Abstract
We describe a half-day workshop to teach third-year medical students three focused end-of-life care skills: breaking bad news, discussing advance directives, and assessing and managing pain. Our workshop included a readers’ theater exercise and three role-play exercises. In two of the workshops, faculty members played the role of patients. We used readers’ theater to engage the students on an emotional level and set a reflective tone for the workshop. Evaluations reflected that most respondents felt that the workshop enhanced their understanding and ability to address these skills with patients. By 6 months, many students reported applying these skills to patient care in a way they thought was effective.
Keywords: palliative care, teaching methods, curriculum, education, medical
Medical educators are increasingly recognizing the importance of education about end-of-life care, and are calling for improvement in this area.1–3 There is evidence that deficits in end-of-life training and education have negative consequences for both patients and physicians. For example, poor physician communication can affect patients' satisfaction and psychosocial adjustment.4 Furthermore, physicians' perception of the adequacy of their training in palliative care management and communication is associated with a physicians' own adjustment.5 In spite of this, many physicians do not receive formal training in key communication and management skills that are essential for end-of-life care, such as treating pain or breaking bad news,6,7 and many medical students and physicians do not feel adequately prepared for these important tasks.8–11
Educational innovations to improve end-of-life care must not only teach knowledge and skills, they should foster an attitude of caring and compassion. Students engaged in such efforts must be willing to reflect on their own communication style and their own emotional reactions to such encounters. A safe environment for exploring emotionally charged issues is important to the success of such educational endeavors.12
We set out to create a learning experience that would meet the following goals: 1) to educate the entire third-year class, which is usually divided among different hospitals on their clinical clerkships, on 3 skills necessary for end-of-life care; 2) to employ active learning techniques that would allow students to practice essential skills; and 3) to teach a complex set of patient-centered communication skills, including active listening, expressions of empathy, and responses to strong emotions.
Description
The workshop was designed by a core group of faculty, the End-of-Life Curriculum Team. The team formed when the dean of the school of medicine determined the need for better end-of-life care and requested that the group plan a curriculum to include interventions throughout the 4 years of medical school. To date, we have developed and implemented curricula for medical students in years 1 through 3. During year 1, the curriculum includes 6 required half-day sessions and 4 elective sessions in a local hospice, and focuses on learning to build a relationship with a patient who is dying. During the second year, the curriculum focuses on advanced interviewing and communication skills with dying patients, and consists of 2 half-day exercises that include role-play demonstration and practice.
The third year, as described in this paper, is devoted to skills for end of life care. To introduce these skills, we developed a required half-day workshop for all third-year medical students, which was held for the first time in February 2003. This took place on an “interclerkship day,” in which the entire third-year class is brought together to teach skills that are essential for clinical training but may not be addressed by any one required clerkship. Educational methods used in our workshop included: a readers’ theater exercise13 to set a reflective tone for the day; the use of faculty playing the role of patients; and an extended role-play exercise using a standardized patient to teach about pain management. A small group format with focused faculty mentoring provided the opportunity to create a safe learning environment for such exercises. Faculty were encouraged to help the students succeed in the exercise, through the use of feedback and coaching.
The workshop was required for 108 third-year medical students. The class was divided in two by alphabet, with half of the students in a morning session and half in the afternoon. Within each half-day session, students met in a large group for the readers’ theater exercise and brief (15-minute) didactic lectures about advance directives and breaking bad news. We recruited a total of 13 additional faculty, composed of 1 clinical ethicist, 11 faculty physicians from the school of medicine with an interest in palliative care and patient-doctor communication (3 general internists, 3 geriatricians, 2 hospitalists, 2 family physicians, 1 emergency physician, and 1 chief resident), and 1 physician from the community who was the medical director of a hospice. Each faculty member conducted the same exercise several times, with students rotating between exercises.
Faculty Development
Prior to the workshop day, 9 of the 13 workshop faculty participated in a 1-day faculty development course led by the End-of-Life Curriculum Team. This involved an overview of the end-of-life curriculum at our institution, a writing exercise in which participants wrote about and discussed their own experiences with death, and the opportunity to participate in the role-play exercise that they would be leading.
