Breaking Bad News

Last Monday, I had my Breaking Bad News OSCE (objective structured clinical exam). In a roleplaying scenario, I had to tell a person that the cancer he or she had had spread, and was not cureable.

Obviously, breaking bad news happens in every medical field. It can be telling a person with diabetes that they will have to lose a limb, or it can be telling someone they are having a heart attack. Informing parents that their child might not be the way they had thought. And yes, telling someone they have cancer.

In these situations, there isn’t any particular biomedical work to be done. This is a time to simply be present with the person, and help them live through the moment. Mercifully, I and my class were not just thrown into the scenario unprepared.

We had a lecture focussed on this OSCE, and about two years of Patient-Centred Care courses, some of which hopefully rubbed off. Specifically, we were trained in the communication theory made known by the late and very, very great Dr. Robert Buckman.

I have to put in a quick aside about Dr. Buckman, although I never met him. I had heard his voice before on an episode of CBC’s White Coat, Black Art, but it was only after the breaking bad news lecture that I realized the protocol developer and this voice were made by one and the same person. Alas, he his now gone, and I regret that I never got the opportunity to meet him in person. The night before the BBN OSCE, I “studied” by watching interviews of Dr. Buckman on Youtube, and I truly believe that small a contact with this magnanimous man helped me perform well in the OSCE. Dr. Brian Goldman wrote a beautiful and poignant eulogy that describes Dr. Buckman far better than I ever could.

After the quite indirect tutelage of Dr. Buckman, I felt ready for the encounter.  I didn’t have the usual OSCE nerves, at least not until I walked past the sign saying “Second year OSCE proceed to holding room” notice. Then I felt energized. Ready to act and react.

We lined up in chairs as we always do, with identifying stickers pre-loosened to give to the preceptor. The door to the hall opened, and we marched in single file, to our assigned rooms (and they are assigned by a huge letter, so that it’s very difficult to make a mistake). We read the stub, making the occasional frantic note, until the buzzer sounded, commanding us to knock and enter.

Sticker goes to preceptor. At the same time, pretend you’re not doing that and introduce self to patient. Sanitize hands, shake, sit down. Off we go. Until the buzzer.

I have to admit that OSCEs seem very dependent on the attitude of the preceptor marking, and the standardized patient. (A standardized patient is an actor who is well, rather than a patient with findings). Luckily for me, I had both a lovely preceptor and a lovely standardized patient. I was able to listen, work with the patient through the story so far, check in that it was okay for me to continue the plot. The news was bad, and earthshaking; my standardized patient played it very well, and I could feel the energy in the room crash.

However, I did not let the patient get lost in his or her shock. I am pleased, and a little proud, to say that I was there and I helped. I know I did well because the feedback I received was very positive.

The specific method I used is outlined in this preview for one of Dr. Buckman’s informational DVDs; I won’t try to make it clear in tedious print.

 

What is great about skill sets like these is that they pretty much always work. Even if they are used on someone who knows the protocol, it will still help that person. Having been stressed out while I worked for a walk-in distress centre, I can attest firsthand to their efficacy, and I don’t think I do a disservice to make this information more public.

Having a skill set to use should not be confused with not caring about the person you or I are helping. As I have learned, skills such as the SPIKES protocol described in the video are just tools that enhance the practitioner’s innate, unstructured want to help. I will probably blog in greater detail about this in the future.

Overall, I am glad that this was a positive experience. When I have to do this for real, I will think back to this feeling I have of having helped someone through a hard time, rather than “the time I totally put my foot in my mouth and was a nasty person.” That would make a hard time even harder, for the patient and for myself.

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