Delivering Bad News Research Articles

Creating Moral Organizations

A recent movie, The Corporation, presents a diagnosis of corporations as though they were psychopathic individuals. The filmmakers cite the Diagnostic and Statistical Manual of Mental Disorders, which describes the following psychopathic symptoms: deceitfulness, lying for personal profit, aggressiveness, reckless disregard for safety, irresponsibility, and lack of remorse, rationalizing the fact that they have hurt or mistreated others. According to law, corporations are treated as though they were individuals and, regrettably, more than a few have behaved in ways that fit the DSM diagnosis. That's why a growing number of young people believe that one has to bend the rules to succeed in business (Business Week, Sept. 20, 2004). That's why William Donaldson, chairman of the securities & Exchange Commission has accused many U.S. bosses of failing to provide ethical leadership for companies (Financial Times, Sept. 20, 2004). That's why the U.S. Congress passed the Sarbanes-Oxley bill, which imposes costly regulations on corporations. Many CEOs are complaining about the regulations, but unless they start working to raise the ethical and moral levels of their companies, they will remain vulnerable to even more legal constraints. This is what compelled a group of CEOs, legal experts and large investors, together with a sprinkling of government officials and academics, to convene last summer at the invitation of the Aspen Institute and the Conference Board to discuss corporate values. Typically, the corporate leaders focused on incentives that influence the decisions of executives and investors. They reasoned that companies act unethically because they are trying to raise the share price. Because investors are looking for short-term profit, managers cut corners and sacrifice the future for quick gains. For example, they sell off strategically valuable factories in order to show a quick bump in return on capital employed. This pleases the Wall Street analysts and lifts the share price. The theory: if investors were incented to act like owners and executive pay was based on long-term results, there would be better long-term decisions and less motivation to cut corners. Possibly this is so, but it doesn't explain why, given the current incentives, some organizations act ethically and morally while others do not. Behaving Morally There is a difference between ethical and moral behavior. Ethics has to do with obeying the rules. Morality has to do with reasoning and behaving according to values that go beyond narrow self-interest. A change of incentives combined with regulation can improve long-term results and corporate ethics. But it won't create moral organizations. To make both companies and government organizations behave morally, we need to focus on organizational values and leadership. Some people will argue that organizations cannot be moral; only people can be moral. But while some organizations encourage and reinforce moral reasoning and behavior, others do not. The Harvard psychologist Lawrence Kohlberg studied levels of moral reasoning (7). At the lowest level he described unquestioned obedience to authority. At the next level, people conform to a limited view of what is good for their family or organization. At higher levels, they decide what will benefit others, beyond the immediate group. Most organizations espouse idealistic values emphasizing respect and integrity. But all too often, managers in government as well as companies make decisions according to what most benefits them and improves their quality of life, rather than what is best for customers, employees, investors, and communities. All too often, fearful employees follow leaders who stunt their moral development. Raising the Moral Level Why do people in organizations remain at lower levels of moral reasoning and behavior? What needs to be done to raise the moral level? One key factor is whether employees feel it's safe to tell the truth, argue minority views and deliver bad news, especially when telling the truth may be essential to the well-being of others. …

The Day One Talk.

