S P E C I A L T H E M E A R T I C L E
Teaching Medical Students and Residents Skills for
Delivering Bad News: A Review of Strategies
Marcy E. Rosenbaum, PhD, Kristi J. Ferguson, PhD, and Jeffrey G. Lobas, MD
ABSTRACT
Although delivering bad news is something that occurs
daily in most medical practices, the majority of clinicians
have not received formal training in this essential and
important communication task. A variety of models are
currently being used in medical education to teach skills
for delivering bad news. The goals of this article are (1) to
describe these available models, including their advan-
tages and disadvantages and evaluations of their effective-
D
elivering bad news, a task that occurs in any
medical practice, can be daunting for the clini-
cian. Although it is most often thought of as
communicating about life-threatening illness, the
imminence of death, or communicating about the death of a
loved one to a family member, Bor et al.1 provide a useful and
more inclusive definition of bad news: “. . . situations where
there is either a feeling of no hope, a threat to a person’s
mental or physical well-being, a risk of upsetting an estab-
lished lifestyle, or where a message is given which conveys to
an individual fewer choices in his or her life.” Given this
definition, delivering bad news is something that occurs daily
for most practicing clinicians.
How bad news is delivered can have a significant impact
on patients’ perspective of illness, their long-term relation-
ships with clinicians, and both patient and provider satisfac-
tion.2–5 Several authors have reported that patients had
significantly more distressing feelings toward clinicians they
felt delivered the news in an inappropriate manner.2–5
Dr. Rosenbaum is assistant professor of family medicine and Dr. Lobas is
professor of pediatrics, Roy J. and Lucille A. Carver College of Medicine; Dr.
Ferguson is associate professor of community and behavioral health, College
of Public Health. All are at the University of Iowa, Iowa City.
Correspondence should be addressed to Dr. Rosenbaum, 1204 MEB, Uni-
versity of Iowa College of Medicine, Iowa City, IA 52245; e-mail:
具marcy-rosenbaum@uiowa.edu典.
ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004
ness; and (2) to serve as a guide to medical educators who
are initiating or refining curriculum for medical students
and residents. Based on a review of the literature and the
authors’ own experiences, they conclude that curricular
efforts to teach these skills should include multiple ses-
sions and opportunities for demonstration, reflection, dis-
cussion, practice, and feedback.
Acad Med. 2004;79:107–117.
Practicing physicians and residents have been shown to
lack both confidence and skill in performing this basic
clinical task.6 –9 A number of factors can contribute to this
discomfort, such as feeling responsible for patients’ misfor-
tune, perceptions of failure, unresolved feelings about death
and dying, concerns about patients’ responses to the news,
and clinicians’ concerns about their own emotional responses
to the circumstances.7
Another contribution to low confidence and discomfort in
this task is that the majority of practicing physicians have
reported having received no formal training in effectively
communicating bad news.6,10,11 Thus, until recently, most
practitioners learned to give patients bad news through trial
and error and perhaps by observing role models during their
training. Because negative role models for giving bad news
are common,6 relying on experience and role-modeling may
result in communication patterns that do not meet patient
needs rather than in effective approaches to this task. There-
fore, teaching the skills for delivering bad news increases the
likelihood that physicians will learn how to deliver bad news
effectively.
Much has been written about the skills necessary for
effective delivery of difficult news, including extensive re-
views of the literature and creation of consensus guidelines
for this practice.2,3,7,12,13 In the literature specifically focus-
ing on educational interventions, several useful content
models have been developed and implemented in both un-
107
 SKILLS FOR DELIVERING BAD NEWS,
Table 1
The SPIKES Protocol for Delivering Bad News to Patients*
Step Description of Task
Setting Establish patient rapport by creating an appropriate setting
that provides for privacy, patient comfort, uninterrupted
time, setting at eye level, and inviting significant other(s)
(if desired).
Perception Elicit the patient’s perception of his or her problem.
Invitation Obtain the patient’s invitation to disclose the details of the
medical condition.
Knowledge Provide knowledge and information to the patient. Give
information in small chunks, check for understanding,
and frequently avoid medical jargon.
Empathize Empathize and explore emotions expressed by the patient.
Summary and Provide a summary of what you said and negotiate a
