See, reflect, learn more: qualitative analysis of breaking bad news reflective narratives.

CONTEXT: Breaking bad news (BBN) is a challenge that requires multiple professional competencies. BBN teaching often includes didactic and group role-playing sessions. Both are useful and important, but exclude another critical component of students' learning: day-to-day role-model observation in the clinics. Given the importance of observation and the potential benefit of reflective writing in teaching, we have incorporated reflective writing into our BBN course. The aim of this study was to enhance our understanding of the learning potential in reflective writing about BBN encounters and the ability to identify components that inhibit this learning. METHODS: This was a systematic qualitative immersion/crystallization analysis of 166 randomly selected BBN narratives written by 83 senior medical students. We analysed the narratives in an iterative consensus-building process to identify the issues discussed, the lessons learned and the enhanced understanding of BBN. RESULTS: Having previously been unaware of, not invited to or having avoided BBN encounters, the mandatory assignment led students to search for or ask their mentors to join them in BBN encounters. Observation and reflective writing enhanced students' awareness that 'bad news' is relative and subjective, while shedding light on patients', families', physicians' and their own experiences and needs, revealing the importance of the different components of the BBN protocol. We identified diversity among the narratives and the extent of students' learning. DISCUSSION: Narrative writing provided students with an opportunity for a deliberative learning process. This led to deeper understanding of BBN encounters, of how to apply the newly taught protocol, or of the need for it. This process connected the formal and informal or hidden curricula. To maximise learning through reflective writing, students should be encouraged to write in detail about a recent observed encounter, analyse it according to the protocol, address different participants' behaviours and emotions, and identify dilemmas and clear lessons learned.

The hidden curriculum of breaking bad news: Identification of three dimensions and four communication patterns.

OBJECTIVES: To explore students' observations in the hidden curriculum of physicians' breaking bad news interactions and identify dimensions and patterns within them. METHODS: We qualitatively analyzed 156 written narrative descriptions of bad news encounters in the clinics written by senior medical students. RESULTS: The analysis identified three dimensions within the encounters: providing information, dealing with emotions, and discussing treatment plans. These dimensions were observed in different proportions, identifying four communication patterns. Half of the encounters focused solely on presenting a treatment plan. Within them, the news was communicated abruptly while neglecting to share information or address emotions. CONCLUSIONS: Compared to the main literature on breaking bad news that focuses on two dimensions-the present study identified a third, prominent dimension-discussing the treatment plan. Half of the hidden curriculum experiences contradict the taught protocol, paying little/no attention to emotion and information. PRACTICE IMPLICATIONS: When teaching breaking bad news, it is essential to address the day-to-day practices students' observe. Students exposed to these encounters might misinterpret the physician's reliance on a single dimension as best practice. To mitigate this and help recognize their and others' tendency to focus primarily or solely on one dimension, we suggest a simple reflective prompt.

The associations between reflective ability and communication skills among medical students.

OBJECTIVES: Assess associations between medical students' reflective ability demonstrated in written narratives, and communication skills demonstrated later in simulated-patient breaking bad news interactions. METHODS: We analyzed 66 medical students' reflective ability, using 'REFLECT' rubric and four newly developed parameters: Noticing Explanations provided to patients, Noticing Emotions, Remoteness/Connectedness in their writing, and mentioning Self-Emotions. 'BAS' and 'SPIKES' questionnaires measured students' communication skills. Spearman and Chi-square tests examined correlations among all variables. Multiple regressions examined associations between reflective ability and demographic variables with communication skills. RESULTS: Significant positive correlations between students' reflective ability, measured by REFLECT and three of the new parameters, and global communication skill scores. Reflective ability of Noticing Explanations in writing was associated with ability to tailoring information to patients' needs and address emotions. CONCLUSIONS: High reflective ability may improve communication skills. Specifically, ability to notice explanations to patients may enhance later capability to tailor information to patients and address emotions empathically. PRACTICE IMPLICATIONS: Encourage educational interventions enhancing reflective ability; specifically observation and detailed writing about how explanations are given to patients and patients' reactions to them. This process may help students develop competency to share and tailor difficult information sensitively-a critical skill when communicating bad news.

Near-fatal myocarditis complicating typhoid fever in a traveler returning from Nepal.

We report a 27-year-old traveler who returned from Nepal suffering from typhoid fever. His disease was complicated by life-threatening myocarditis and ventricular fibrillation, a rare manifestation in travelers.