Annual Workshop for Upper-level Residents: Delivering Bad News in Pediatrics
Setting: Annual day-long educational retreat for 2nd year pediatric residents
Target: Communication skills
Title: How Pediatricians Deliver Bad News
Typical Learner Group: 25-2nd year pediatric residents
Educators: 4-6 attending faculty physician, 1-2 lawyers from the risk management section, 1 psychologist
Time Frame: 2.5 to 3 hours
Typical Term of Participation by Learners: 1 workshop
Description: We have provided this workshop for approximately 6 years. The initial design included the following components: Introduction, Brief Lecture, Video Demonstration (good and bad examples of delivering bad news), Role-Play of Bad News Scenarios, and Plenary Discussion. Evaluations indicated that the lecture and video demonstrations were not considered as helpful as the other components so our current design does not include them.
During the first 30 minutes of the seminar the faculty introduce themselves, describe what they do and why they think the topic is important; we review the structure of the workshop and the learning targets; and residents are assigned to two break out groups for role play. We then spend at least 90 minutes in role-play of 3-4 types of bad news scenarios. Examples of the cases include:
- Disclosure of a difficult diagnosis (CF)
- Disclosure of a difficult diagnosis (Ambiguous Genitalia)
- Disclosure of an adverse outcome (With hostile parent reaction)
- Negotiation of DNAR (Patient well known by physician)
Faculty begin by explaining the basic principles of role playing. Most scenarios involve 2 volunteers. Before each scenario begins the faculty take the volunteers out of room and coach them about their character and the scenario. Each role player is given a different script – usually one for a physician and one for a parent. Just before the role play begins one of the faculty will prepare the audience/participants for the upcoming scenario by giving just enough background to the case for the participants to appreciate the context of the interactions. Faculty will limit role-play to 5-7 minutes and discussion period to 15; after each role-play the faculty debriefs actors first then opens it up to reactions from audience. The role of the physician is usually the more difficult role, so it is advisable to debrief the resident taking this role first, then the parent(s) role(s). The faculty should remind the audience that the volunteers are playing a role and that comments should be about the role, not about the resident who took the role.
During the discussion faculty should try to pose variations on the conditions of each scenario to broaden the applicability of principles articulated in the discussion and ensure coverage of all of the learning objectives. For example the terminal condition scenario below features a child with a chronic condition who is well known to the physician. Faculty could ask how the residents might think their way through the circumstances of a sudden death of a child who is not known by the physician.
A one-year follow up survey indicated that residents frequently encountered these types of situations and that the workshop experience was useful in managing the situations (81-87% agree or strongly agree on all dimensions).