strategy strategy for treatment or follow-up.
*From Baile WF, Kudelka AP, Beale EA, et al. Communication skills training in oncology:
description and preliminary outcomes of workshops on breaking bad news and managing
patient reactions to illness. Cancer. 1999;86:887–97. Baile et al.’s protocol was adapted from
Buckman R. How to Break Bad News: A Guide For Healthcare Professionals. Baltimore: Johns
Hopkins University Press, 1992.
dergraduate and graduate settings. For example, the SPIKES
model (setting, perception, invitation, knowledge, empathy,
summary and strategy) developed by Buckman7 for delivering
difficult news is used in many medical schools (see Table 1).
In this article, we review published reports (based on
Medline searches) of strategies that have been used to teach
effective delivery of bad news to medical students and resi-
dents.* We describe available models and offer our opinions
based on our experiences and on our review of the broader
medical education literature on the advantages and disad-
vantages of each strategy (see Table 2). We also discuss
findings from evaluations of these models. This article pro-
vides a guide to medical educators who are initiating or
refining curriculum for medical students and residents to
learn this essential and important communication task.
Based on our review of the literature, we conclude that,
optimally, any curriculum should include a model for effec-
tive delivery of bad news (e.g., SPIKES), and opportunities
for learners to discuss relevant issues, and practice and
* We limited this review to models of bad news education described in
published articles indexed in Medline. Attention should be drawn to the
availability of descriptions of other models for bad news education in the
End of Life/Palliative Education Resource Center (EPERC) Online Data-
base, managed by the Medical College of Wisconsin. This database (具www.
eperc.org典) provides peer-reviewed descriptions of curricula focused on
delivering bad news and other end-of-life communication skills, and is a
useful resource for persons interested in developing or enhancing education
in these areas.
108 ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004
CONTINUED
receive feedback on their skills. Potential strategies for pro-
viding education in bad-news delivery include lectures,
small-group discussions, role-playing with peers and stan-
dardized patients (SPs), and teaching in the context of
patient care.
STRATEGIES FOR TEACHING SKILLS FOR DELIVERING
BAD NEWS
Didactic Approaches
In a comprehensive review published in 1997, Billings and
Block found that lectures were the most widely used strategy
for teaching end-of-life content in the medical curriculum,
under which bad-news delivery is often addressed.14
In a lecture on delivering bad news described in one
report, residents learned death notification skills as part of an
advanced cardiac life support course.15 This lecture focused
on methods of notification, understanding grief and after-
notification issues. We found no other published reports of a
sole reliance on lectures to teach learners about delivering
difficult news. Several studies have discussed using interac-
tive lecture formats to convey basic information and as a
catalyst for discussion and skills practice in subsequent small-
group sessions.16 –19 In one example, two faculty provided an
interactive lecture on delivering difficult news.16 They in-
volved the audience and role-played both poor and effective
encounters, using elements of the model described by Buck-
man.7 Trigger videotapes, showing dramatized bad-news en-
counters, can also be used in this process.19 After each
demonstration, the audience was asked to identify effective
and noneffective behaviors on the part of the clinician, based
on the patient’s communication needs. Then steps in effec-
tive delivery of bad news (see Table 1) were presented in
detail while referring to both case examples.
In an alternate approach, an audience member was asked
to volunteer to give bad news to a SP. For a student audience,
a scenario that required little medical knowledge was pro-
vided. For a more advanced audience (residents and practic-
ing clinicians), volunteers were asked to identify a typical
situation. As this example shows, a spontaneous demonstra-
tion has the advantage of being perceived as more genuine.20
In addition, learners in the audience can more easily imagine
themselves in the volunteer’s position and ponder what they
would do in a similar circumstance. The disadvantage is that
some common ineffective or effective behaviors will be left
out if they are not scripted.
Several education programs have used speaker panels to
present information about delivering bad news.10,17,21 In one
example, parents of children in whom cancer had been
diagnosed described their responses and needs in relation to
 SKILLS FOR DELIVERING BAD NEWS, CONTINUED

