Medical Teacher
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
Telling the truth: Medical students’ progress with an ethical skill Carine Layat Burn, Samia A. Hurst, Marinette Ummel, Bernard Cerutti & Anne Baroffio To cite this article: Carine Layat Burn, Samia A. Hurst, Marinette Ummel, Bernard Cerutti & Anne Baroffio (2014) Telling the truth: Medical students’ progress with an ethical skill, Medical Teacher, 36:3, 251-259, DOI: 10.3109/0142159X.2013.853118 To link to this article: http://dx.doi.org/10.3109/0142159X.2013.853118
Published online: 05 Feb 2014.
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Date: 08 October 2017, At: 06:59
2014; 36: 251–259
Telling the truth: Medical students’ progress with an ethical skill CARINE LAYAT BURN1,2, SAMIA A. HURST3, MARINETTE UMMEL3,4, BERNARD CERUTTI1 & ANNE BAROFFIO1 1
Geneva University Medical School, Switzerland, 2HESAV – University of Health Sciences, Switzerland, 3Institute for Biomedical Ethics, Geneva University Medical School, Switzerland, 4CURML – University Centre of Legal Medicine, Switzerland
Background: Truth-telling is a complex task requiring multiple skills in communication, understanding, and empathy. Its application in the context of breaking bad news (BBN) is distressing and problematic if conducted with insufficient skills. Purpose: We investigated the long-term influence of a simulated patient-based teaching intervention integrating the learning of communication skills within an ethical reflection on students’ ethical attitudes towards truth-telling, perceived competence and comfort in BBN. Methods: We followed two cohorts of medical students from the preclinical third year to their clinical rotations (fifth year). We analysed their ethical attitudes and level of comfort and competence in BBN before, after the intervention, and during clinical rotations. Results: Students’ ethical attitudes towards truth-telling remained stable. Students feeling uncomfortable or incompetent improved their level of perceived comfort or competence after the intervention, but those feeling comfortable or competent became more aware of the difficulty of the situation, and consequently decreased their level of comfort and competence. Conclusions: Confronting students with a realistic situation and integrating the practice of communication skills within an ethical reflection may be effective in maintaining ethical attitudes towards truth-telling, in developing new skills and increasing awareness about the difficulty and challenges of a BBN situation.
Introduction
Practice points
Truth-telling makes their personal information available to individual patients and constitutes an essential component of respect for self-determination. Although uncertainty as to how much of the truth to tell remains an ethical difficulty for clinicians in many countries (Hurst et al. 2007), truth-telling is generally in the interest of patients as it breaks the conspiracy of silence which prevails in its absence. An increasing body of research shows patients themselves wish to be told the truth about their clinical situation (Hoff et al. 2007). This also applies in the case of bad news, more specifically news regarding the diagnosis and – to the degree with which it is knowable – the prognosis of incurable disorders. Physicians’ attitudes towards disclosure of bad news are variable. The World Health Organisation proposed a theoretical framework to relate the style of doctor–patient relationship with the type of attitudes towards breaking bad news (BBN; De Valck et al. 2001). The non-disclosure model is a kind of paternalistic doctor–patient relationship, in which the physician knows and makes the decision. The full-disclosure model implies giving full information to the patient and puts the decision-making under the patient’s responsibility. The individualised disclosure model implies that the amount of information given to the patient should be tailored to his
. A simulated patient (SP)-based teaching intervention integrating skills in communication with ethical reflection helps medical students to increase their skills in breaking bad news (BBN), through self-practice and peer-observation . This intervention allows students to increase their awareness of the difficulties and challenges raised by a situation of BBN . Medical students evolve differently according to their feeling of comfort or competency in BBN before the intervention . Ethical attitudes towards truth-telling can remain stable across time after an SP-based intervention integrated within a longitudinal strategy in teaching truth-telling
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Abstract
information preferences, resulting in joint decision-making. Whatever the model, BBN is a distressing, difficult (Stenmarker et al. 2010) and, in rare cases, even dangerous task, which can go devastatingly wrong if conducted with insufficient skill or care (Helft & Petronio 2007). Moreover, truth-telling is a complex task requiring multiple skills in communication, understanding, and empathy (Eggly et al. 2006).
Correspondence: Dr Anne Baroffio, Unite´ de De´veloppement et de Recherche en Education Me´dicale, CMU 1 rue Michel Servet, CH-1211 Gene`ve 4, Switzerland. Tel: (+41) 022 379 59 39; fax: (þ41) 022 379 51 22; email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/14/030251–9 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2013.853118
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For these reasons, truth-telling has been included in medical curricula for medical students and graduates. It was first incorporated into medical ethics programmes, aiming to analyse values and value conflicts underpinning truth-telling and applying it to clinical cases. In a second step, it has increasingly been included in communication skills training. However, the skills involved in truth-telling are not usually integrated into the context of ethical teaching (Rosenbaum et al. 2004). We have attempted integration between the ethics and communication curricula in teaching truth-telling at the Geneva University Medical School. Students follow a longitudinal programme of ethics teaching running from the first ( preclinical) to the fifth (clinical) years of the curriculum, progressing from basic concepts to increasingly concrete application to realistic cases. Initially, the ethical concept of truth-telling was taught through a case-based seminar exploring the values involved in disclosure or non-disclosure of information to a patient. This format, however, did not enable students to sense the difficulty of the exercise. Based on the evidence from a literature review, the team decided to modify the teaching method by introducing an experiential learning approach using a simulated patients (SP) methodology (DayerZamora 2001). An SP is a person trained to portray a patient in a simulated scenario for educational purposes (May et al. 2009; Nestel et al. 2011). This technique is particularly efficient for the development of communication skills (Zweifler et al. 2000; Perera et al. 2010), in a BBN situation (Rosenbaum et al. 2004) and other specific situations including teaching the informed consent process (Johnson et al. 1992; Roberts et al. 2003). Small group teaching with SPs give participants a chance to practise delivering bad news and receive a multisource feedback from SPs, faculty, and peers, with the limitation that frequently not all participants may practice, and perform in front of their peers. The aims of the modified seminar were (1) to provide students with the opportunity to experience the application of ethical concepts in a realistic situation and (2) to integrate the teaching of communication and ethical skills. Thus, the intervention with the group of students was guided by a tandem of clinician and ethicist facilitators and included both an ethical discussion on truth-telling and practicing communication skills in the context of a BBN case. Teamteaching allowed the tutors to encourage students to reflect on what information is critical, and to focus on how to deliver bad news and also on the ethical aspects of truth-telling within the practical exercise. Teaching on truth-telling within clinical skills training has been shown to be effective. These interventions are generally based on a situation of BBN (Cushing & Jones 1995; Fallowfield & Jenkins 2004; Kiluk et al. 2012) and use several educational models (Rosenbaum et al. 2004). Lectures and small group discussions with trigger videotapes were the most common method used at first, but produced a modest improvement in learners’ satisfaction, knowledge and skills (Knox & Thomson 1989; Romm 2002; Rosenbaum & Kreiter 2002; Schildmann et al. 2006, 2012) and a poor effect on the development of clinical skills (Johnson et al. 1992; Angelos et al. 1999; Vetto et al. 1999; Roberts et al. 2003). More recently, teaching interventions using experiential methods 252
such as SP methodology and the principle of learner-centred learning approach (Cushing & Jones 1995; Kiluk et al. 2012; van Weel-Baumgarten et al. 2012), resulted in a significant increase in learners’ self-reported comfort, confidence and self-efficacy (Cushing & Jones 1995; Kahn et al. 2001; Rosenbaum & Kreiter 2002; Dikici et al. 2009; Kiluk et al. 2012). Recent data suggest in addition that it improved students’ skills in BBN based on raters’ observation after SP interaction (Schildmann et al. 2012). Although this teaching appeared efficient, only its short-term effect on competency has been studied. Longitudinal surveys, assessing potential changes of skills in a situation of BBN, are scarce. In particular, little is known on how the teaching prepares students to deal with real-life situations and how it interacts with experience acquired during clinical rotations. Moreover, there is, to our knowledge, no report on the effect of an SP-based intervention on medical students’ ethical attitudes. To explore these questions, we designed a longitudinal study with a quantitative and qualitative component, aimed at investigating the long-term effect of this SP-based intervention on (1) ethical attitudes of medical students towards truthtelling and BBN, (2) the level of perceived competence and comfort, and (3) ethical and communication difficulties encountered by students while dealing with this situation, before and after the intervention, and during clinical rotations. The current article reports the quantitative part of the study.
