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Thursday Review: Position paper: Teaching breaking bad news (BBN) to undergraduate medical students

I find the idea of medicine and healing as an exchange of stories compelling. Seeing a medical provider is one of the times in life when we want the trajectory of our own story changed. We tell a healer our story and they interpret it. Then, through the lens of their expertise, they tell it back to us for the sake of changing it. Most often, the goal of medical encounters is to get us back to “normal” life.

In the best-case scenario, when a physician breaks bad news (“BBN”), we have to change what we thought was going to be the path back to normal. At its worst, it completely changes what “normal” is in our life. In their position paper, Karnieli-Miller, Pelles, and Meitar recommend setting BBN as an advanced communication skill that relies on good basic foundations for continuity in communication-skill teaching. BBN as an “advanced skill” makes sense in the grander context of medicine. Broadly speaking, learning to hear a patient’s story in medical terms is the goal of clinical skills education. Breaking bad news should be taught in the advanced clinical years, since it is only by then that the students have accumulated multiple and diverse complex experiences of meeting patients, listening to their narratives, and witnessing their interactions with caregivers.

The authors point out that more than other types of clinical encounters, BBN requires the clinician’s whole self. BBN shapes not just the patient and their loved ones, present for the discussion or not. It has the potential to shape the physician themselves. Viewing communication as a tidy, turn-based exchange of information, like hitting a tennis ball back and forth, is too simple a model even for the briefest and most mundane encounters. Our experiences are always shaped by what is communicated to us, and we are shaped by communicating. This might seem very metaphysical if a physician is discussing a treatment for a mild case of flu, or writing a routine prescription for antibiotics. Breaking bad news, though, is the kind of conversation that has to be steered, adapted, and sculpted as it progresses. More than most other kinds of interactions, the information being fed back to the physician while the bad news conversation is happening steers the next steps of the conversation.

The authors’ main point is to outline what the best ways are to teach someone to have this interaction. In their discussion, they bring up practical pointers from their experiences. Some of them are extremely practical, like the point that BBN isn’t always about cancer, so it’s important to teach to the subjective, individualistic nature of bad news that is relevant to all specialties. Some of them are practically humorous, like their example of previous work modeling how a teenager [should] BBN to his parent that he drove their car into the family’s swimming pool.1

It’s instructive that something so far removed from the clinical as a car in a swimming pool can help teach clinical communication techniques. The authors summarize several protocols for use in teaching BBN, and what structural touchpoints they highlight. What’s remarkable about the chart the authors compile is the similarities between methods. Some methods skip a certain domain or emphasize another, but the order and flow from beginning to end is the same for all of them.

Here’s a high-level abstraction of the table the authors compile:

Pre-conversationRapport and BackgroundTransitionBreak the NewsEmpathize with EmotionsDiscussion of Treatment

When I read this paper, I couldn’t help but think that I’d seen this table before. This kind of structure is remarkable not just because the protocols are so similar, but because it’s so close to work on classic narratives.

When the folklorist Vladimir Propp (1895–1970) analyzed the structure of the Russian folklore canon, he found the same general idea: some stories skip an element or two or exaggerate another, but even with skips there is an order of the flow from one element to another. Here’s a very small excerpt from the comparative tables he published of his findings:

In his labeling, A is some kind of villainy. For example A1 is a kidnapping and A16 is a “threat of forced matrimony”. B is some kind of connective incident to the rest of the story, like B1 is “a call for help,” C is getting consent to counteract whatever villainy was present in A, and the arrow is the “departure, dispatch of the hero from home.” These tables go on for pages and pages as an appendix to Propp’s landmark The Morphology of the Folktale.

Every BBN conversation has to be individualized for the patient, their family, and the physician. Despite that, there is still a certain flow to the physician-guided journey that this communication entails.