Table 2

Advantages and Disadvantages of Strategies for Teaching Medical Students and Residents Skills for Delivering Bad News

Strategy Advantages Disadvantages

Didactic approaches Presents core concepts to large numbers of learners efficiently Little opportunity for discussion
Minimal faculty time and resources No opportunity for practice and feedback
Learners are anonymous
Opportunity for efficient use of skills demonstration and use of
speaker panels can be done efficiently

Small-group discussion Opportunity to discuss issues, skills, and concerns No opportunity for practice and feedback
Faculty time intensive

Small-group, peer role-play Opportunity to discuss issues, skills and concerns Variable ability of learners to portray patients
Skills practice with feedback Faculty time intensive
Insight into patient perspective

Small-group standardized patient role-play
Multiple scenarios show range of approaches and patient
responses
Skills practice with feedback from faculty, peers, and
standardized patients
More realistic than peer role-play
Peer performance anxiety
Standardized patients and faculty time intensive
Less realistic than one-to-one standardized
patient encounter

One-to-one standardized patient encounters Skills practice with feedback from standardized patients or No group discussion
faculty No exposure to different approaches and patient
More realistic than group encounters responses
Faculty or standardized patient intensive

Teachable moments in clinical settings Actual context of patient care Clinical time restraints
Observation, demonstration, and feedback Patient privacy

bad news, and they fielded questions from the audience.17 In
another example, a panel of clinicians discussed their ap-
proaches to delivering bad news and described the challenges
they had faced.10
The main advantage of lectures is that they take minimal
time and faculty resources to deliver content to a wide
audience. However, they allow for only limited assessment of
learner needs, limited discussion of issues, and no chance for
practice and refinement of the skills discussed.
Small-Group Discussions
Reported interventions using small-group discussion sessions
for teaching delivery of difficult news have included trigger
tapes, demonstrations, case descriptions, or presession read-
ings to generate discussion (see Table 3).20 –24 These tools are
used in a manner similar to didactic approaches but include
opportunity for learners to discuss the issues raised. For
example, during a one-hour case conference in internal
medicine, a student or faculty member was invited to give
bad news to a SP in front of the group as a catalyst for
discussion during the session.20 In another intervention,
during two-hour sessions with groups of 16 –18 second-year
medical students, group members discussed their perceptions
of bad-news tasks and challenges, watched two videotapes on
delivering bad news, and then interacted with a handicapped
child and his or her parents, or a patient with cancer. This
approach is particularly innovative in including actual pa-
tients as part of the small group discussion.22
Although small-group discussions give learners an oppor-
tunity to discuss their concerns more deeply and explore
their reactions, these discussions can require more faculty
time than do lectures to reach the same number of learners,
and there is no opportunity for skills practice and feedback.
Small Groups with Peer Role-Playing
Some small-group interventions include giving learners an
opportunity to practice and receive feedback on their skills
through peer role-play exercises following discussion of basic
bad-news delivery issues.2,10,17,25,26 Some interventions have

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 SKILLS FOR DELIVERING BAD NEWS, CONTINUED

Table 3

Summary of Literature on Strategies for Teaching Medical Students and Residents Skills for Delivering Bad News to Patients*

Format Authors Level of Learner Strategies Assessment Measures/Results†

15
Lecture Pollack 1999 PGY One-hour lecture on death notification Design: Random assignment to lecture or nonlecture
group and all participated in SP death-notification
encounter
Measures: SP global rating
Results: Lecture group did significantly better than
nonlecture group

Small-group Edinger et al. 199920 MS3 Demonstration SP role-play Not available

discussion 21
Romm 2002 Obstetrics/ Panel of parents Learner satisfaction
Gynecology Group discussion
PGY
Knox et al. 198922 MS2 Trigger videos Learner satisfaction three months and 18 months after the
Discussion with family of disabled child seminar
Demonstration cancer diagnosis role-play
McNeilly et al. MS3 Presentation of Buckman model Design: Pre/post knowledge and attitude
200123 Trigger videos Measures: Students asked to name six steps in Buckman
Application of model to videos model and if they had a plan for breaking bad news
Results: Significant improvement in bad news knowledge
and attitude after the seminar
Angelos et al. Surgery PGY Small-group discussion Design: Pre/post confidence questionnaire and learner
199924 Limited role-play with prepared cases satisfaction
Video review Measure: Self-assessed confidence in “explaining bad
news”
Results: No significant difference before and after the
seminar

Small-group Vetto et al. 199910 MS1–2 Self-study readings Design: Comparison of objective structured clinical
peer role- Clinician panel examination scores from intervention and
play Group discussion nonintervention groups
Written case-based peer role-play Measures: SP-rated knowledge and humanistic skills and
faculty-rated humanistic skills
Results: Intervention group did significantly better on
humanistic skills with no significant difference on
knowledge
Morgan et al. Pediatrics PGY1 Didactic Learner satisfaction
199617 Panel of parents
Peer role-play with resident-generated
cases
Magnani et al. MS2 Clinical incidents Learner satisfaction
200225 Trigger videos
Written case based peer role-play, three
cases
Reflection questions
Ungar et al. 200226 PGY2 14 sessions, 90 minutes each Learner satisfaction
Group discussion
Written case-based peer role-play
Video review

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 SKILLS FOR DELIVERING BAD NEWS, CONTINUED

Table 3 (Continued)