For the family of a child with cancer, the time of diagnosis is a time of emotional anguish. The formal discussion about the diagnosis and intended treatment frequently comes after a period of uncertainty. During this period, families are often acutely aware that cancer is the likely diagnosis, but the type of cancer, expected treatment, and likely outcome are initially unclear even to the physician. In addition, the child must often go through a series of uncomfortable tests and procedures. When the pediatric oncologist finally discusses the diagnosis and treatment with the family, fear about the news to come, combined with uncertainty, has created an anxiety that is difficult for the family to endure. Because cancer in children is rare, few physicians will find themselves in the position we just described. But every physician will at times need to deliver bad news to patients, and the principles that apply to our specific scenario may be generalized to the care of other patients with serious illnesses. Previous reports have indicated that the initial communication of bad news can negatively [1-4] or positively [5] affect adjustment to the diagnosis. Recurrent themes in the literature include the need for a quiet and private physical setting [4-7], the importance of accurate information [3,4,8,9], the need for clear communication without either overly technical language or euphemisms [10], and the importance of letting the patient’s or family’s reaction guide the flow of conversation [5]. Families frequently note the physician’s own emotional response [10,11] as one helpful aspect of the conversation that allowed for a sense of connection with the physician. Beyond the impact of communication on coping and adjustment, the patients’ understanding of their prognosis affects their choices for therapy [12], underscoring the need for physicians to communicate information about the natural history of the disease effectively and honestly. Similarly, in studies using hypothetical scenarios, patients’ understanding of the burden of treatment and the likely outcome of treatment influenced their choices about therapies [13]. Yet even when the physician communicates with accuracy and compassion, the stress of receiving bad news may prevent a patient or family member from retaining information. For example, one third of parents of children with newly diagnosed cystic fibrosis felt they had understood and retained less than half of what their doctor told them [14]. These findings suggest that one essential aspect of delivering bad news is ensuring that the exchange of information among the patient, family, and physician will continue as the shock of the initial diagnosis fades. Despite the importance of communication to the daily life of a physician, standards for education in this area have only recently started to emerge for medical students, with fewer established standards in residency and fellowship training [15]. Nevertheless, medical students and attending physicians alike can benefit from training in this area [16,17]. Although others [6,9,18,19] have reported on their personal approaches to delivering bad news, few guidelines exist for pediatricians or offer guidance about communicating with whole families. Here, we offer one method of delivering bad news to parents of children with cancer in hopes that our approach may be helpful to others and From the Department of Pediatric Oncology, Dana-Farber Cancer Institute; the Division of Pediatric Hematology/ Oncology Children’s Hospital; and the Department of Pediatrics, Harvard Medical School, Boston, MA.

Teaching Medical Students and Residents Skills for Delivering Bad News: A Review of Strategies

Although delivering bad news is something that occurs daily in most medical practices, the majority of clinicians have not received formal training in this essential and important communication task. A variety of models are currently being used in medical education to teach skills for delivering bad news. The goals of this article are (1) to describe these available models, including their advantages and disadvantages and evaluations of their effectiveness; and (2) to serve as a guide to medical educators who are initiating or refining curriculum for medical students and residents. Based on a review of the literature and the authors' own experiences, they conclude that curricular efforts to teach these skills should include multiple sessions and opportunities for demonstration, reflection, discussion, practice, and feedback.

The role of the critical care nurse in the delivery of bad news.

The NHS Plan and the Code of Professional Conduct direct the nurse to include the family in decisions made about the care of the patient. Well-developed communication is an essential interpersonal skill and a professional means of establishing nurse-patient/family trust. The use of a reliable and valid assessment tool based on Leske's Inventory will enable the nurse to prioritize the needs of each family at a stressful time and in unfamiliar surroundings, whether it is the intimidating critical care setting or not. Key training of critical care nurses in the sensitive area of delivering bad news is lacking. Failure to assess effectively individualized family needs and to plan, implement and evaluate the care given to relatives precludes holistic care. When care is managed to include the family, empowerment of the patient and family will lead to autonomy.

Poster 158: Teaching Residents in rehabilitation to communicate bad news to their patients.

