Physicians work with actors to get better at breaking bad news

The patient is stunned, then furious. “A mistake? You made a mistake?” he thunders, before breaking down in ragged sobs.

The surgeon, a urology resident, has just told his patient that the pathology report indicating no evidence of prostate cancer had been misfiled in “Mr. Smith’s” chart. The patient’s actual report, however, shows aggressive prostate cancer.

The surgeon is shaken and momentarily at a loss for words. This, in spite of the fact that the charts are fictitious and Mr. Smith is an actor. It’s all part of the Ottawa Hospital’s Breaking Bad News, a training program devised by Fraser Rubens, a cardiac surgeon at the University of Ottawa Heart Institute and a professor in U of O’s faculty of medicine.

Dr. Rubens says all physicians will have to deliver some bad news – a death, a mistake, a surgical slip – and the delivery can affect overall patient outcomes. He acknowledges the perception that surgeons tend to lack empathy in their interactions with patients and patients’ families. This led to the idea of putting surgical residents into scenarios with professional actors, using stories culled from patient advocacy groups and files from the Ottawa Hospital.

“It’s really hard but satisfying,” says Ottawa actor John Koensgen who has played numerous roles including half of a pair of warring siblings dealing with their mother’s unexpected death on the operating table and a man mistakenly given a clean bill of health and suddenly facing imminent death. “You have to be ready to respond. You have to make it so believable that the doctors forget it’s an exercise. To me this is a necessary and frankly revolutionary kind of teaching.”

“Despite the fact that they have all this knowledge and all this experience, they still need to be human beings,” he says. “They’re not gods so when things go wrong, they have to be able to empathize and help people deal with the situation.”

The role-play program is among the new ways faculty are implementing the CanMEDS initiative created by the Royal College of Physicians and Surgeons of Canada that focuses on seven overlapping roles of a physician that include medical expert, but also communicator, scholar and health advocate. “When doctors used to be trained, all you were taught was the medical expert part which is about how to put the mitral valve in or how to treat a blood clot in the leg,” says Dr. Rubens.

“If you understand how important it is to look someone in the eye, to get at their level, to appropriately hold their hand, to use the right tone of voice, you can’t help but bring that over into day-to-day dealings with patients,” he says. “Utilizing some of those same behaviours can certainly lead to an improvement in patient compliance and outcome and patient satisfaction. I think every hospital is striving for that.”