Format Authors Level of Learner Strategies Assessment Measures/Results†

Small-group Rosenbaum et al. MS3 Lecture/demonstration Design: Pre/post questionnaire

SP role-play 200216 SP role-play with others watching, five Measures: Self-assessed comfort in delivering bad news in
cases different situations
Results: Significant increase in comfort after the session
Garg et al. 199718 MS3 Video critique Design: Pre/post questionnaire
Small-group exercises Measures: Self-assessment of whether students had a plan
Peer role-play for approaching delivering bad news and if felt competent
SP role-play to do so
(Four cases chosen out of 12 possible) Results: Significant increases posttest on both measures
Cushing et al. 199527 MS4–5 Discussion Design: Pre/post questionnaire
Video critique Measures: Students were asked to give level of confidence
Peer role-play in specific bad-news situations and list as many things a
SP role-play clinician can do to help recipients when giving bad news
Results: Significant increases in confidence level and longer,
more comprehensive list of steps in effective bad news
Van Winkle et al. 199828 MS4 Discussion Learner satisfaction
SP role-play with others watching, three
cases
Tolle et al. 198929 PGY1 SP role-play with learners consulting as Learner satisfaction
team
Group feedback
Kahn et al. 200130 MS3 SP role-play with four learners taking Design: Pre/post self-efficacy questionnaire
turns on same case Measure: Self-assessment of “I am comfortable giving bad
Group feedback news to patients”
Discussion Results: Significant increase in self-efficacy
Fortin et al. 200231 MS2 Mini-lecture Learner satisfaction
SP role-play with others watching
Feedback
Serwint et al. 200232 PGY2 All day seminar Learner satisfaction, use of techniques
Video triggers Self-assessed 18 months after the seminar
SP role-play with others watching, two cases
Lectures

One-on-one Coletti et al. 200133 MS3 Reading packet Design: Comparison between SP encounter and non-SP
SP SP with feedback encounter groups on end-of-rotation clinical practice
encounters examination bad-news SP station
Measures: SP ratings on numbered item evaluation form
addressing content and communication skills
Results: SP encounter group did significantly better on the
examination
Greenberg et al. 199934 Pediatrics SP encounter with feedback Design: Comparison across two SP encounters, before and
PGY2–3, SP encounter without feedback after feedback.
fellows Measures: I. SP ratings on content checklist, Gibb trust
scale, and National Board of Medical Examiners Patient
Perception Questionnaire. II. Resident self-assessed
comfort level pre/post
Results: Significant improvement in content categories of
communication and follow-up. Significant differences in
counseling skills. No significant differences in Patient
Perception Questionnaire

continued on next page

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 SKILLS FOR DELIVERING BAD NEWS, CONTINUED

Table 3 (Continued)

Format Authors Level of Learner Strategies Assessment Measures/Results†

Goldschmidt et al. MS4, Family SP encounter with feedback Learner satisfaction

198735
Rosenbaum et al.
199636
Jewett et al. 198237
Roth et al. 200238
Pan et al. 200239
medicine SP encounter
PGY1
PGY1 SP encounter with faculty feedback Design: Pre/post questionnaire
Measure: Self-assessed rating of confidence in giving bad
news
Results: Significantly less confidence after one encounter
Pediatrics One SP encounter with feedback at Design: Posttest control group design, comparison of
PGY2–3 beginning of rotation performance before training and after
One SP encounter with feedback at end Measures: SP rating of critical information giving, clarity
of rotation of information, and interpersonal skills
Results: Significant improvement in critical information,
general improvement in clarity, and improvement in
interpersonal skills, especially listening and partnering
with patients
Medicine PGY1 SP encounter with feedback from SP and Learner satisfaction
observing faculty
MS3 Small-group session using role-play, Learner satisfaction
reflection, and discussion.
SP encounter with feedback from faculty

Clinical Muir et al. 199940 MS4 Didactic Learner satisfaction

teaching Rounds
Bedside modeling
Videotaped SP
*MS, medical student; PGY, postgraduate year (resident); SP, standardized patient.
†We did not report measure for studies that relied on learner satisfaction. All authors reported high ratings of interventions by learners. Assessment methods are explained only to the extent they were
clearly explained in the original article.