Methods Recruitment We recruited students at the time of the intervention ( preclinical third year of a six-year curriculum) in 2004 and 2005 (respectively 120 and 105 medical students) and followed the two cohorts of medical students to their clinical rotations (fifth year).
Teaching intervention The teaching intervention was a 90-min, SP-based intervention jointly developed by the ethics and clinical communication teams. It included a 15-min ethical discussion on truth-telling and a 60-min practice of communication skills in the context of a BBN case. The learning objectives were (1) to provide students with an opportunity to apply ethical concepts to a realistic situation, and (2) to integrate doctor–patient communication skills and ethical skills in balancing what to tell and how to tell it. The SP scenario portrayed a young female pianist with an initial episode of multiple sclerosis. She was presently asymptomatic although laboratory and imaging analyses confirmed the diagnosis. The choice of this clinical situation aimed at giving students a scenario which included uncertainty about the future, thus increasing the ethical challenges concerning truth-telling. The SPs’ emotional responses to the bad news included shock and denial. The SP scenario was developed to require minimal in-depth medical knowledge. Three SPs were trained for this role.
Telling the truth
The intervention was facilitated by a tandem constituted of a specialist in ethics and a clinician and involved a group of a maximum of 10 students. They were first informed of the session’s objectives, and received key medical information needed to answer the SP’s medical questions. Then, each student rotated, conducting a sequence of the medical interview. Each student was observed by the rest of group. Between each sequence, time-outs allowed facilitators and SPs to provide feedback, guide students, and reflect on alternative techniques to practice. Thus, the interview could benefit from each student’s experience, and evolve towards better student performance and patient satisfaction.
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Survey instrument The instrument was developed using closed-ended items selected from published surveys (Garg et al. 1997; De Valck et al. 2001; Rosenbaum & Kreiter 2002). Table 1 gives the details of the items used in the questionnaires. Published items were translated into French and back-translated into English for quality control. Socio-demographic questions such as gender and previous participation to the teaching intervention were integrated into the questionnaire. Six ethical attitudes were rated by medical students on a five-point Likert scale (1 ¼ not agree at all to 5 ¼ totally agree) before and after the intervention on BBN (third year of study), and again during clinical rotations (fifth year of study).
Medical students self-assessed their feeling of comfort and competence in BBN on a five-point scale, before and after intervention, and during clinical rotations. After the teaching intervention, they also retrospectively assessed how competent they felt before the intervention. Finally, four items asked directly whether the teaching intervention and the clinical experience helped them to break bad news and to feel more comfortable in doing it.
Data collection The study was conducted from October 2004 to May 2008. Participants answered the questionnaires three times during medical ethics seminars: one week before the intervention, one month after the intervention, and two years later during clinical rotations.
Data analysis To compare our data measuring the ethical attitudes towards BBN with data originally published (De Valck et al. 2001), principal factors were derived from a principal component analysis with varimax rotation method, keeping the three main factors. Analyses of variance (ANOVA) or multivariate ANOVA were used to investigate a potential effect of the time of survey (before and after the intervention, and during clinical
Table 1. Survey instrument. Surveyb Items Attitudes toward breaking bad newsa Valck model Full-disclosure Patients need to be protected from bad news Patients do not want to hear bad news about themselves Non-disclosure All patients want to know bad news about themselves Patients have right to full information about themselves Individualised disclosure Patients are different in their information preferences It takes time to absorb and adjust to bad news
a
Scale
1
2
3
5-point Likert scale (1 ¼ not agree at all to 5 ¼ totally agree)
x x
x x
x x
x x
x x
x x
x x
x x
x x
Comfort Being a doctor, this often means breaking bad news. How comfortable do you feel in this task?
5-point Likert-scale (1 ¼ not at all to 5 ¼ very comfortable)
x
x
x
Competence How competent do you feel now in breaking bad news? How competent did you feel in breaking bad news before participating in the SP-based seminar?
5-point Likert-scale (1 ¼ not at all to 5 ¼ very competent)
x
x x
x x
Seminar Did the seminar help you in breaking bad news? Did the seminar help you to feel more comfortable in breaking bad news?
5-point Likert-scale (1 ¼ not at all to 5 ¼ strongly)
x x
x x
Experience Did clinical experience help you in breaking bad news? Did clinical experience help you to feel more comfortable in breaking bad news?
5-point Likert-scale (1 ¼ not at all to 5 ¼ strongly)
x x
x x
From De Valck et al. 2001. 1 ¼ pre-intervention; 2 ¼ post-intervention; 3 ¼ during clinical rotations.
b
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rotations, 9 students declared they themselves had delivered bad news, 85 had observed their resident doing it, and 20 students had never been in the situation.
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rotations), or gender effect, regarding attitudes, and selfperceived levels of comfort and competence. The significance of the survey factor was checked against the within subjects residual error with Fisher F tests. In the other situations, between subjects residual error was used. Type I error rates were all set at 0.05. A further insight was also given to the evolution of perceived comfort or competence through the three surveys. Linear regression models were used, and deviation from an unchanged level of perception was checked with the Fisher test (comparison with linear models with a slope one, and no intercept). All the analyses were done with IBMÕ SPSSÕ Statistics Version 19, and TIBCO Spotfire S þ Õ 8.1 for Window, TIBCO Software Inc.
Ethical attitudes The factor analysis of the six-item version of the ‘‘Attitudes Towards BBN’’ questionnaire allowed us to extract three factors explaining 63–66% of the total variance. However, before the teaching intervention, it failed to represent the same three factors reported by De Valck et al. (2001). After intervention and during clinical rotations, factors were identical (De Valck et al. 2001), but not represented in the same order. We therefore report individual item scores. Students’ attitudes towards BBN overall changed across time for the three questionnaire surveys (Table 2, p ¼ 0.04). Looking at individual items revealed that a single attitude, ‘‘Patients are different in their information preferences’’, was scored higher after the intervention and during clinical rotations ( p ¼ 0.002), the other attitudes remaining stable.