Readers’ Theater
Readers’ theater involves the use of a script that depicts a short story or other text. It is performed without props or sets, and actors usually sit rather than move around the stage. In medical settings, scripts that illustrate some aspect of a patient's experience or the patient-doctor relationship can be a powerful way to engage learners and to begin a dialogue about these experiences.13
In our readers’ theater exercise, fourth-year medical students were recruited ahead of time to act as readers. They had one rehearsal, and then performed in front of the rest of the workshop group (approximately 55 students). One of our faculty (KK) adapted a short story by Lorrie Moore, about the diagnosis and treatment of an infant with Wilm's tumor told from the mother's perspective.14 For our workshop, faculty members led a discussion that focused on the students’ reactions to the story and how the characters’ behavior related to their own images of physicians and their communication with families.
Pain Management Role Play
This exercise was conducted with groups of 12 to 16 students, and was led by a faculty member who is a clinical oncologist (WE) and experienced in the clinical management of pain. In order to teach both the pharmacologic aspects of pain management and the communication aspects of caring for a patient in pain, we developed an extended role-play exercise in which three students had the opportunity to interview a standardized patient with cancer pain. Each student conducted an interview at a different point in her care.
At each step, the student was given the general goals of showing concern and empathy for the patient and assessing her pain. Specific learning goals for each encounter included choosing appropriate pain medications and doses, converting intravenous to oral formulations, and considering the treatment of side effects such as constipation. Following each interview, the faculty member led a discussion about appropriate management, and provided necessary information about medications, doses, and side effects. The faculty member sought to actively involve the other students in the exercise by soliciting suggestions for management and feedback on the student interviews.
Breaking Bad News Role Play
After reviewing the literature,9,15,16 we developed a 3-step process for breaking bad news (see Table 1). This process included communication skills for building the patient-doctor relationship.17 Each student was provided with a handout and a laminated pocket card that outlined the steps. In this role play, the faculty preceptor played the roles of a man returning for the result of a lung biopsy that reveals cancer and then a woman who finds out she has malignant melanoma. A faculty member worked with four students during this exercise. Each student conducted one phase of the breaking bad news discussion and was given feedback immediately after. Specific learning goals included demonstrating the 3-step process for breaking bad news and demonstrating emotion-handling skills such as expressions of empathy and partnering with the patient.
Table 1.
Instructions for Discussions About Breaking Bad News and Advance Directives
| Breaking Bad News |
| 1. Preparation and Delivery of News |
| A. Ask permission to talk |
| B. Ask about patient's understanding of the problem |
| C. Determine how much patient knows |
| D. Determine how much patient wants to know |
| E. Preparation: “I am afraid I have some bad/difficult news” |
| F. Deliver the news, no medical jargon |
| 2. Patient's Response to Difficult/Bad News |
| A. Allow time for patient to hear the news and react |
| B. Check to be sure patient understood |
| C. Respond to patient's emotions |
| D. Explore patient's concerns |
| E. Explore the meaning of news to patient |
| 3. Plan for the Next Steps |
| A. Offer support to the patient |
| B. Ask whether patient wants more information about diagnosis and prognosis |
| C. Make a plan for follow-up and referral |
| D. Tell patient you will stick with them |
| Advance Directives |
| 1. Opening the End-of-Life/Advance Directive Discussion |
| A. Ask permission to talk |
| B. Ascertain the patient's understanding of the disease |
| C. Ask about patient's emotional state |
| D. Introduce the topic |
| E. May need to reassure patient that you are not raising these issues because he/she is about to die now |
| 2. Assess Patient Preferences Regarding End-of-Life Care |
| A. Explain treatment options at the end of life |
| B. Gain a deep understanding of patient preferences |
| 3. Critical Steps to Creating an Advance Directive |
| A. Identify patient preferences |
| B. Identify surrogate decision maker(s) |
| C. Plan to communicate with surrogate decision maker(s) regarding preferences |
| D. Plan to communicate with health care providers regarding preferences |
| E. Document preferences and surrogate decision maker(s) |
| F. Offer resources/referrals for patient |
| 4. Supportive Closing |
| A. Emphasis on active and engaged supportive care of patient |
| B. Arrange follow-up |
Role-play techniques have been used with success in workshops addressing end-of-life issues with attending physicians18 and residents.19 We could find few published reports of other educational exercises in which faculty play the role of the patient.20,21 This approach is economically feasible for a large class of students who are working in small groups and allows the patient to be played by someone who is very familiar with the clinical presentation and concerns of typical patients, creating a realistic role player. Additionally, the faculty member remains in control of the direction of the role play, and can be sure that key issues arise.