used preprepared cases in which one learner portrayed the
patient and the other acted as the clinician delivering the
news.25,26 Preprepared cases can be especially appropriate for
learners who have little actual experience to draw on. In one
example, second-year medical students were introduced to
issues about delivering bad news through clinicians’ describ-
ing their experiences and then the students critiqued trigger
videotapes. Students then role-played detailed, written bad-
news encounters, and answered a series of questions.25,26
Some interventions for higher-level learners use learner-
generated cases. These cases can be elicited either before or
during the actual session. For example, one intervention
based a seminar on cases written by the institution’s own
residents.17 Using cases generated during sessions, group
members identified a clinical experience they would like to
“reenact” (often one they felt did not go as well as they would
have liked).11,26 This approach allows participants to address
concerns they feel they need to work on, making it especially
relevant for them.
In one approach to learner-generated cases, the learner
provides medical information, patient circumstance, patient
reaction, and clinician’s approach to the encounter. Then, a
group member portrays the patient, and the clinician–learner
delivers the news in a different way than he or she did in the
actual encounter, applying some of the concepts already
discussed in the group. The group provides feedback about
ineffective and effective behaviors demonstrated in the en-
counter and alternative ways to approach the situation.
Alternatively, the clinician whose “case” is being role-played
takes on the role of the patient, and another group member
takes on the role of the clinician. In this configuration, the
person who generated the case gains insight into both a
different way to approach the case and what the patient may
have been experiencing in this encounter. In both situations,

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 SKILLS FOR DELIVERING BAD NEWS, CONTINUED

if groups of three are formed then one person can observe and form in front of one’s peers can be intimidating for some and
provide feedback. creates a less realistic situation than a one-to-one encounter
In summary, role-playing allows learners to practice their with SPs.
skills, receive feedback, and gain insight into the patient’s
perspective; it also generates discussion. Peer role-playing is
One-to-One Learning with Standardized Patients
less demanding of resources and organizational needs than
role-playing with SPs. Disadvantages to role-playing are
Several schools have reported using one-to-one encounters
variation in learners’ abilities to portray patients in a realistic
between learners and SPs as their primary approach to
manner, familiarity among peers, and more faculty time
teaching delivery of difficult news.33–39 This approach has
required than less interactive sessions.
most often been used with learners who have already had
patient care experiences. In some approaches, the SP was the
main teacher during this intervention. In one example, in
Small Groups Using Standardized Patients
two SP encounters students learned about delivering bad
news during surgery and obstetrics/gynecology rotations.33
The majority of published educational interventions that
After reviewing written materials on techniques for deliver-
focus on delivering bad news used SPs who can be trained to
ing difficult news, each student delivered difficult news (rec-
portray patient responses to bad news in a realistic and
tal cancer diagnosis or pregnancy loss) to the SP, who
standardized manner.16,18,27–32 These interventions included
afterward provided feedback to the learner on strengths and
portrayal of multiple scenarios, giving most (if not all)
suggestions for improvement. Using this approach minimizes
participants a chance to practice delivering difficult news.
demand on faculty time but requires more intensive use of SP
Using multiple scenarios in bad-news role-playing sessions
time for training and teaching sessions.
can provide insight into the common and contrasting patient
Other examples reported using faculty observers and feed-
responses and skills needed in different situations and also
back in one-to-one simulated sessions. One approach used
allows for exposure to different learners’ approaches to the
two SP encounters of providing a cancer diagnosis to train
task.16 For example, two reported interventions with medical
residents and fourth-year students during a family practice
students used a combination of preprepared cases and stu-
rotation.35 After the second encounter with a SP, faculty
dent-generated cases in role-plays with SPs during small-
members reviewed the videotape with learners and provided
group sessions (four to ten students each).18,27 Each student
feedback on skills improvement. One advantage of this
role-played with the SP, and then the group proceeded with
approach is that it provides an opportunity for faculty to
feedback and discussion. Some interventions have used
observe learners actually delivering news to a patient, albeit
closed-circuit television with small groups, allowing learners
a standardized one, which is often difficult for faculty during
to watch as individual group members deliver bad news to a
clinical rotations.
SP in a separate room.16,28 Closed-circuit observation sys-
One-to-one SP encounters eliminate the discomfort that
tems can provide a more realistic context than can perform-
can accompany role-playing in front of groups and can
ing directly in front of the group and the setting allows the
provide a more clinically realistic encounter. In addition, the
observers to comment as the encounter proceeds. In one
time commitment for both learners and faculty is minimized.
example, each student in a small group of students delivered
Disadvantages of this approach are that learners do not have
difficult news to a different SP while being observed by others
an opportunity to benefit from observing multiple approaches
over closed circuit television.16 In another example, four to
and multiple patient responses to bad news.
six students observed over closed circuit television as three
other students each took a turn delivering difficult news in a
variety of situations. Each scenario was followed by feedback Teachable Moments in Delivering Bad News
and discussion with a faculty facilitator, the students and the
SP. In this configuration, not all participants may practice Although rarely described in the literature, faculty have
delivering the news but they are exposed to multiple ap- ample opportunities to teach and reinforce skills for deliver-
proaches and varying scenarios. ing bad news in the direct context of clinical care. These
Use of SPs in role-play situations gives learners an oppor- teachable moments can be identified and used in inpatient
tunity to practice their skills with skilled and nonfamiliar ward round and outpatient staffing settings.6,8,19,40 – 42 Before
“patients” and receive feedback from peers, SPs, and faculty. a bad-news encounter, faculty members can discuss concerns
This role-playing, however, requires intense use of both and possible approaches to bad-news delivery. They can ask
faculty and SP time and audiovisual support resources if the learner(s) about their experiences and concerns regard-
closed-circuit television is used. In addition, having to per- ing delivering bad news, and thus assess their learning needs