Protection of human subjects Students’ participation in the research was voluntary and anonymous. The Chair of the Public Health Research Ethics Committee in Geneva designated this study exempt from ethical review. To respect autonomy, students received the information that they were free to participate in the study. We considered the students’ responses to the questionnaires as the consent to participate in the study. Confidentiality was ensured by using a self-generated unique non-identifying code for each student to match responses from each student across the duration of the study.
Evolution of the level of comfort in BBN after the teaching intervention and during clinical rotations Before the teaching intervention with SP, students’ overall selfassessed as not being comfortable in BBN (mean 2.43, 65% feeling not at all or not comfortable, 10% comfortable, and 25% undetermined). Female students felt less comfortable than male students (Table 3). The teaching intervention somewhat helped students in BBN (mean 3.43 0.99, median 4) and made them moderately more comfortable (3.16 0.07, median 3). After the intervention, students, although feeling significantly more comfortable, stayed in the uncomfortable range (mean 2.63, 53% not at all or not comfortable, 15% comfortable, and 32% undetermined) (Table 3). During clinical rotations, the acquired experience moderately helped students to break bad news (mean 3.23 0.99, median 3) and to be more comfortable (mean 3.07 0.90,
Results Participants The 2004 (n ¼ 120) and 2005 (n ¼ 105) cohorts of third year medical students were invited to participate in this study. From the 225 students, 164 (73%) took the survey before the teaching intervention, 150 (67%) after the intervention, and 114 (51%) during their fifth year of study during clinical rotations. Females represented 55% of the total. During clinical
Table 2. Medical students’ ethical attitudes towards truth-telling before and after a teaching intervention, and during clinical rotations. Manovad
Before interventiona Median Mean Patients need to be protected from bad news Patients do not want to hear bad news about themselves All patients want to know bad news about themselves Patients have the right to full information about themselves Patients are different in their information preferences It takes time to absorb and adjust to bad news a
SD
After interventionb
Median Mean SD Median Mean SD
Inter subject: Within subject: gender survey 0.15
0.04*
2 2
2.15 2.28
0.98 0.91
2 2
2.11 2.20
1.0 0.96
2 2
1.96 2.16
0.87 0.92
0.10 0.81
0.17 0.31
2
2.23
1.06
2
2.35
1.05
2
2.25
1.06
0.29
0.65
5
4.35
0.77
5
4.35
0.85
5
4.41
0.78
0.16
0.50
5
4.29
0.92
5
4.45
0.81
5
4.67
0.63
0.64
0.002*
5
4.75
0.59
5
4.80
0.52
5
4.90
0.35
0.09
0.06
n ¼ 163 students; bn ¼ 149 students; cn ¼ 114 students; dn ¼ 417 observations (219 students). *p50.05.
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Clinical rotationsc
Telling the truth
Table 3. Medical students’ self-assessed level of comfort and feeling of competence in breaking bad news before and after a teaching intervention, and during clinical rotations.
2 2 2
2.43 2.27 2.67
0.82 0.68 0.98
3 2 3
2.61 2.44 2.87
0.97 0.92 0.99
2 2 3
2.63 2.52 2.81
0.89 0.73 1.1
3 3 3
2.84 2.81 2.90
0.87 0.79 1.02
on female students’ feeling of competence ( p ¼ 0.015 for the interaction gender survey, Table 3). A closer analysis of students’ individual evolution revealed that approximately two thirds of the students who felt noncompetent before the intervention, increased their feeling of competence after having been trained during the teaching intervention (Figure 2a). The situation was the opposite for students who felt competent before the intervention: two thirds of them felt less competent after the intervention. About half of the undetermined students remained stable, whereas the other half were distributed on all modalities. A similar picture arose during clinical rotations: 73% of students feeling incompetent before acquiring clinical experience felt more competent after it (Figure 2b).
3 2 3
2.71 2.64 2.89
0.82 0.77 0.93
3 3 3
3.04 2.99 3.09
0.68 0.66 0.74
Discussion
COMFORT
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Survey
n
Before intervention All 156 Female 94 Men 62 After intervention All 146 Female 88 Men 58 Clinical rotations All 108 Female 73 Men 35 ANOVA Inter subject gender Within subject survey Interaction gender survey
COMPETENCE
Median Mean SD Median Mean SD
50.001* 0.003*
0.007* 50.001* 0.015*
*p50.05.
median 3). However, when self-assessing their level of comfort, students slightly increased their feeling of comfort (mean 2.71, Figure 2, Table 3). Female students’ comfort level evolved in parallel to men’s, but stayed lower. A closer analysis of students’ individual evolution (Figure 1a) revealed that two thirds of those feeling uncomfortable before the intervention increased their level of comfort after having been trained during the intervention. Conversely, two thirds of comfortable students felt less comfortable after the intervention. About half of the undetermined students did not modify their level of comfort after the intervention, the other half distributing on the other four modalities. During clinical rotations, about half of those students who felt uncomfortable before acquiring clinical experience, increased their comfort level (Figure 1b), and two thirds of the comfortable students felt less comfortable.
Evolution of the feeling of competence in BBN after the teaching intervention and during clinical rotations Before the teaching intervention with SP, students selfassessed as having little competence in BBN (mean 2.61, 47% feeling not at all or not competent, 18% competent, and 35% being undetermined; Table 3). When asked again after the intervention to estimate their level of competence before the intervention, about 40% revised downwards their level of competence, whereas 50% confirmed it (Figure 2c). After the intervention, students overall felt more competent than before (mean 2.84, 35% feeling not competent, 22% competent, and 43% undetermined) and continued to increase their feeling of competence during clinical rotations (Table 3). The attained competence level was nevertheless still moderate (mean 3.04). Female students declared being less competent than male students before the intervention, but achieved similar levels after the intervention and during clinical rotations. This suggested a higher effect of the intervention
This longitudinal cohort survey assessed the effects of a teaching intervention with SP in a context of BBN on medical students’ ethical attitudes towards truth-telling and on levels of perceived comfort and competence. Our findings show that students’ ethical attitudes towards truth-telling remained stable over time and even increased. Overall, students self-assessed as more comfortable and competent in BBN after the teaching intervention and during clinical rotations. However, our teaching intervention benefited the students differently according to how comfortable or competent in BBN they felt before the intervention. Students who reported that they did not feel comfortable or competent improved their level of perceived comfort or competence after the intervention, but those who reported feeling comfortable or competent became more aware of the difficulty of the situation when they faced a realistic situation, and consequently decreased their perceived level of comfort and competence. To our knowledge, this is the first report of the effect of an SP-based intervention on medical students’ ethical attitudes. We used the scale on ethical attitudes towards truth-telling developed by De Valck et al. (2001). Most ethical attitudes remained stable over time, one attitude even increasing, revealing an increase in students’ awareness that all patients are different in their information preferences. Indeed, many studies show that ethical attitudes of medical students erode during undergraduate medical education, an effect that has been interpreted as an interruption of their moral growth (Hebert et al. 1992; Feudtner et al. 1994; Price et al. 1998; Tsimtsiou et al. 2007; van Weel-Baumgarten et al. 2012). This effect seems to be particularly marked in the first clinical year (Hojat et al. 2009), and attitudes towards truth-telling also show an increase in preference towards non-disclosure (De Valck et al. 2001). However, educational interventions can be effective in preventing this erosion and in maintaining ethical sensitivity, growth and empathy (Rosenthal et al. 2011). Our observations are consistent with these findings and suggest that the SP-based intervention was part of an effective longitudinal strategy in teaching ethical attitudes towards truth-telling. On the whole, our teaching intervention helped students to develop their feelings of competence and comfort. In comparison to other studies (Cushing & Jones 1995; Garg et al.