Objective: To determine if an educational program can improve a physical medicine and rehabilitation resident’s ability to deliver bad news to patients. Design: Preeducation and posteducation assessment of residents’ communication ability with a standardized patient. Setting: Clinical skills center. Participants: 10 rehabilitation residents (PGY-2 to PGY-4). Intervention: Preeducation experience with a standardized patient with a simulated C6 complete spinal cord injury followed by a 1-hour educational lecture using the American Medical Association’s (AMA) Education for Physicians on End-of-Life Care (EPEC) program on communicating bad news to patients. This was followed by a posteducation experience with the original standardized patient. The person monitoring the session then provided feedback to the resident before a novel standardized patient, who simulated a mother of a patient who had been in a persistent vegetative state for over a year. The monitor and the standardized patient used a standardized checklist to assess the resident’s performance. Main Outcome Measures: Monitor checklist of 8 items: score 1 if done and 0 if not done (max=8, min=0). Standardized patient checklist of 7 items rated on a Likert scale: excellent, 5; very good, 4; good, 3; fair, 2; poor, 1 (max=35, min=7). Results: Monitor checklist: the preeducation mean was 2.9 (95% confidence interval [CI], 1.81–3.99); the posteducation mean was 5.4 (95% CI, 4.377–6.423); and the novel case mean was 5.9 (95% CI, 5.044–6.756) (multivariate test [Hotelling trace], P=.002). Standardized patient checklist: the preeducation mean was 31.4 (95% CI, 29.609–33.191); the posteducation mean was 34.2 (95% CI, 33.636–34.764); and the novel case mean was 27.9 (95% CI, 25.577–30.223) (multivariate test [Hotelling trace], P=.001). Resident survey (5-point scale): worthwhile educational experience was 4.9; I will use what I learned in the future was 4.7; and I would participate again if not compensated was 4.4. Conclusions: A 1-hour lecture on delivering bad news to patients using the AMA’s EPEC program produced a significant change in resident behavior in interaction with a standardized patient. Residents felt that it was a worthwhile educational experience that would help them in their future practice.

Self-Assessment of Communication Skills Preparedness: Adult Versus Pediatric Skills

To characterize and compare incoming residents' self-reported 1) amount and sufficiency of medical school training in clinical communication for patients of different ages, and 2) training experience and anticipated comfort level when breaking news of serious diagnoses with patients of different ages. A self-assessment tool was voluntarily completed by residents entering Brown- and Dartmouth-affiliated residencies. Descriptive statistics were generated and 2-tailed t tests were used to compare mean responses for patient age categories within each area of questioning. A total of 143 (78%) of 184 residents completed self-assessments. Estimates of training time with adult patients were greater than any other patient age category and were rated most sufficient. Twelve percent and 11% of respondents reported no formal training in pediatric and adolescent skills, respectively, and more than half reported that they had never observed a pediatric or adolescent "bad news" interaction. Half of the respondents had personally informed a patient or family of a serious diagnosis, most often concerning middle-aged or elderly patients. Respondents anticipated greatest discomfort discussing serious illness in younger patients and least discomfort discussing serious illness in adult and elderly patients. Residents feel less prepared for and receive less training in general communication skills, particularly skills required for delivering bad news, in pediatric clinical interactions as compared with interactions with adult patients. Additional formalized training in communication skills and strategies for breaking bad news to pediatric and adolescent patients may be warranted.

Delivering bad news and precepting student/resident learners.

Case Scenario: You are caring for a previously healthy 52-year-old man with a new problem of abdominal pain. After conservative treatments fail, a diagnostic abdominal computed tomography (CT) scan is done showing a focal mass with ulceration in the body of the stomach and numerous (more than 10) densities in the liver compatible with liver metastases. The radiologist feels that the findings are absolutely typical of metastatic stomach cancer. How do you prepare to discuss these test results with the patient?

Delivering Bad News in Catastrophic Medicine

Delivering Bad News in Catastrophic Medicine

Breaking bad news.