One of the sections in the tables Propp lays out in his Morphology is the “Preparatory section”. This is a kind of story-before-the-story, which in most folktales is a kind of exposition leading up to the villainy that kicks off the main narrative. In folktales, the story-before-the-story doesn’t have a resolution of its own, but is a way to set up the big story that’s coming.*

A story-before-the-story can be useful and effective when a story is being used to present information. When a story is told for entertainment purposes, it withholds the climax until the very end. The tension of not knowing how the story is resolved is one of the things that make stories so effective. A kind of spoiler, though, can be used with great effect as a teaching tool. I once spoke with a parent whose daughter had some kind of issue with her lungs. The doctor went to great pains to explain the causes of the symptoms, the progression of the illness, the risks if the disease wasn’t treated immediately, and on and on and on. It’s a suspenseful story. Too suspenseful. The parents were beside themselves with stress. By the time the physician got around to the climax of the story, that treatment was a routine, safe prescription, the parents didn’t care about hearing anything else except what they could do to end their little girls’ harrowing adventure.

It would have been a much different conversation if the physician had allowed themselves a kind of spoiler. The story-before-the-story could have gone something like, “Your daughter has a certain condition, which is why she’s been experiencing the symptoms she has. We need to treat it right away so it doesn’t get worse. Curing it is as simple as a routine, safe, effective prescription. Now, I’d like to circle back, and go into a little more detail…” All the necessary information is present, but the story moves quickly and at a high level. Armed with this information and having presented the happy ending (spoiler) to the story, the physician can go back and explain as much as they felt was necessary, and provide answers to any of the parent’s remaining questions.

BBN has a kind of story-before-the-story, too. Different protocols handle this in different ways. PACIENTE advises the physician to assess how much the patient knows and how much they want to know.5 The I in SPIKES stands for invitation: obtaining the patient’s invitation to the type and depth of information they want to receive.2 The “w” in SPwICES is probably the most direct story-before-the-story: warning call — a transition stage, from listening and gathering information to sharing the news. In this stage, the news is not actually shared yet. The words are chosen carefully, to prepare the recipients mentally, emotionally, and physically, that bad news is coming.6

This transition is necessarily a delicate balance. The story-before-the-story isn’t the bad news, but it’s the story leading into the bad news. The patient’s understanding of their life and health is about to shift. Whatever that shift entails is going to be a part of their story from then on.

*PS: If you watch an episode of The Simpsons, there’s often a folktale-esque story-before-the-story or “Preparatory section”. If you notice, the first 4 to 5 minutes of the show often have nothing to do with the main story line. It’s just there to get the Simpsons into some circumstance to kick off the rest of the show.


The article reviewed: Karnieli-Miller, Orit, Sharon Pelles, and Dafna Meitar. “Position Paper: Teaching Breaking Bad News (BBN) to Undergraduate Medical Students.” Patient Education and Counseling, May 31, 2022.

1 Kukora, Stephanie K., Brittany Batell, Rachel Umoren, Megan M. Gray, Nithin Ravi, Christopher Thompson, and Brian J. Zikmund-Fisher. “Hilariously Bad News: Medical Improv as a Novel Approach to Teach Communication Skills for Bad News Disclosure.” Academic Pediatrics 20, no. 6 (August 2020): 879–81.

2 Baile, Walter F., Robert Buckman, Renato Lenzi, Gary Glober, Estela A. Beale, and Andrzej P. Kudelka. “SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer.” The Oncologist 5, no. 4 (August 1, 2000): 302–11.

3 Vandekieft, Gregg K. “Breaking Bad News.” American Family Physician 64, no. 12 (December 15, 2001): 1975–79.

4 Narayanan, Vijayakumar, Bibek Bista, and Cheriyan Koshy. “‘BREAKS’ Protocol for Breaking Bad News.” Indian Journal of Palliative Care 16, no. 2 (2010): 61.

5 Pereira, Carolina Rebello, Marco Antônio Marchetti Calônego, Lino Lemonica, and Guilherme Antonio Moreira De Barros. “The P-A-C-I-E-N-T-E Protocol: An Instrument for Breaking Bad News Adapted to the Brazilian Medical Reality.” Revista Da Associação Médica Brasileira 63, no. 1 (January 2017): 43–49.

6 Meitar, Dafna, and Orit Karnieli-Miller. “Twelve Tips to Manage a Breaking Bad News Process: Using S-P-w-ICE-S — A Revised Version of the SPIKES Protocol.” Medical Teacher 44, no. 10 (October 3, 2022): 1087–91.

Featured Image: Detail of a photo by Karolina Kaboompics; used under Pexels’ License