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39
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Very comfortable
Not at all comfortable
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5 Very comfortable
Before intervention
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(b)
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Before intervention
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5 Very comfortable
Figure 1. Individual self-assessed level of comfort in breaking bad news (a) before and after intervention; (b) after intervention and during clinical rotations. Points (n) represent individual students. The dotted line represents an unchanged level of comfort, and the continuous line the actual level of comfort (cubic smoothing spline adjustment). 1997; Rosenbaum & Kreiter 2002; Back et al. 2007; Kiluk et al. 2012; Schildmann et al. 2012), experiential sessions with SPs seem to help students to increase their skills in BBN, through self-practice and peer-observation. Moreover, and contrasting with other studies (Garg et al. 1997; Rosenbaum & Kreiter 2002), we used a single session with a single SP scenario and still obtained a measurable effect on perceived competence and comfort, which is promising in terms of efficacy. Our specific setting offered students the opportunity to apply ethical concepts to a realistic situation and to integrate communication practice in a situation presenting students with an ethical difficulty requiring specific skills. In addition, 256
during an immediate debriefing after the simulation, students received a multisource feedback ( peers, facilitator, and SP) and could rapidly practice or observe new communication strategies. This approach has been shown to be effective in developing clinical and communication skills (Issenberg et al. 2005; Yudkowsky et al. 2009; McGaghie et al. 2010; Perera et al. 2010). Learning new skills could consequently increase students’ levels of perceived competence and accordingly improve their comfort in BBN. However, we hypothesize that the intervention could produce a second effect with an antagonistic outcome. The direct confrontation with a difficult task as an observer and/or an actor constitutes a
Telling the truth
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(b)
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Not at all competent
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Not at all competent
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Undetermined
Prospective
1
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Figure 2. Individual self-assessed feeling of competence in breaking bad news (a) before and after intervention; (b) after intervention and during clinical rotations; (c) before intervention: prospective and retrospective. Points (n) represent individual students. The dotted line represents an unchanged feeling of competence, and the continuous line the actual level of competence (cubic smoothing spline adjustment).
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benchmarking of performance, to which each student has to compare. Second, an SP’s emotional reaction while receiving the bad news, and the opportunity to receive feedback from peers, teachers and SPs, promote reflection (Kalish et al. 2011), and may act on students’ awareness about the real difficulty of the task. This could consequently decrease students’ own perceived competence and comfort in BBN. These two effects could weigh differently according to students’ prior representation of the difficulty of telling the truth. Such a combined effect has already been suggested by Garg et al. (1997). Whereas half of our students clearly identified themselves as not competent in BBN, about 20% presumed they were, and the rest of them felt they were not being able to decide. The fate of these populations suggests that the students who were ‘‘feeling not-competent’’ focused more on learning new skills during the teaching intervention (and perceived themselves as getting more competent), whereas the students who were ‘‘feeling competent’’ entered a reflective process and re-evaluated their own presumed competence in a more realistic manner: they perceived themselves as getting less competent. As already stressed in a number of studies, self-assessment is very inaccurate, even for confirmed physicians (Davis et al. 2006). In addition, poorly competent people tend to overestimate their test performance and skills (Kruger & Dunning 1999; Eva et al. 2004; Davis et al. 2006). Self-assessment needs to be informed through learning and assessment activities and from external sources (Sargeant et al. 2010, 2011). Thus, we propose that our setting likely helped to inform the self-assessment of unaware students. This was one goal of our teaching intervention, and may also have helped students be more receptive to learning from their clinical experiences with BBN. Our study had several limitations. We used a Frenchtranslated version of the six-item questionnaire on attitudes towards BBN (De Valck et al. 2001). Despite a back-translation and verification, we did not go through with the whole validation process for the French version of the questionnaire. This is often true for translated questionnaires used in a different cultural context. It was, however, reassuring that the factorial analysis was similar when the questionnaire was administered after the teaching intervention. As for any negative results (absence or very modest change in ethical attitudes), it could be argued that this instrument could not capture potential changes. Further studies are required to explore the possibility of small effects, and qualitative analysis of our students’ open comments will help to assess this. Our setting also presents several weaknesses. We used a single SP scenario and did not have a control group. We report selfassessed competence, and any change in perceived competence should be verified through an external assessment (see e.g. Schildmann et al. 2012). Students answered questionnaires during ethical teaching sessions, which could constitute a bias towards more attention to ethical aspects.
Conclusion Our findings suggest that an SP-based intervention was part of an effective longitudinal strategy in teaching communication skills and ethical attitudes towards truth-telling. 258
This intervention led to an overall increase in students’ reported comfort and competence in BBN. This, however, was not true of all students as those reporting the greatest comfort and competence prior to the seminar seemed to enter a reflective process and re-evaluated their presumed competence in a more realistic manner. Ethical attitudes towards truth-telling remained stable throughout the study. This is reassuring in a context where other studies identify erosion of moral reasoning and empathy in general, and erosion of attitudes towards truth-telling specifically. Our findings suggest that such an intervention, which integrates the practice of communication skills and ethical reflection in a realistic situation, might allow students not only to develop new skills, but also to increase their awareness about the difficulties and challenges raised by a situation of BBN. This study needs to be refined by a qualitative analysis of students’ ethical concerns on truth-telling and how they evolve with the intervention.
Acknowledgements We would like to thank all the facilitators who were involved in this SP teaching intervention, all medical students who participated in the study and the SPs for their appreciated contribution to teaching. This research was conducted while Carine Layat Burn was an SP trainer and a research assistant at the Unit of Development and Research in Medical Education, Geneva University Medical School. Declaration of interest: Samia Hurst was supported by a grant from the Swiss National Science Foundation (PP00P3-123340). The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Notes on contributors CARINE LAYAT BURN, PhD, is the Director of the Unit of Educational Innovation with responsibility for simulation-based education at HESAV – University of Health Sciences, Lausanne, Switzerland. She has over 10 years of experience working with simulated/standardised patients (SPs) in medical education and other health professional education. SAMIA HURST, MD, is Professor of Bioethics at Geneva University Medical School in Switzerland and ethics consultant to the Geneva University Hospitals’ clinical ethics committee. Her research focuses on fairness in clinical practice, and the protection of vulnerable persons. MARINETTE UMMEL, MD, JD, is the Lecturer at the Institute for Biomedical Ethics, Geneva University Medical School and at the University Centre of Legal Medicine, Lausanne-Geneva. BERNARD CERUTTI, PhD, MPH, is a Statistician at the Faculty of Medicine and Associate Member of the Research Center for Statistics, University of Geneva, and consultant to the Service of Clinical Epidemiology, Geneva University Hospital. ANNE BAROFFIO, PhD, is Senior Researcher at the Unit of Development and Research in Medical Education and Director of the Faculty Development programme at the Geneva University Medical School. She leads research projects related to programme evaluation and faculty development interventions.