Cancer is still, for many patients, an incurable disease. For many patients, cancer takes on a chronic course, with repeated recurrences and bouts of treatment. For still too many patients, it takes a fatal course, as the recurrences worsen and the patient slowly or quickly develops disease that results in death. Those who work with cancer patients must grapple with giving them, or helping them to hear from others, bad news of many sorts. Questions of how to handle bad news in cancer have been widely discussed. In the April 15, 2002, issue of the Journal of Clinical Oncology, Walter F. Baile and his colleagues at the M. D. Anderson Cancer Center addressed this issue again in a paper titled “Oncologists’ Attitudes Toward and Practices in Giving Bad News: An Exploratory Study.” Their study surveyed 167 oncologists attending the 1998 annual meeting of the American Society of Clinical Oncology. The participants were asked to fill in questionnaires on the frequency with which they discussed bad news of a variety of types and the difficulties they encountered in these discussions. Participating physicians were able to rate difficulties on a scale of 0 to 4. Results from the questionnaire were analyzed by gender, age, practice setting (academic or nonacademic), and whether the physician practiced in a Western or non-Western country. Findings of the study included the calculation that the physicians discussed bad news with patients an average of 35 times per month. Bad news included new cancer diagnosis, recurrence, treatment failure, lack of further curative treatments, referrals to hospice, do not resuscitate (DNR) orders, and euthanasia. The study population found discussions of lack of availability of further curative treatment the most difficult of these items to discuss (an average of 3.8 points out of 4 possible), while new cancer diagnosis was the least difficult (2.6 points). Other difficult issues that received an average of 3 or more points were difficulties in finding enough time to talk to patients, dealing with the families of patients, responding to patients’ emotions, being honest with patients without being depressing, and handling one’s own negative emotions. Specific types of communications were also explored with the participants. More than 40% of the physicians reported that they occasionally to frequently adopted these communication strategies: shielding patients from grave prognoses if the patient does not ask about the subject, withholding discussion of the prognosis from the patient at the request of his or her family, using euphemisms when discussing issues of prognosis in order not to destroy the patient’s hope, and proposing treatments that the physician knows will not work in order to maintain hope. Physicians practicing in non-Western countries were more likely to use these strategies. Male physicians were more likely to use euphemisms than were female physicians, and they were also more likely to give patients specific probabilities that treatments would not work. Participants were also asked the time at which they thought it was best to discuss DNR orders. Close to 40% of physicians felt the time of diagnosis or presentation with metastatic disease was optimal, and a similar number felt that the time after treatment failure was the best time. Smaller numbers reported that the time just before hospice referral or a few days to hours before the patient’s death were the optimal times. Integrative cancer physicians are not spared from the necessity of delivering bad news about treatment failure to patients or from referrals to hospice, DNR orders, or any other of the topics discussed in the paper of Baile et al. The staff of Integrative Cancer Therapies wondered, however, if the openness of many integrative practitioners to a variety of alternative therapies and the commitment of most integrative practitioners to treating the patient in a holistic framework would change the strategies they use in discussing painful topics with patients. Will they, for instance, be more ready than conventionally practicing Point-Counterpoint

Parents’ Satisfaction with Medical and Social Assistance Provided to Children with Down Syndrome: Experience in Estonia

Objective: Parents of children with mental or physical disabilities have been assumed to live more stressful lives than other parents, and people with Down syndrome (DS) may get second-rate care because of their diagnosis. The aim of this work is to investigate the extent of parents’ satisfaction with medical and social services in Estonia provided for the DS individuals and their families. Methods: From 1999 to 2001, fifty-nine DS families answered questionnaires in which we inquired about their satisfaction with medical and social assistance. Results: We found that satisfaction with the quality of the information about DS is low, and most of the parents are not satisfied with the social benefits and rehabilitation options. Conclusions: The DS families need more medical information about this syndrome. The medical staff has to learn more about how to deliver bad news and how to support parents. More work needs to be done in the area of rehabilitation options and social assistance.

The good news about giving bad news to patients.

There are few data available on how physicians inform patients about bad news. We surveyed internists about how they convey this information. We surveyed internists about their activities in giving bad news to patients. One set of questions was about activities for the emotional support of the patient (11 items), and the other was about activities for creating a supportive environment for delivering bad news (9 items). The impact of demographic factors on the performance of emotionally supportive items, environmentally supportive items, and on the number of minutes reportedly spent delivering news was analyzed by analysis of variance and multiple regression analysis. More than half of the internists reported that they always or frequently performed 10 of the 11 emotionally supportive items and 6 of the 9 environmentally supportive items while giving bad news to patients. The average time reportedly spent in giving bad news was 27 minutes. Although training in giving bad news had a significant impact on the number of emotionally supportive items reported (P <.05), only 25% of respondents had any previous training in this area. Being older, a woman, unmarried, and having a history of major illness were also associated with reporting a greater number of emotionally supportive activities. Internists report that they inform patients of bad news appropriately. Some deficiencies exist, specifically in discussing prognosis and referral of patients to support groups. Physician educational efforts should include discussion of prognosis with patients as well as the availability of support groups.