Advance Directives Role Play
We developed a 4-step process for conducting a discussion of advance directives (see Table 1) and provided students with a handout and a card outlining the steps. The faculty physician again portrayed the same patient with lung cancer at a later stage in his disease. Each of four students conducted one portion of the discussion. Learning goals included demonstrating the 4-step process for discussing advance directives and demonstrating an understanding of advance directive documents through explanation to the patient.
EVALUATION
Evaluation Methods
Students completed surveys at the end of the workshop session, and again 6 months later. The survey given immediately after the session assessed each of the individual exercises. The 6-month follow-up evaluation focused on the students’ experiences using these skills in the care of patients.
Course Evaluation
Response rates for the first evaluation were 60 of 108. Overall, 20 responders (37%) rated the course as excellent and 30 (56%) rated the course as good. Fifteen responding students (25%) strongly agreed and 33 (55%) agreed that the reader's theater exercise enhanced the introduction to the course.
The majority of responding students agreed or strongly agreed that the different aspects of the course enhanced their understanding of how to address these topics with patients and how to build a relationship with a patient (see Table 2).
Table 2.
Course Evaluation (N = 60)*
| Question | SA | A | D | SD | M† |
|---|---|---|---|---|---|
| The reader's theater enhanced the introduction to the course | 15 | 33 | 9 | 2 | 1 |
| I would recommend reader's theater to future classes | 14 | 34 | 9 | 2 | 1 |
| Advance Directives | Breaking Bad News | Pain Management | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SA | A | D | SD | M | SA | A | D | SD | M | SA | A | D | SA | M | |
| This role-play exercise enhanced my understanding of (this skill) | 24 | 33 | 1 | 1 | 1 | 23 | 34 | 1 | 1 | 1 | 41 | 18 | 1 | 0 | 0 |
| This role-play exercise enhanced my understanding of how to build a relationship with a patient | 16 | 40 | 1 | 1 | 2 | 16 | 40 | 2 | 1 | 1 | 29 | 29 | 1 | 1 | 0 |
| This session provided me with practical information for caring for patients | 23 | 34 | 1 | 1 | 1 | 15 | 41 | 2 | 1 | 1 | 39 | 20 | 1 | 0 | 0 |
| Patient, preceptor, and fellow classmate feedback was very helpful | 25 | 33 | 0 | 1 | 1 | 27 | 29 | 1 | 2 | 1 | – | – | – | – | – |
| I feel prepared to address (this skill) with a patient | 12 | 44 | 3 | 0 | 1 | 10 | 44 | 5 | 0 | 1 | 18 | 34 | 7 | 0 | 1 |
| My faculty leader was an effective teacher | 33 | 26 | 0 | 0 | 1 | 32 | 25 | 1 | 1 | 1 | 40 | 18 | 1 | 0 | 1 |
| I would recommend this session | 23 | 35 | 0 | 1 | 1 | 21 | 36 | 1 | 1 | 1 | – | – | – | – | – |
Blanks reflect questions that were not asked regarding that particular exercise.
SA = strongly agree, A = agree, D = disagree, SD = strongly disagree, M = not applicable or data missing.
Perceived Skills and Knowledge
For the 6-month follow-up, 58 of 108 students responded. A majority of respondents felt prepared to address these issues with a patient. Twenty-one (36%) had discussed advance directives, 22 students (46%) had broken bad news, and 34 students (59%) had addressed pain issues. The majority of students agreed that the advance directives and breaking bad news workshops prepared them for the clinical skill (see Table 3).
Table 3.
Six-month Follow-up (N = 58)*
| Question | Advance Directives | Breaking Bad News | Pain Management |
|---|---|---|---|
| Since the session, I have addressed this topic with a patient | |||
| Yes | 21 | 27 | 34 |
| No | 35 | 28 | 16 |
| Missing | 2 | 2 | 8 |
| SA | A | D | SD | M† | SA | A | D | SD | M | SA | A | D | SD | M | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| If Yes: | |||||||||||||||
| This session was helpful in preparing me to address (this topic). | 1 | 14 | 3 | 1 | 2 | 6 | 18 | 1 | 1 | 1 | – | – | – | – | – |
| I was able to explain (the topic) in terms the patients could understand. | 6 | 15 | 0 | 0 | 0 | 6 | 20 | 0 | 0 | 1 | – | – | – | – | – |
| I was able to help the patient make decisions about advance directives. | 1 | 18 | 0 | 0 | 2 | – | – | – | – | – | – | – | – | – | – |
| I was able to provide empathy and support to the patient. | – | – | – | – | – | 8 | 18 | 0 | 0 | 1 | 4 | 26 | 4 | 0 | 0 |
| I was able to adequately assess the patient's pain. | – | – | – | – | – | – | – | – | – | – | 5 | 28 | 1 | 0 | 0 |
| I was able to treat the pain effectively. | – | – | – | – | – | – | – | – | – | – | 6 | 22 | 6 | 0 | 0 |
| If No (circle all that apply): | Number | Number | Number | ||||||||||||
| I have not treated a patient for whom the issue has arisen. | 21 | 17 | 8 | ||||||||||||
| Other members of the team addressed the issue. | 10 | 7 | 7 | ||||||||||||
| I am not comfortable addressing the issue. | 4 | 0 | 0 | ||||||||||||
| Other | 3 | 1 | 0 | ||||||||||||
Blanks reflect questions that were not asked regarding that particular exercise.