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 SKILLS FOR DELIVERING BAD NEWS,
and levels of comfort with the task. This also encourages
approaching the encounter with a set plan in mind for
delivering the news.18 In addition, learners can ask questions
and be queried regarding their perceptions of the patient’s
reactions and needs, as well as the effectiveness of ap-
proaches. Providing self-study resources such as articles and
videotapes can also be useful for enhancing learning and skill
development in these venues.18
Role modeling and demonstration are important ways
trainees can learn and refine their bad-news delivery skills. In
a curriculum at our institution, we told third-year medical
students that if they found themselves in a position of giving
bad news that they were uncomfortable with at their level of
training, the students could ask a supervisor to deliver the
news while they observed.16 One of the challenges to bedside
teaching of this skill is to maintain patients’ privacy during
this emotionally charged encounter while still being able to
teach learners these important skills. Setting aside time
outside of rounds with one or two learners is advised, in order
to deal with the interaction sensitively and effectively while
maximizing the experience for the learners. The patient
should be informed of the reason for the learner’s(s’) pres-
ence in this type of encounter. If bad news must be delivered
during rounds we suggest that the encounter be saved until
the end of rounds to avoid time pressure and also allow the
attending physician to limit the number of learners that
participate. In addition to giving enough time to the patient,
this also can allow time immediately after the encounter to
process with the learner(s).
Observing learners giving difficult news can also allow
faculty to provide feedback to improve skills. However, roles
of the learner(s) and the attending physician need to be
clearly defined before a bad-news encounter. For example,
with a resident–physician who has his or her own patient
pool, the attending can offer to accompany the resident as a
resource if he or she cannot answer patient questions. The
resident can inform the patient of the attending’s role as an
observer. The challenge in observing learners with patients is
for the attending physician to resist the temptation to dom-
inate the encounter and have the patient focus on the
attending physician. However, with observation, feedback
on actual performance can be even more effective than
giving feedback regarding SP encounters.
Teaching about bad-news delivery in the context of actual
patient care can open the door to identify ways for learners to
improve and acknowledge the emotional challenges that ac-
company being the bearer of bad news. In addition, faculty can
relay both negative and positive outcomes from different ap-
proaches they have tried. Finally this approach allows for ap-
plication of skills in the context in which they will be used.
Potential disadvantages include time constraints for teaching in
the clinical setting and concerns about patients’ privacy.
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CONTINUED
EVALUATION OF TEACHING STRATEGIES
The number of published reports evaluating different strate-
gies for teaching skills for delivering bad news are limited and
the majority limit their assessment of the impact of educa-
tional interventions to learner satisfaction and confidence
rather than assessing change in learners’ actual behavior (see
Table 3). However, the following evidence points to the
advantage of using some strategies over others.
We found only one report specifically that evaluated a
lecture for teaching bad-news delivery.15 In a prospective,
randomized study, 18 of 36 residents received a lecture on
death notification. Members in the lecture group performed
significantly better in a death-notification encounter with a
standardized survivor. Although this report indicates a lec-
ture can have some immediate impact on learners’ skills for
delivering bad news, the literature on teaching communica-
tion skills in general and delivering bad news in particular
argues against sole reliance on lectures to teach these behav-
ioral skills.13,19,41– 43 Learners must have an opportunity to
practice the skills before they can internalize them. In com-
bination with other methods, however, didactic presentation
of the principles of delivering bad news can provide impor-
tant baseline information for discussion and practice. When
using lectures, we encourage teachers to employ more inter-
active techniques, such as incorporating demonstrations,
role-plays, panels, and audience feedback, as a way to engage
the audience and help with retention of information.
The majority of reports on small-group activities to teach
skills for delivering bad news relied on learner self-assess-
ments of confidence before and after the intervention, and
learner evaluation of the usefulness of the educational activ-
ity (see Table 3).16 –18,21,24-27,30 Almost all interventions
using these assessments reported significant changes in
learner self-confidence and high ratings of the usefulness of
the training. One study found no significant differences in
confidence in delivering bad news after a small-group discus-
sion session with residents.24 The authors postulated that this
was due to lack of opportunity for feedback and practice of
these skills within the session. The majority of small-group
studies indicate that learners desire more training opportu-
nities and the opportunity to practice with SPs.16,22,25,27
Some studies have evaluated the impact of small-group
activities on learners’ knowledge and attitudes. For example,
in a pre/post study, learners were able to describe the six steps
in Buckman’s model for delivering bad news and were more
likely to have a plan for giving bad news following a small-
group intervention in which learners applied the model to
trigger videos.23 In another pre/post comparison study, learn-
ers could provide longer, more comprehensive lists of steps in
effective bad-news delivery after small-group, SP sessions
than they could before the intervention. We found one study
 SKILLS FOR DELIVERING BAD NEWS,
evaluating the impact of small-group training on learners’
behaviors.10 Objective structured clinical examination scores
of students who had participated in small-group training and
those who had not were compared and the comparison
demonstrated significantly better humanistic behavior scores
(e.g., communication and empathy skills) among those stu-
dents who had participated in the training sessions.
One-to-one learning with SPs allows for simultaneous
assessment of actual bad-news delivery behaviors during and
after educational interventions. In most of these interven-
tions faculty and/or SPs use checklists to identify learners’
strengths and weaknesses. In two reports, residents partici-
pated in encounters with SPs and were provided once with