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ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
Telling the truth: Medical students’ progress with an ethical skill Carine Layat Burn, Samia A. Hurst, Marinette Ummel, Bernard Cerutti & Anne Baroffio To cite this article: Carine Layat Burn, Samia A. Hurst, Marinette Ummel, Bernard Cerutti & Anne Baroffio (2014) Telling the truth: Medical students’ progress with an ethical skill, Medical Teacher, 36:3, 251-259, DOI: 10.3109/0142159X.2013.853118 To link to this article: http://dx.doi.org/10.3109/0142159X.2013.853118
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Date: 08 October 2017, At: 06:59
2014; 36: 251–259
Telling the truth: Medical students’ progress with an ethical skill CARINE LAYAT BURN1,2, SAMIA A. HURST3, MARINETTE UMMEL3,4, BERNARD CERUTTI1 & ANNE BAROFFIO1 1
Geneva University Medical School, Switzerland, 2HESAV – University of Health Sciences, Switzerland, 3Institute for Biomedical Ethics, Geneva University Medical School, Switzerland, 4CURML – University Centre of Legal Medicine, Switzerland
Background: Truth-telling is a complex task requiring multiple skills in communication, understanding, and empathy. Its application in the context of breaking bad news (BBN) is distressing and problematic if conducted with insufficient skills. Purpose: We investigated the long-term influence of a simulated patient-based teaching intervention integrating the learning of communication skills within an ethical reflection on students’ ethical attitudes towards truth-telling, perceived competence and comfort in BBN. Methods: We followed two cohorts of medical students from the preclinical third year to their clinical rotations (fifth year). We analysed their ethical attitudes and level of comfort and competence in BBN before, after the intervention, and during clinical rotations. Results: Students’ ethical attitudes towards truth-telling remained stable. Students feeling uncomfortable or incompetent improved their level of perceived comfort or competence after the intervention, but those feeling comfortable or competent became more aware of the difficulty of the situation, and consequently decreased their level of comfort and competence. Conclusions: Confronting students with a realistic situation and integrating the practice of communication skills within an ethical reflection may be effective in maintaining ethical attitudes towards truth-telling, in developing new skills and increasing awareness about the difficulty and challenges of a BBN situation.
Introduction
Practice points
Truth-telling makes their personal information available to individual patients and constitutes an essential component of respect for self-determination. Although uncertainty as to how much of the truth to tell remains an ethical difficulty for clinicians in many countries (Hurst et al. 2007), truth-telling is generally in the interest of patients as it breaks the conspiracy of silence which prevails in its absence. An increasing body of research shows patients themselves wish to be told the truth about their clinical situation (Hoff et al. 2007). This also applies in the case of bad news, more specifically news regarding the diagnosis and – to the degree with which it is knowable – the prognosis of incurable disorders. Physicians’ attitudes towards disclosure of bad news are variable. The World Health Organisation proposed a theoretical framework to relate the style of doctor–patient relationship with the type of attitudes towards breaking bad news (BBN; De Valck et al. 2001). The non-disclosure model is a kind of paternalistic doctor–patient relationship, in which the physician knows and makes the decision. The full-disclosure model implies giving full information to the patient and puts the decision-making under the patient’s responsibility. The individualised disclosure model implies that the amount of information given to the patient should be tailored to his
. A simulated patient (SP)-based teaching intervention integrating skills in communication with ethical reflection helps medical students to increase their skills in breaking bad news (BBN), through self-practice and peer-observation . This intervention allows students to increase their awareness of the difficulties and challenges raised by a situation of BBN . Medical students evolve differently according to their feeling of comfort or competency in BBN before the intervention . Ethical attitudes towards truth-telling can remain stable across time after an SP-based intervention integrated within a longitudinal strategy in teaching truth-telling
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Abstract
information preferences, resulting in joint decision-making. Whatever the model, BBN is a distressing, difficult (Stenmarker et al. 2010) and, in rare cases, even dangerous task, which can go devastatingly wrong if conducted with insufficient skill or care (Helft & Petronio 2007). Moreover, truth-telling is a complex task requiring multiple skills in communication, understanding, and empathy (Eggly et al. 2006).
Correspondence: Dr Anne Baroffio, Unite´ de De´veloppement et de Recherche en Education Me´dicale, CMU 1 rue Michel Servet, CH-1211 Gene`ve 4, Switzerland. Tel: (+41) 022 379 59 39; fax: (þ41) 022 379 51 22; email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/14/030251–9 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2013.853118
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C. Layat Burn et al.
For these reasons, truth-telling has been included in medical curricula for medical students and graduates. It was first incorporated into medical ethics programmes, aiming to analyse values and value conflicts underpinning truth-telling and applying it to clinical cases. In a second step, it has increasingly been included in communication skills training. However, the skills involved in truth-telling are not usually integrated into the context of ethical teaching (Rosenbaum et al. 2004). We have attempted integration between the ethics and communication curricula in teaching truth-telling at the Geneva University Medical School. Students follow a longitudinal programme of ethics teaching running from the first ( preclinical) to the fifth (clinical) years of the curriculum, progressing from basic concepts to increasingly concrete application to realistic cases. Initially, the ethical concept of truth-telling was taught through a case-based seminar exploring the values involved in disclosure or non-disclosure of information to a patient. This format, however, did not enable students to sense the difficulty of the exercise. Based on the evidence from a literature review, the team decided to modify the teaching method by introducing an experiential learning approach using a simulated patients (SP) methodology (DayerZamora 2001). An SP is a person trained to portray a patient in a simulated scenario for educational purposes (May et al. 2009; Nestel et al. 2011). This technique is particularly efficient for the development of communication skills (Zweifler et al. 2000; Perera et al. 2010), in a BBN situation (Rosenbaum et al. 2004) and other specific situations including teaching the informed consent process (Johnson et al. 1992; Roberts et al. 2003). Small group teaching with SPs give participants a chance to practise delivering bad news and receive a multisource feedback from SPs, faculty, and peers, with the limitation that frequently not all participants may practice, and perform in front of their peers. The aims of the modified seminar were (1) to provide students with the opportunity to experience the application of ethical concepts in a realistic situation and (2) to integrate the teaching of communication and ethical skills. Thus, the intervention with the group of students was guided by a tandem of clinician and ethicist facilitators and included both an ethical discussion on truth-telling and practicing communication skills in the context of a BBN case. Teamteaching allowed the tutors to encourage students to reflect on what information is critical, and to focus on how to deliver bad news and also on the ethical aspects of truth-telling within the practical exercise. Teaching on truth-telling within clinical skills training has been shown to be effective. These interventions are generally based on a situation of BBN (Cushing & Jones 1995; Fallowfield & Jenkins 2004; Kiluk et al. 2012) and use several educational models (Rosenbaum et al. 2004). Lectures and small group discussions with trigger videotapes were the most common method used at first, but produced a modest improvement in learners’ satisfaction, knowledge and skills (Knox & Thomson 1989; Romm 2002; Rosenbaum & Kreiter 2002; Schildmann et al. 2006, 2012) and a poor effect on the development of clinical skills (Johnson et al. 1992; Angelos et al. 1999; Vetto et al. 1999; Roberts et al. 2003). More recently, teaching interventions using experiential methods 252
such as SP methodology and the principle of learner-centred learning approach (Cushing & Jones 1995; Kiluk et al. 2012; van Weel-Baumgarten et al. 2012), resulted in a significant increase in learners’ self-reported comfort, confidence and self-efficacy (Cushing & Jones 1995; Kahn et al. 2001; Rosenbaum & Kreiter 2002; Dikici et al. 2009; Kiluk et al. 2012). Recent data suggest in addition that it improved students’ skills in BBN based on raters’ observation after SP interaction (Schildmann et al. 2012). Although this teaching appeared efficient, only its short-term effect on competency has been studied. Longitudinal surveys, assessing potential changes of skills in a situation of BBN, are scarce. In particular, little is known on how the teaching prepares students to deal with real-life situations and how it interacts with experience acquired during clinical rotations. Moreover, there is, to our knowledge, no report on the effect of an SP-based intervention on medical students’ ethical attitudes. To explore these questions, we designed a longitudinal study with a quantitative and qualitative component, aimed at investigating the long-term effect of this SP-based intervention on (1) ethical attitudes of medical students towards truthtelling and BBN, (2) the level of perceived competence and comfort, and (3) ethical and communication difficulties encountered by students while dealing with this situation, before and after the intervention, and during clinical rotations. The current article reports the quantitative part of the study.