SA = strongly agree, A = agree, D = disagree, SD = strongly disagree, M = not applicable or data missing.
Other responses reflected that students who had addressed any of these issues with a patient generally felt that they were able to meet essential goals of the encounter (see Table 3).
DISCUSSION
Our goal was to create a half-day workshop that introduced students to key communication and clinical skills related to end-of-life care. We accomplished our objectives by using a small group format, a rotating schedule with repeating sessions on each topic, a readers’ theater exercise, and role-play exercises. We used the readers’ theater exercise to engage the students on an emotional level through the use of a patient's story. Although we did not directly compare readers’ theater to other techniques such as trigger videos or demonstration role plays, we hypothesize that an adapted short story engages people on a deeper emotional level because it involves an extended narrative. Gaining a deep understanding of patients' experience through narrative has been increasingly recognized as a component of good medical practice.22 Although readers’ theater has been used as a part of medical conferences or workshops in other settings (Todd Savitt, personal communication, January 16, 2004), we are unaware of other publications that assess student reaction to the exercise. Our evaluations reflect the experience of other educators who have found that role play can be a useful way to teach about psychosocial and emotional aspects of care,23 communication skills,24 and specific tasks involved in end-of-life care,7,12,18,25 and add to the limited literature on using faculty as role players20,21 by demonstrating that responding students thought such exercises enhanced their understanding and skills.
Our workshop has several limitations. First, our evaluation is preliminary. We did not objectively assess knowledge, attitudes, or skills, and our evaluation design was posttest only without a control group, limiting our ability to conclude that there were changes in any of these areas. Second, our response rates of 50% to 60% raise the possibility of selection bias in responses. Third, we did not specifically elicit student assessments of the faculty role plays. It is possible that students may have felt intimidated by role playing with faculty and that this may have inhibited learning. Fourth, two of our role-play exercises allowed each student the opportunity to participate, but the pain management exercise did not. This exercise may have had less of an impact on those students who did not play an active role. Finally, this workshop is not a complete curriculum in itself. It was designed as one part of an overall approach to teaching end-of-life care that recognizes the importance of a multilevel, multimethod approach to teaching and reinforcing knowledge, attitudinal, skill, and performance objectives.
Not withstanding these limitations, we have demonstrated that it is feasible to integrate into an interclerkship curriculum a well-conceived half-day workshop that addresses specific end-of-life skills and that incorporates multiple learning strategies, such as readers’ theater, role-play, and standardized patient exercises. It is encouraging that respondents viewed the workshop favorably, and felt their knowledge and ability to address specific end-of-life skills were improved. Most importantly, a substantial percentage reported using these skills with patients during the subsequent 6 months, in ways they felt were effective.
Acknowledgments
This project was supported by a grant from the Courts Foundation, Atlanta, Ga. We wish to thank Tanisha J. Sullivan, BA for coordinating the workshop.