feedback.35,36 In addition to demonstrating skills in certain
areas of bad-news delivery (learners’ concern for patients,
honesty, and appropriate follow-up plans), faculty observers
of these encounters identified areas for improvement, such as
providing too much data and scientific information during
the encounter.35 Studies suggest the limitation of only pro-
viding one opportunity for learners to practice their skills and
receive feedback without having the chance to practice
applying behaviors recommended in the feedback. For exam-
ple, one study36 found that residents’ ratings of their own
abilities were actually lower after a one-time encounter with
feedback than they were before the encounter. In contrast,
reports by others33,34 demonstrate improvement of learner
skills when compared across two simulated encounters. For
example, one of these studies33 found significant differences
in content and communication skills between students who
had received training and feedback through previous simu-
lated encounters for delivering bad news and those who had
not received training and feedback.
We found no published reports that systematically evalu-
ated the effectiveness of learning about delivering bad news
in the less formal settings of inpatient wards and outpatient
clinics. A few studies have reported student and resident
experiences in bad-news delivery in the context of patient
care. Two recent reports42,44 found that many students and
residents received little guidance from or opportunity to
debrief with faculty around these bad-news encounters. They
also reported that students and residents desired this guid-
ance and found discussion, observation, and feedback bene-
ficial when provided in these contexts.
CONCLUSIONS
There are a variety of approaches available for teaching skills
in bad-news delivery. All of the interventions we describe
here have been rated highly by learners and have demon-
strated impact on learner self-confidence and, in some cases,
learner knowledge and behaviors.
ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004
CONTINUED
Adult learning is best facilitated through instruction that
is interactive and learner-centered, draws on previous expe-
rience and knowledge, is relevant to the learner’s practice,
allows the learner to apply what is being learned in a timely
manner, and includes the opportunity for feedback and
reflection. Based on these adult learning principles and
findings in the education literature on delivering bad news,
we conclude that the most effective interventions present
basic steps to effectively delivering bad news, and provide
opportunities for learners to discuss concerns, practice, and
receive feedback on their skills.
Our recommendation of best practices in teaching skills
for delivering bad news echoes recommendations made by
others.6,19 In addition, evaluations that include observation
of actual behaviors point to the benefit of learners having
more than one opportunity to practice and receive feedback
so that they can try out new behaviors they may not have
demonstrated in their first encounter. It is striking that in
evaluation of many of the interventions, learners indicated a
desire for more training and opportunities for practice. In
addition, researchers need to examine the impact of educa-
tional interventions on learners’ actual behaviors and learn-
ers’ long-term retention of these skills. Measures have been
developed specifically for assessing skills for delivering bad
news that could be used for this purpose.9
This review demonstrates there are many models for
teaching skills for delivering bad news; one’s choice will
depend on resources available in terms of faculty, SPs, and
curricular time. In addition, deciding when to provide this
training to learners will depend on available resources, but
the training is likely to be most effective if it is provided early
and often. As suggested by Kurtz et al.,43 following a helical
model where communication skills are reiterated and rein-
forced throughout medical training is essential to maximum
skill development. Thus, prior to or early in their direct
patient care experiences, medical students can benefit from
training by having an opportunity to practice giving bad
news in a safe, simulated environment before having to
deliver bad news with actual patients and families. Early
training also gives students a framework in which to critically
evaluate role models they may observe giving bad news on
the wards and in the clinics. As students and residents have
increased patient-care responsibilities, new and more com-
plex aspects of bad-news delivery can arise. It has also been
argued that students’ communication skills tend to degrade
over the four years of medical school if the skills are not
reinforced.43 Faculty who have the skill to recognize and
capture these teachable moments in the context of clinical
rotations can help learners discuss these issues and hone their
skills. At the resident level, formal instruction and practice
in delivering bad news guarantees that all residents, regard-
115
 SKILLS FOR DELIVERING BAD NEWS,
less of where they went to medical school, are equipped to
adequately perform this task.
In recommending more faculty-intensive educational in-
terventions to teach skills for delivering bad news (e.g., small
groups, role-plays with feedback, clinical teaching), it follows
that faculty also need and deserve training in providing this
instruction. Several successful models have been imple-
mented to train practicing physicians, some for the first time,
to deliver bad news.11,45,46 Thus, training will help improve
physicians’ own interactions with patients, as well as their
ability to teach others in formal settings and to identify
learning opportunities in the context of patient care.
Learning to deliver bad news effectively is an important
part of providing good medical care, maintaining productive
relationships with patients, and enhancing patient and phy-
sician satisfaction. Through educational interventions, the
bad-news encounter can be made less distressing for both
clinician and patient. To incorporate effective behaviors for
delivering bad news into practice, we encourage medical
education programs to commit the necessary resources to
provide a comprehensive approach to teaching this task, one
that includes multiple sessions and opportunities for demon-
stration, reflection, discussion, practice, and feedback.
We are grateful to Dr. Jerold Woodhead for supporting our implementation
and refinements of the curriculum for bad-news delivery and assisting in
thinking through the issues involved in this review. We are also grateful to
Dr. John F. Wilson for inspiration and assistance in development and
implementation the curriculum for bad-news delivery. In addition, we want
to thank Dr. Paul Casella for his editorial assistance.
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Teaching and Learning Moments