Medical residents' first clearly remembered experiences of giving bad news.

Communication of bad news to patients or families is a difficult task that requires skill and sensitivity. Little is known about doctors' formative experiences in giving bad news, what guidance they receive, or what lessons they learn in the process. To learn the circumstances in which medical residents first delivered bad news to patients or families, the nature of their experience, and their opinions about how best to develop the needed skills. Confidential mailed survey. All medicine house officers at 2 urban, university-based residency programs in Boston. Details of medical residents' first clearly remembered experiences of giving bad news to a patient or family member; year in training; familiarity with the patient; information about any planning prior to, observation of, or discussion after their first experience; and the usefulness of such discussions. We also asked general questions about delivering bad news, such as how often this was done, as well as asking for opinions about actual and desired training. One hundred twenty-nine of two hundred thirteen surveys (61%) were returned. Most (73%) trainees first delivered bad news while a medical student or intern. For this first experience, most (61%) knew the patient for just hours or days. Only 59% engaged in any planning for the encounter. An attending physician was present in 6 (5%) instances, and a more-senior trainee in 14 (11%) others. Sixty-five percent of subjects debriefed with at least 1 other person after the encounter, frequently with a lesser-trained physician or a member of their own family. Debriefing focused on the reaction of those who were given the bad news and the reaction of the trainee. When there were discussions with more-senior physicians, before or after the encounter, these were judged to be helpful approximately 80% of the time. Most subjects had given bad news between 5 and 20 times, yet 10% had never been observed doing so. Only 81 of 128 (63%) had ever observed an attending delivering bad news, but those who did found it helpful 96% of the time. On 7-point scales, subjects rated the importance of skills in delivering bad news highly, (mean 6.8), believed such skill can be improved (mean 6.6), and thought that more guidance should be offered to them during such activity (mean 5.8). Medical students and residents frequently deliver bad news to patients and families. This responsibility begins early in training. In spite of their inexperience, many do not appear to receive adequate guidance or support during their earliest formative experiences.

Beach Glass.

Journal of Genetic CounselingVolume 11, Issue 4 p. 301-303 CommentaryFree Access Beach Glass Tillie Young, Corresponding Author Tillie Young youngti@umdnj.edu Center for Human and Molecular Genetics, New Jersey Medical School, Newark, New JerseyCorrespondence should be directed to Tillie Young, Center for Human and Molecular Genetics, New Jersey Medical School, 90 Bergen Street, Suite 5400, Newark, New Jersey 07103-2499; e-mail: youngti@umdnj.eduSearch for more papers by this author Tillie Young, Corresponding Author Tillie Young youngti@umdnj.edu Center for Human and Molecular Genetics, New Jersey Medical School, Newark, New JerseyCorrespondence should be directed to Tillie Young, Center for Human and Molecular Genetics, New Jersey Medical School, 90 Bergen Street, Suite 5400, Newark, New Jersey 07103-2499; e-mail: youngti@umdnj.eduSearch for more papers by this author First published: 29 December 2002 https://doi.org/10.1023/A:1016394819148Citations: 3AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. REFERENCES Kaufman JL, Kennedy A, Spitzer Kim K, Wertz D (2000) The emotions genetic counselors experience in delivering bad news. J Genet Counsel 9: 520– 521. Kunitz S (1995) The layers. In: S Kunitz (ed) Passing Through—The Later Poems, New and Selected. New York: Norton, pp. 107– 108. Roggenbuck J, Olson JE, Sellers TA, Ludowese C (2000) Perception of genetic risk among genetic counselors. J Genet Counsel 9: 47– 59. Citing Literature Volume11, Issue4August 2002Pages 301-303 ReferencesRelatedInformation

Teaching Delivery of Bad News Using Experiential Sessions With Standardized Patients