REFERENCES
- 1.Billings JA, Block S. Palliative care in undergraduate medical education: status report and future directions. JAMA. 1997;278:733–8. [PubMed] [Google Scholar]
- 2.Field MJ, Cassel CK. Approaching Death: Improving Care at the End of Life. Institute of Medicine Report. Washington, DC: National Academy Press; 1997. [PubMed] [Google Scholar]
- 3.Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18:685–95. doi: 10.1046/j.1525-1497.2003.21215.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Butow PN, Kazemi JN, Beney LJ, Griffin LJ, Dunn SM, Tattersall MH. When the diagnosis is cancer: patient communication experiences and preferences. Cancer. 1996;77:2630–7. doi: 10.1002/(SICI)1097-0142(19960615)77:12<2630::AID-CNCR29>3.0.CO;2-S. [DOI] [PubMed] [Google Scholar]
- 5.Ramirez AJ, Graham J, Richared MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer. 1995;71:1263–9. doi: 10.1038/bjc.1995.244. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Foley KM. Competent care for the dying instead of physician assisted suicide. N Engl J Med. 1997;336:54–8. doi: 10.1056/NEJM199701023360109. [DOI] [PubMed] [Google Scholar]
- 7.Novack CH, Volk G, Drossman DA, Lipkin M. Medical interviewing and interpersonal skills teaching in US medical schools. Progress, problems and promise. JAMA. 1993;269:2101–5. [PubMed] [Google Scholar]
- 8.Charlton R, Ford E. Education need is in palliative care. Fam Pract. 1995;12:70–4. doi: 10.1093/fampra/12.1.70. [DOI] [PubMed] [Google Scholar]
- 9.Fallowfield L. Giving sad and bad news. Lancet. 1993;341:476–8. doi: 10.1016/0140-6736(93)90219-7. [DOI] [PubMed] [Google Scholar]
- 10.Frankel RM, Speice J, Branca L, et al. Oncology providers’ and patients' experience with communication problems. Proc Am Soc Clin Oncol. 1997;16:45a. [Google Scholar]
- 11.Rappaport W, Witzke D. Education about death and dying during the clinical years of medical school. Surgery. 1993;113:163–5. [PubMed] [Google Scholar]
- 12.Pan CX, Soriano RP, Fischberg DJ. Palliative care module within a required geriatrics clerkship: taking advantage of existing partnerships. Acad Med. 2002;77:936–7. doi: 10.1097/00001888-200209000-00042. [DOI] [PubMed] [Google Scholar]
- 13.Savitt Todd L. Medical Readers’ Theater: A Guide and Scripts. Iowa City: University of Iowa Press; 2002. [Google Scholar]
- 14.Moore L. People like that are the only people here: canonical babbling in peed onk. 1998. In Birds of America. Knopf. [DOI] [PubMed]
- 15.Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press; 1992. [Google Scholar]
- 16.Ptacek JT, Eberhardt TL. Breaking bad news: a review of the literature. JAMA. 1996;276:496–502. [PubMed] [Google Scholar]
- 17.Cole SA, Bird J. Medical Interviewing: The Three-Function Approach. St. Louis: Mosby; 2000. p. 1991. [Google Scholar]
- 18.Baile WF, Kudelka AP, Beale EA, et al. Communication skills training in oncology: description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer. 1999;86:887–97. [PubMed] [Google Scholar]
- 19.Serwint JR. The use of standardized patient in pediatric residency training: anatomy of a standardized patient case scenario. J Palliat Med. 2002;5:146–53. doi: 10.1089/10966210252785123. [DOI] [PubMed] [Google Scholar]
- 20.Benbassat J, Baumal R. A step-wise role playing approach for teaching patient counseling skills to medical students. Patient Educ Couns. 2002;46:147–52. doi: 10.1016/s0738-3991(01)00150-1. [DOI] [PubMed] [Google Scholar]
- 21.Littlefield JH, Hahn HB, Meyer AS. Evaluation of a role-play learning exercise in an ambulatory clinic setting. Adv Health Sci Educ. 1999;4:167–73. doi: 10.1023/A:1009789110719. [DOI] [PubMed] [Google Scholar]
- 22.Charon R. The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286:1897–902. doi: 10.1001/jama.286.15.1897. [DOI] [PubMed] [Google Scholar]
- 23.Mann BD, Sachdeva AK, Nieman LZ, Nielan BA, Rovito MA, Damsker JI. Teaching medical students by role playing: a model for integrating psychosocial issues with disease management. J Cancer Educ. 1996;11:65–72. doi: 10.1080/08858199609528398. [DOI] [PubMed] [Google Scholar]
- 24.Knowles C, Kinchington F, Erwin J, Peters B. A randomized controlled trial of the effectiveness of combining video role play with traditional methods of delivering undergraduate medical education. Sex Transm Infect. 2001;77:376–80. doi: 10.1136/sti.77.5.376. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Schmidt TA, Norton RL, Tolle SW. Sudden death in the ED: educating residents to compassionately inform families. J Emerg Med. 1992;10:643–7. doi: 10.1016/0736-4679(92)90155-m. [DOI] [PubMed] [Google Scholar]