NOT JUST A REGULAR CUSTOMER

As a third-year resident at University of Illinois at Chicago, “Mary” was a regular “customer.” She was a frail white
woman in her early 50s with grace in her features, but suffered from cirrhosis due to alcoholism. Mary required
repeated admissions for encephalopathy and variceal bleedings.
In one of her many admissions to the intensive care unit, I had to evaluate her. Seeing her repeatedly as an intern
and a resident, it seemed routine work. Her husband of more than 30 years recited her familiar medical history to me
and I thought she was in her usual encephalopathic state. As I proceeded to examine her, a small grin appeared on
her face. As I was doing a routine head and neck examination, I heard her whisper weakly, “You have a nice smell
doctor.” I didn’t know what to say and was stunned by the comment. In that moment, I realized I had lost the
humanistic part of my patient during the years of seeing her repeatedly.
In our routine work and dealings with patients with chronic diseases, physicians tend to develop a “not again”
approach to these patients and ignore the fact that these chronic cases appreciate life and its subtleties—just like
everyone else. A fresh smell of a person had made such an impact amongst the aroma of alcohol, Betadine, and other
chemicals in the hospital. Mary’s surprising comment changed my attitude towards patients with chronic diseases. I
learned to separate the disease and the human being in my patients more easily. This also reminded me of the quote:
“Patients are evaluating you while you are evaluating the patients.”1 Over the next few months, Mary continued to
be admitted and I continued to treat her until she died of massive variceal bleeding. Not only did Mary change my
perspective of managing patients with chronic illnesses, but her evaluation of me gave her comfort and a smile. I am
proud that I was able to give her that moment of comfort. I continue to try to bring comfort and smiles to all of my
patients, especially my regular customers.
NAUMAN TARIF, MD
Dr. Tarif is assistant professor of medicine and consultant nephrologist, Department of Medicine, College of Medicine,
King Saud University, Riyadh, Saudi Arabia.

REFERENCE

1. Orient JM, Sapira JD. Sapira’s Art and Science of Bedside Diagnosis. 1st ed. New York: Lippincott Williams & Wilkins, 1998:9.

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