Background: Delivering bad news is a difficult task that is important to address in medical education. Purpose: This study evaluated the impact of an experiential educational intervention using multiple standardized patient scenarios on medical students' comfort with delivering difficult news. Methods: In small groups, 3rd-year medical students practiced communicating bad news within the context of five different patient scenarios. During 1999 and 2000, surveys were administered to 341 students before and 4 weeks and 1 year after the program. Students rated comfort level in discussing bad news, terminal illness, hospice, and dying with patients. Results: A significant one standard deviation change was observed in students' self-reported comfort in communicating bad news after the educational program. The intervention was highly rated, especially the encounters with standardized patients and observation of others. Conclusions: Experiential education using multiple standardized patient scenarios is a successful model for increasing student comfort in responding to difficult clinical communication tasks

A Communication Assessment and Skill-building Exercise (CASE) for First-year Residents

Good communication skills are essential for residents entering postgraduate education programs. However, these skills vary widely among medical school graduates. This pilot program was designed to create opportunities for (1) teaching essential interviewing and communication skills to trainees at the beginning of residency, (2) assessing resident skills and confidence with specific types of interview situations, (3) developing faculty teaching and assessment skills, (4) encouraging collegial interaction between faculty and new trainees, and (5) guiding residency curricular development. During residency orientation, all first-year internal medicine residents (n = 26) at the University of Minnesota participated in the communication assessment and skill-building exercise (CASE). CASE consisted of four ten-minute stations in which residents demonstrated their communication skills in encounters with standardized patients (SPs) while faculty members observed for specific skills. Faculty and SPs were oriented to the educational purposes and goals of their stations, and received instructions on methods of providing feedback to residents. With each station, residents were provided one and a half minutes of direct feedback by the faculty observer and the SP. The residents were asked to deal with an angry family member, to counsel for smoking cessation, to set a patient-encounter agenda, and to deliver bad news. A resident's performance was analyzed for each station, and individual profiles were created. All residents and faculty completed evaluations of the exercise, assessing the benefits and areas for improvement. Evaluations and feedback from residents and faculty showed that most of our objectives were accomplished. Residents reported learning important skills, receiving valuable feedback, and increasing their confidence in dealing with certain types of stressful communication situations in residency. The activity was also perceived as an excellent way to meet and interact with faculty. Evaluators found the experience rewarding, an effective method for assessing and teaching clinical skills, a faculty development experience for themselves in learning about structured practical skills exercises, and a good way to meet new interns. The residency program director found individual resident performance profiles valuable for identifying learning issues and for guiding curricular development. Time constraints were the most frequently cited area for improvement. The exercise became feasible by collaborating with the medical school Office of Education-Educational Development and Research, whose mission is to collaborate with faculty across the continuum of medical education to improve the quality of instruction and evaluation. The residency program saved considerable time, effort, and expense by using portions of the medical school's existing student skills-assessment programs and by using chief residents and faculty as evaluators. We plan to use CASE next year with a wider variety of physician-patient scenarios for interns, and to expand the program to include beginning second- and third-year residents. Also, since this type of exercise creates powerful feedback and assessment opportunities for instructors and course directors, and because feedback was so favorable from evaluators, we will encourage participation in CASE as part of our faculty educational development program.

Enhancing physician-patient communication.

Physician-patient communication encompasses the verbal and nonverbal interactions that form the basis for the doctor-patient relationship. A growing body of research and guidelines development acknowledges that physicians do not have to be born with excellent communication skills, but rather can learn them as they practice the other aspects of medicine. Improvement in physician-patient communication can result in better patient care and help patients adapt to illness and treatment. In addition, knowledge of communication strategies may decrease stress on physicians because delivering bad news, dealing with patients' emotions, and sharing decision making, particularly around issues of informed consent or when medical information is extremely complex, have been recognized by physicians as communication challenges. This paper will provide an overview of research aimed at improving patient outcome through better physician-patient communication and discuss guidelines and practical suggestions immediately applicable to clinical practice.

Survey of veterinary technical and professional skills in students and recent graduates of a veterinary college.

