication and high-quality patient care. Future studies measuring clinical outcomes and changes in learner behavior as a result of this intervention are needed. Ongoing observation and feedback on these skills will be important to solidify learning and sustain impact.