Methods Recruitment We recruited students at the time of the intervention ( preclinical third year of a six-year curriculum) in 2004 and 2005 (respectively 120 and 105 medical students) and followed the two cohorts of medical students to their clinical rotations (fifth year).
Teaching intervention The teaching intervention was a 90-min, SP-based intervention jointly developed by the ethics and clinical communication teams. It included a 15-min ethical discussion on truth-telling and a 60-min practice of communication skills in the context of a BBN case. The learning objectives were (1) to provide students with an opportunity to apply ethical concepts to a realistic situation, and (2) to integrate doctor–patient communication skills and ethical skills in balancing what to tell and how to tell it. The SP scenario portrayed a young female pianist with an initial episode of multiple sclerosis. She was presently asymptomatic although laboratory and imaging analyses confirmed the diagnosis. The choice of this clinical situation aimed at giving students a scenario which included uncertainty about the future, thus increasing the ethical challenges concerning truth-telling. The SPs’ emotional responses to the bad news included shock and denial. The SP scenario was developed to require minimal in-depth medical knowledge. Three SPs were trained for this role.
Telling the truth
The intervention was facilitated by a tandem constituted of a specialist in ethics and a clinician and involved a group of a maximum of 10 students. They were first informed of the session’s objectives, and received key medical information needed to answer the SP’s medical questions. Then, each student rotated, conducting a sequence of the medical interview. Each student was observed by the rest of group. Between each sequence, time-outs allowed facilitators and SPs to provide feedback, guide students, and reflect on alternative techniques to practice. Thus, the interview could benefit from each student’s experience, and evolve towards better student performance and patient satisfaction.
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Survey instrument The instrument was developed using closed-ended items selected from published surveys (Garg et al. 1997; De Valck et al. 2001; Rosenbaum & Kreiter 2002). Table 1 gives the details of the items used in the questionnaires. Published items were translated into French and back-translated into English for quality control. Socio-demographic questions such as gender and previous participation to the teaching intervention were integrated into the questionnaire. Six ethical attitudes were rated by medical students on a five-point Likert scale (1 ¼ not agree at all to 5 ¼ totally agree) before and after the intervention on BBN (third year of study), and again during clinical rotations (fifth year of study).
Medical students self-assessed their feeling of comfort and competence in BBN on a five-point scale, before and after intervention, and during clinical rotations. After the teaching intervention, they also retrospectively assessed how competent they felt before the intervention. Finally, four items asked directly whether the teaching intervention and the clinical experience helped them to break bad news and to feel more comfortable in doing it.
Data collection The study was conducted from October 2004 to May 2008. Participants answered the questionnaires three times during medical ethics seminars: one week before the intervention, one month after the intervention, and two years later during clinical rotations.
Data analysis To compare our data measuring the ethical attitudes towards BBN with data originally published (De Valck et al. 2001), principal factors were derived from a principal component analysis with varimax rotation method, keeping the three main factors. Analyses of variance (ANOVA) or multivariate ANOVA were used to investigate a potential effect of the time of survey (before and after the intervention, and during clinical
Table 1. Survey instrument. Surveyb Items Attitudes toward breaking bad newsa Valck model Full-disclosure Patients need to be protected from bad news Patients do not want to hear bad news about themselves Non-disclosure All patients want to know bad news about themselves Patients have right to full information about themselves Individualised disclosure Patients are different in their information preferences It takes time to absorb and adjust to bad news
a
Scale
1
2
3
5-point Likert scale (1 ¼ not agree at all to 5 ¼ totally agree)
x x
x x
x x
x x
x x
x x
x x
x x
x x
Comfort Being a doctor, this often means breaking bad news. How comfortable do you feel in this task?
5-point Likert-scale (1 ¼ not at all to 5 ¼ very comfortable)
x
x
x
Competence How competent do you feel now in breaking bad news? How competent did you feel in breaking bad news before participating in the SP-based seminar?
5-point Likert-scale (1 ¼ not at all to 5 ¼ very competent)
x
x x
x x
Seminar Did the seminar help you in breaking bad news? Did the seminar help you to feel more comfortable in breaking bad news?
5-point Likert-scale (1 ¼ not at all to 5 ¼ strongly)
x x
x x
Experience Did clinical experience help you in breaking bad news? Did clinical experience help you to feel more comfortable in breaking bad news?
5-point Likert-scale (1 ¼ not at all to 5 ¼ strongly)
x x
x x
From De Valck et al. 2001. 1 ¼ pre-intervention; 2 ¼ post-intervention; 3 ¼ during clinical rotations.
b
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C. Layat Burn et al.
rotations, 9 students declared they themselves had delivered bad news, 85 had observed their resident doing it, and 20 students had never been in the situation.
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rotations), or gender effect, regarding attitudes, and selfperceived levels of comfort and competence. The significance of the survey factor was checked against the within subjects residual error with Fisher F tests. In the other situations, between subjects residual error was used. Type I error rates were all set at 0.05. A further insight was also given to the evolution of perceived comfort or competence through the three surveys. Linear regression models were used, and deviation from an unchanged level of perception was checked with the Fisher test (comparison with linear models with a slope one, and no intercept). All the analyses were done with IBMÕ SPSSÕ Statistics Version 19, and TIBCO Spotfire S þ Õ 8.1 for Window, TIBCO Software Inc.
Ethical attitudes The factor analysis of the six-item version of the ‘‘Attitudes Towards BBN’’ questionnaire allowed us to extract three factors explaining 63–66% of the total variance. However, before the teaching intervention, it failed to represent the same three factors reported by De Valck et al. (2001). After intervention and during clinical rotations, factors were identical (De Valck et al. 2001), but not represented in the same order. We therefore report individual item scores. Students’ attitudes towards BBN overall changed across time for the three questionnaire surveys (Table 2, p ¼ 0.04). Looking at individual items revealed that a single attitude, ‘‘Patients are different in their information preferences’’, was scored higher after the intervention and during clinical rotations ( p ¼ 0.002), the other attitudes remaining stable.