To determine perceptions of veterinary technical and professional skills among veterinary students and recent graduates. Cross-sectional study. 281 students and 142 recent graduates from the Ontario Veterinary College. A survey was designed and administered to first- through fourth-year students and veterinarians who had graduated either 1 or 6 years before survey administration. Overall response rate was 70%. Learning about technical and professional skills was highly valued. Most participants felt they had not received instruction about professional skills, but those who had felt more competent about them. Perceptions of competence increased slightly with increased comfort discussing emotional veterinary issues with instructors. Neither gender nor increased age was related to increased feelings of competence. Almost all fourth-year students felt competent and comfortable about examining an animal with the client present, assessing suffering, diagnosing parvovirus infection, performing surgery, and working as group members. However, many did not feel competent or comfortable about delivering bad news, setting time limits yet providing quality service, helping clients with limited funds make treatment decisions, dealing with demanding people, and euthanasia. Feelings of competence and comfort were closely related but were not identical. In the interests of best preparing entry-level veterinarians, technical and professional skills need to be emphasized in a learning environment where students feel comfortable discussing emotional veterinary issues. A professional skills curriculum addressing underlying self-awareness, communication, and interpersonal issues, as well as procedural matters, would likely increase the proportion of fourth-year students who feel competent and comfortable about professional skills by the end of their undergraduate training.

Breaking bad news and discussing death

The ability to discuss bad news with a patient and family is one clinical skill that is essential to providing effective end-of-life care. Patients and families value direct, nontechnical explanations that are given by a physician with compassion and kindness. Patients and families also value time to talk, express their feelings and ask questions. The authors review research on delivering bad news, then describe a six step process to guide physicians in discussing bad news with patients: (1) create an appropriate environment; (2) open the meeting; (3) discuss the news; (4) develop a follow-up plan; (5) document the conference; and (6) engage in self-reflection.

Two Tribes Divided by a Common Language? The True Nature of the Divide between Account Planners and Market Researchers

At the MRS Conference, 2000, Rupert Howell in a keynote speech attacked the research industry for failing to innovate or adapt to change. The authors take up the challenge of trying to understand the nature of the antipathy that often exists between advertising agency and research people, so as to see how it might be overcome. Analysis of the speech and responses to it make clear that the main contention concerns quantitative pre-testing. Three hypotheses are raised: 1) researchers and planners have different expectations from research; 2) they have different mental models about how advertising works; 3) they are fundamentally different people. Evidence is adduced confirming all three. Mental models quoted include those of Millward Brown, Hall &amp; Partners, HPI, TRBI, low-involvement processing, persuasion shift testing. These researchers’ models are contrasted with opinions from a sample of planners. That researchers and planners are different people is confirmed by results of a survey among senior researchers and planners using the Social Styles Inventory Model (described in appendix) to establish personality type. Ends with a series of recommendations for avoiding the conflict: build long-term relationships with clients, be honest and open, insist on proper briefings, involve the marketing director, understand and explain the advertising strategy and the brand/consumer relationship, ensure that enough time is devoted to the job, how to deliver bad news, understand the difference between idea and execution, use research early in the creative process, avoid delegating too much responsibility to junior people. Clients also need to appreciate the limits of research, understand, respect and trust the researcher, allow enough time and be prepared to pay for quality. Winner of the 2001 ISBA Award.

Barriers to breaking bad news among medical and surgical residents

Communicating "bad news" to patients and their families can be difficult for physicians. This qualitative study aimed to examine residents' perceptions of barriers to delivering bad news to patients and their family members. Two focus groups consisting of first- and second-year medical and surgical residents were conducted to explore residents' perceptions of the bad news delivery process. The grounded theory approach was used to identify common themes and concepts, which included: (1) guidelines to delivering bad news, (2) obstacles to delivering bad news and (3) residents' needs. McMaster University, Hamilton, Ontario, Canada. First- and second-year residents. Residents were able to identify several guidelines important to communicating the bad news to patients and their family members. However, residents also discussed the barriers that prevented these guidelines from being implemented in day-to-day practice. Specifically, lack of emotional support from health professionals, available time as well as their own personal fears about the delivery process prevented them from being effective in their roles. Residents relayed the need for increased focus on communication skills and frequent feedback with specific emphasis on the delivery of bad news. The residents in our study also stressed the importance of processing their own feelings regarding the delivery process with staff. Although most residents realize important guidelines in the delivery of bad news, their own fears, a general lack of supervisory support and time constraints form barriers to their effective interaction with patients.