#KeyLIMEPodcast 168: Good news about bad news – see one, reflect on one, learn more

On this week’s KeyLIME episode, Linda grapples with some big questions: How did you learn to break bad news (BBN)? Do you do it well? BBN is a challenging task even for experienced practicing physicians, even more so for trainees. Read on, and check out the podcast here (or on iTunes!)


KeyLIME Session 168:

Listen to the podcast.

Read the episode abstract here.

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Karnieli-Miller, O. Palombo, M. Meitar, D See, Reflect, Learn more: Qualitative Analysis of Breaking Bad News Reflective Narratives Medical Education 2017. [ePub ahead of print]

Reviewer: Linda Snell (@LindaSMedEd)


How did you learn to break bad news (BBN)? Do you do it well? BBN is a challenging task even for experienced practicing physicians, even more so for trainees.

Training is needed – the SPIKES framework can help frame training, which is often a combo of providing knowledge and enhancing skills.

S = Setting: Arranging the setting where bad news is delivered—a quiet room with privacy and enough time to deliver the news with as few interruptions as possible

P = Perception: Assessing the patient’s perception and what s/he already knows about his/her medical situation

I = Invitation: Obtaining the patient’s invitation to receive the news; establishing how much information the patient wants to hear and how it should be delivered

K = Knowledge: Deliver knowledge—the information—about the bad news, with explanations consistent with the patient’s level of comprehension, questions, and needs

E = Emotion & empathy: Addressing the emotions that arise and empathically supporting the patient and family throughout the encounter.

S = Strategy & summary: Outlining strategy and summary——at the end of the encounter

However, these do not address students’ everyday learning experiences in their clinical rotations―the hidden curriculum, which is ‘a powerful determinant of future physicians’ conceptions of desired behaviors and values that do not necessarily follow and sometimes contradict the formal, taught curriculum.’ Students need time and focus to reflect on these, one way is via reflective writing. Authors list potential benefits of RW.

The authors med school has a 20 hour BBN course for senior students – didactic + role play practice + reflective discussions, to which they added attendance at a minimum of two real-life BBN encounters, then writing reflective narratives with reference to these encounters. Students instructed to (1) Describe the BBN experience (2) Analyze the encounter according to the SPIKES protocol, (3) Reflect on thoughts and feelings that arose during and following the encounter, and (4) Reflect on future actions and lessons learned.


“to enhance our understanding of the learning potential in reflective writing about BBN encounters and the ability to identify components that enhance or inhibit this learning”

Key Points on Method

Qualitative analysis of randomly selected BBN mandatory reflective de-identified narratives from 83 final year med students enrolled in the described BBN course Immersion-Crystallization method of analysis:

  • ‘immersion – a process whereby researchers immerse themselves in the data they’ve collected by reading or examining some portion of the data in detail;
  • crystallization – is the process of temporarily suspending the process of examining or reading the data (immersion) in order to reflect on the analysis experience and attempt to identify and articulate patterns or themes noticed during the immersion process
  • These dual processes continue until all the data have been examined and patterns and claims emerge from the data that are meaningful and can be well articulated and substantiated’  

Key Outcomes

166 narratives, 54 F, 36 M students; a variety of settings, specialties, patient age

45% positive role model, 37% negative role model, 15% mixed, 8% unclear

Learning benefits and factors that enhance:

  • in-depth description of encounter
  • usefulness of SPIKES components and application to real life
  • importance of considering all parties’ perspectives and emotions
  • importance of reflection for lessons learned
  • inhibitors of learning
  • no specific encounter
  • no use of SPIKES
  • description of encounter from only 1 perspective


Key Conclusions

The authors conclude that there are benefits of attending, observing, and reflective writing about real-life BBN encounters. Bridges real life observations (hidden curriculum) and what is learned in formal curriculum; learning from both + & – experiences via reflection.

Requirement to analyze and reflect using framework enhanced rest of 20h course, and enhanced student understanding of applicability

Authors suggest ways to improve BBN courses and instructions to students re RW

Spare Keys – other take home points for clinician educators

Can we enhance reflection?

Type of Paper

Research: qualitative methodology

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