Balancing patient care and student education: Learning to deliver bad news in an optometry teaching clinic

Abstract

Learning to counsel patients in a teaching clinic or hospital occurs in the presence of the competing agendas of patient care and student education. We wondered about the challenges that these tensions create for clinical novices learning to deliver bad news to patients. In this preliminary study, we audio-taped and transcribed the interviews of seven senior optometry students and six optometrist instructors at a Canadian optometry teaching clinic. The participants described their experiences in learning to deliver bad news. Using a grounded theory approach, our analysis was informed by situated learning and activity theory. Optometry students received formal classroom training regarding how to deliver bad news, including exposure to the medically-based six-step SPIKES protocol (Baile et al. The Oncologist, 5, 302-311, 2000). Yet, application of this protocol to the teaching clinic was limited by the lack of exposure most instructors had received to this strategy. Determinants of the students' complex learning process during their clinical apprenticeship, included: (i) knowing one's place, (ii) knowing one's audience, (iii) knowing through feedback, and (iv) knowing who speaks. The experiences of these participants pointed toward the need for: (1) more instructional "scaffolding" (Bruner and Sherwood Play: Its role in development and evolution, p. 280, 1976) in the clinical setting when the learning task is complex, and (2) explicit discussions about the impacts that unfold when the activities of patient care and student education overlap. We reflect on the possible consequences to student education and patient care in the absence of these changes.

Entrega de malas noticias en la práctica clínica

“…Este protocolo ha sido aplicado en distintos países como por ejemplo Alemania 52 , Francia 53 , China 54 , Estados Unidos de Norteamérica 51 , entre otros, y en distintos contextos además del cáncer, como lo son la psiquiatría 55 , oftalmología 56 , veterinaria 57 y la odontología 58 . En la Tabla 1 se muestra un compendio con lo expuesto por los autores Kaplan 51 , Baile et al 3 y DHSSPS 4 sobre SPIKES.…”

“…Esto a pesar de la evidencia de que algunos pacientes con tumores desean saber si su enfermedad es cáncer, y otros quieren saber lo más posible acerca de su enfermedad. A menudo más de un médico asume lo que los pacientes quieren saber [54][55][56] .…”

“…Los pacientes quieren que su médico sea honesto, compasivo, cuidadoso, esperanzador e informativo. Quieren que se les entregue la información personalmente, en un lugar privado, a su ritmo, con tiempo para la discusión, y si ellos desean, con una persona de apoyo presente 56 . Además, la entrega del diagnóstico y pronóstico de una enfermedad es una decisión que debe ser tomada en conjunto, tanto entre el médico tratante-familia, y debe ser una decisión informada, la cual debe ser a su vez, registrada en la ficha clínica de cada paciente.…”

Attending to audience: comparing optometry student talk with and about patients

“…Shifting between audiences is a difficult discursive task to learn for novices and we did not observe any instructional scaffolding that would help these clinical novices develop this ability and/or reflect on its implications. As we have shown in the past (Schryer et al 2003;Spafford et al 2006Spafford et al , 2009, students face the potentially competing activities of patient care and student education. Despite their wish to provide quality patient care, students must consider what behaviors and talk will lead to favorable grades and these decisions do not always facilitate quality patient care.…”

“…Clinical apprenticeships can include potential opportunities for active learning such as (1) 'legitimate peripheral participation' (Lave and Wenger 1991, p. 109) where, over time, Attending to audience 779 learners ''move towards full participation in the social-cultural practices of a community'' (p. 29) by observing and doing, and (2) ''scaffolding'' (Bruner and Sherwood 1976, p. 280;Vygotsky 1978), where instructors explicitly lay out a series of graduated tasks to maximize student learning. In a past study of optometry student and instructor perceptions of learning to deliver bad news to patients (Spafford et al 2009), optometry students felt they learned talk mostly by 'trial and error', sometimes through instructor role modeling and seldom via explicit instruction. Thus, we have wondered if novice case presentations offer opportunities for novices to learn ways to transition their talk between changing audiences.…”