Protection of human subjects Students’ participation in the research was voluntary and anonymous. The Chair of the Public Health Research Ethics Committee in Geneva designated this study exempt from ethical review. To respect autonomy, students received the information that they were free to participate in the study. We considered the students’ responses to the questionnaires as the consent to participate in the study. Confidentiality was ensured by using a self-generated unique non-identifying code for each student to match responses from each student across the duration of the study.
Evolution of the level of comfort in BBN after the teaching intervention and during clinical rotations Before the teaching intervention with SP, students’ overall selfassessed as not being comfortable in BBN (mean 2.43, 65% feeling not at all or not comfortable, 10% comfortable, and 25% undetermined). Female students felt less comfortable than male students (Table 3). The teaching intervention somewhat helped students in BBN (mean 3.43 0.99, median 4) and made them moderately more comfortable (3.16 0.07, median 3). After the intervention, students, although feeling significantly more comfortable, stayed in the uncomfortable range (mean 2.63, 53% not at all or not comfortable, 15% comfortable, and 32% undetermined) (Table 3). During clinical rotations, the acquired experience moderately helped students to break bad news (mean 3.23 0.99, median 3) and to be more comfortable (mean 3.07 0.90,
Results Participants The 2004 (n ¼ 120) and 2005 (n ¼ 105) cohorts of third year medical students were invited to participate in this study. From the 225 students, 164 (73%) took the survey before the teaching intervention, 150 (67%) after the intervention, and 114 (51%) during their fifth year of study during clinical rotations. Females represented 55% of the total. During clinical
Table 2. Medical students’ ethical attitudes towards truth-telling before and after a teaching intervention, and during clinical rotations. Manovad
Before interventiona Median Mean Patients need to be protected from bad news Patients do not want to hear bad news about themselves All patients want to know bad news about themselves Patients have the right to full information about themselves Patients are different in their information preferences It takes time to absorb and adjust to bad news a
SD
After interventionb
Median Mean SD Median Mean SD
Inter subject: Within subject: gender survey 0.15
0.04*
2 2
2.15 2.28
0.98 0.91
2 2
2.11 2.20
1.0 0.96
2 2
1.96 2.16
0.87 0.92
0.10 0.81
0.17 0.31
2
2.23
1.06
2
2.35
1.05
2
2.25
1.06
0.29
0.65
5
4.35
0.77
5
4.35
0.85
5
4.41
0.78
0.16
0.50
5
4.29
0.92
5
4.45
0.81
5
4.67
0.63
0.64
0.002*
5
4.75
0.59
5
4.80
0.52
5
4.90
0.35
0.09
0.06
n ¼ 163 students; bn ¼ 149 students; cn ¼ 114 students; dn ¼ 417 observations (219 students). *p50.05.
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Clinical rotationsc
Telling the truth
Table 3. Medical students’ self-assessed level of comfort and feeling of competence in breaking bad news before and after a teaching intervention, and during clinical rotations.
2 2 2
2.43 2.27 2.67
0.82 0.68 0.98
3 2 3
2.61 2.44 2.87
0.97 0.92 0.99
2 2 3
2.63 2.52 2.81
0.89 0.73 1.1
3 3 3
2.84 2.81 2.90
0.87 0.79 1.02
on female students’ feeling of competence ( p ¼ 0.015 for the interaction gender survey, Table 3). A closer analysis of students’ individual evolution revealed that approximately two thirds of the students who felt noncompetent before the intervention, increased their feeling of competence after having been trained during the teaching intervention (Figure 2a). The situation was the opposite for students who felt competent before the intervention: two thirds of them felt less competent after the intervention. About half of the undetermined students remained stable, whereas the other half were distributed on all modalities. A similar picture arose during clinical rotations: 73% of students feeling incompetent before acquiring clinical experience felt more competent after it (Figure 2b).
3 2 3
2.71 2.64 2.89
0.82 0.77 0.93
3 3 3
3.04 2.99 3.09
0.68 0.66 0.74
Discussion
COMFORT
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Survey
n
Before intervention All 156 Female 94 Men 62 After intervention All 146 Female 88 Men 58 Clinical rotations All 108 Female 73 Men 35 ANOVA Inter subject gender Within subject survey Interaction gender survey
COMPETENCE
Median Mean SD Median Mean SD
50.001* 0.003*
0.007* 50.001* 0.015*
*p50.05.
median 3). However, when self-assessing their level of comfort, students slightly increased their feeling of comfort (mean 2.71, Figure 2, Table 3). Female students’ comfort level evolved in parallel to men’s, but stayed lower. A closer analysis of students’ individual evolution (Figure 1a) revealed that two thirds of those feeling uncomfortable before the intervention increased their level of comfort after having been trained during the intervention. Conversely, two thirds of comfortable students felt less comfortable after the intervention. About half of the undetermined students did not modify their level of comfort after the intervention, the other half distributing on the other four modalities. During clinical rotations, about half of those students who felt uncomfortable before acquiring clinical experience, increased their comfort level (Figure 1b), and two thirds of the comfortable students felt less comfortable.
Evolution of the feeling of competence in BBN after the teaching intervention and during clinical rotations Before the teaching intervention with SP, students selfassessed as having little competence in BBN (mean 2.61, 47% feeling not at all or not competent, 18% competent, and 35% being undetermined; Table 3). When asked again after the intervention to estimate their level of competence before the intervention, about 40% revised downwards their level of competence, whereas 50% confirmed it (Figure 2c). After the intervention, students overall felt more competent than before (mean 2.84, 35% feeling not competent, 22% competent, and 43% undetermined) and continued to increase their feeling of competence during clinical rotations (Table 3). The attained competence level was nevertheless still moderate (mean 3.04). Female students declared being less competent than male students before the intervention, but achieved similar levels after the intervention and during clinical rotations. This suggested a higher effect of the intervention
This longitudinal cohort survey assessed the effects of a teaching intervention with SP in a context of BBN on medical students’ ethical attitudes towards truth-telling and on levels of perceived comfort and competence. Our findings show that students’ ethical attitudes towards truth-telling remained stable over time and even increased. Overall, students self-assessed as more comfortable and competent in BBN after the teaching intervention and during clinical rotations. However, our teaching intervention benefited the students differently according to how comfortable or competent in BBN they felt before the intervention. Students who reported that they did not feel comfortable or competent improved their level of perceived comfort or competence after the intervention, but those who reported feeling comfortable or competent became more aware of the difficulty of the situation when they faced a realistic situation, and consequently decreased their perceived level of comfort and competence. To our knowledge, this is the first report of the effect of an SP-based intervention on medical students’ ethical attitudes. We used the scale on ethical attitudes towards truth-telling developed by De Valck et al. (2001). Most ethical attitudes remained stable over time, one attitude even increasing, revealing an increase in students’ awareness that all patients are different in their information preferences. Indeed, many studies show that ethical attitudes of medical students erode during undergraduate medical education, an effect that has been interpreted as an interruption of their moral growth (Hebert et al. 1992; Feudtner et al. 1994; Price et al. 1998; Tsimtsiou et al. 2007; van Weel-Baumgarten et al. 2012). This effect seems to be particularly marked in the first clinical year (Hojat et al. 2009), and attitudes towards truth-telling also show an increase in preference towards non-disclosure (De Valck et al. 2001). However, educational interventions can be effective in preventing this erosion and in maintaining ethical sensitivity, growth and empathy (Rosenthal et al. 2011). Our observations are consistent with these findings and suggest that the SP-based intervention was part of an effective longitudinal strategy in teaching ethical attitudes towards truth-telling. On the whole, our teaching intervention helped students to develop their feelings of competence and comfort. In comparison to other studies (Cushing & Jones 1995; Garg et al.
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Figure 1. Individual self-assessed level of comfort in breaking bad news (a) before and after intervention; (b) after intervention and during clinical rotations. Points (n) represent individual students. The dotted line represents an unchanged level of comfort, and the continuous line the actual level of comfort (cubic smoothing spline adjustment). 1997; Rosenbaum & Kreiter 2002; Back et al. 2007; Kiluk et al. 2012; Schildmann et al. 2012), experiential sessions with SPs seem to help students to increase their skills in BBN, through self-practice and peer-observation. Moreover, and contrasting with other studies (Garg et al. 1997; Rosenbaum & Kreiter 2002), we used a single session with a single SP scenario and still obtained a measurable effect on perceived competence and comfort, which is promising in terms of efficacy. Our specific setting offered students the opportunity to apply ethical concepts to a realistic situation and to integrate communication practice in a situation presenting students with an ethical difficulty requiring specific skills. In addition, 256
during an immediate debriefing after the simulation, students received a multisource feedback ( peers, facilitator, and SP) and could rapidly practice or observe new communication strategies. This approach has been shown to be effective in developing clinical and communication skills (Issenberg et al. 2005; Yudkowsky et al. 2009; McGaghie et al. 2010; Perera et al. 2010). Learning new skills could consequently increase students’ levels of perceived competence and accordingly improve their comfort in BBN. However, we hypothesize that the intervention could produce a second effect with an antagonistic outcome. The direct confrontation with a difficult task as an observer and/or an actor constitutes a
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Figure 2. Individual self-assessed feeling of competence in breaking bad news (a) before and after intervention; (b) after intervention and during clinical rotations; (c) before intervention: prospective and retrospective. Points (n) represent individual students. The dotted line represents an unchanged feeling of competence, and the continuous line the actual level of competence (cubic smoothing spline adjustment).
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benchmarking of performance, to which each student has to compare. Second, an SP’s emotional reaction while receiving the bad news, and the opportunity to receive feedback from peers, teachers and SPs, promote reflection (Kalish et al. 2011), and may act on students’ awareness about the real difficulty of the task. This could consequently decrease students’ own perceived competence and comfort in BBN. These two effects could weigh differently according to students’ prior representation of the difficulty of telling the truth. Such a combined effect has already been suggested by Garg et al. (1997). Whereas half of our students clearly identified themselves as not competent in BBN, about 20% presumed they were, and the rest of them felt they were not being able to decide. The fate of these populations suggests that the students who were ‘‘feeling not-competent’’ focused more on learning new skills during the teaching intervention (and perceived themselves as getting more competent), whereas the students who were ‘‘feeling competent’’ entered a reflective process and re-evaluated their own presumed competence in a more realistic manner: they perceived themselves as getting less competent. As already stressed in a number of studies, self-assessment is very inaccurate, even for confirmed physicians (Davis et al. 2006). In addition, poorly competent people tend to overestimate their test performance and skills (Kruger & Dunning 1999; Eva et al. 2004; Davis et al. 2006). Self-assessment needs to be informed through learning and assessment activities and from external sources (Sargeant et al. 2010, 2011). Thus, we propose that our setting likely helped to inform the self-assessment of unaware students. This was one goal of our teaching intervention, and may also have helped students be more receptive to learning from their clinical experiences with BBN. Our study had several limitations. We used a Frenchtranslated version of the six-item questionnaire on attitudes towards BBN (De Valck et al. 2001). Despite a back-translation and verification, we did not go through with the whole validation process for the French version of the questionnaire. This is often true for translated questionnaires used in a different cultural context. It was, however, reassuring that the factorial analysis was similar when the questionnaire was administered after the teaching intervention. As for any negative results (absence or very modest change in ethical attitudes), it could be argued that this instrument could not capture potential changes. Further studies are required to explore the possibility of small effects, and qualitative analysis of our students’ open comments will help to assess this. Our setting also presents several weaknesses. We used a single SP scenario and did not have a control group. We report selfassessed competence, and any change in perceived competence should be verified through an external assessment (see e.g. Schildmann et al. 2012). Students answered questionnaires during ethical teaching sessions, which could constitute a bias towards more attention to ethical aspects.
Conclusion Our findings suggest that an SP-based intervention was part of an effective longitudinal strategy in teaching communication skills and ethical attitudes towards truth-telling. 258
This intervention led to an overall increase in students’ reported comfort and competence in BBN. This, however, was not true of all students as those reporting the greatest comfort and competence prior to the seminar seemed to enter a reflective process and re-evaluated their presumed competence in a more realistic manner. Ethical attitudes towards truth-telling remained stable throughout the study. This is reassuring in a context where other studies identify erosion of moral reasoning and empathy in general, and erosion of attitudes towards truth-telling specifically. Our findings suggest that such an intervention, which integrates the practice of communication skills and ethical reflection in a realistic situation, might allow students not only to develop new skills, but also to increase their awareness about the difficulties and challenges raised by a situation of BBN. This study needs to be refined by a qualitative analysis of students’ ethical concerns on truth-telling and how they evolve with the intervention.
Acknowledgements We would like to thank all the facilitators who were involved in this SP teaching intervention, all medical students who participated in the study and the SPs for their appreciated contribution to teaching. This research was conducted while Carine Layat Burn was an SP trainer and a research assistant at the Unit of Development and Research in Medical Education, Geneva University Medical School. Declaration of interest: Samia Hurst was supported by a grant from the Swiss National Science Foundation (PP00P3-123340). The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Notes on contributors CARINE LAYAT BURN, PhD, is the Director of the Unit of Educational Innovation with responsibility for simulation-based education at HESAV – University of Health Sciences, Lausanne, Switzerland. She has over 10 years of experience working with simulated/standardised patients (SPs) in medical education and other health professional education. SAMIA HURST, MD, is Professor of Bioethics at Geneva University Medical School in Switzerland and ethics consultant to the Geneva University Hospitals’ clinical ethics committee. Her research focuses on fairness in clinical practice, and the protection of vulnerable persons. MARINETTE UMMEL, MD, JD, is the Lecturer at the Institute for Biomedical Ethics, Geneva University Medical School and at the University Centre of Legal Medicine, Lausanne-Geneva. BERNARD CERUTTI, PhD, MPH, is a Statistician at the Faculty of Medicine and Associate Member of the Research Center for Statistics, University of Geneva, and consultant to the Service of Clinical Epidemiology, Geneva University Hospital. ANNE BAROFFIO, PhD, is Senior Researcher at the Unit of Development and Research in Medical Education and Director of the Faculty Development programme at the Geneva University Medical School. She leads research projects related to programme evaluation and faculty development interventions.
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