Perception of Doctors in Breaking Bad News in North Sudan: Are we in the right track?

Article Information

Amjed Abdu Ali1, Sufian Khalid2, Omnia Alsamwal3, Reem Ibrahim4, Awadelkareem Abdelgeyoom5, Sara Osman6, Mohammed Salaheldin7, Abdelhaleem Elhussain8, Esra A Saeed9*, Ali Adlan10

1Assistant professor, Department of Pediatrics, Faculty of Medicine, Nile Valley University, Sudan

2Professor of Internal medicine, Faculty of Medicine, Nile Valley University, Sudan

3Medical Student, Faculty of Medicine, Nile Valley University, Sudan

4Medical Student, Faculty of Medicine, Nile Valley University, Sudan

5Assistant professor, Department of Urology, Faculty of medicine, Nile Valley University, Sudan

6Associate professor, Department of Medicine, Faculty of Medicine, Nile Valley University, Sudan

7Atbara Teaching Hospital, Atbara, River Nile State, Sudan

8Teaching Assistant, Department of medicine, Faculty of Medicine, University of Medical sciences and Technology, Khartoum, Sudan

9department of anatomy, faculty of medicine, university of Khartoum, Sudan

10Teaching Assistant, Department of Surgery, Faculty of Medicine, International University of Africa, Khartoum, Sudan

*Corresponding author: Esra Ali Mahjoub Saeed, DR demonstrator, Department of anatomy, Faculty of Medicine, University of khartoum, Khartoum, Sudan.

Received: 19 November 2022; Accepted: 29 November 2022; Published: 28 February 2023

Citation: Amjed Abdu Ali, Sufian Khalid, Omnia Alsamwal, Reem Ibrahim, Awadelkareem Abdelgeyoom, Sara Osman, Mohammed Salaheldin, Abdelhaleem Elhussain, Esra A Saeed, Ali Adlan. Perception of Doctors in Breaking Bad News in North Sudan: Are we in the right track?. Archives of Clinical and Biomedical Research 7 (2023): 120-124.

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Abstract

Background: Bad news is defined as any news that adversely and severely affects an individual's view of his or her future. This study aims to assess doctors' perceptions of breaking bad news in Atbara, Ad-damer, and Alsalam Teaching Hospitals.

Methods: A cross-sectional descriptive hospital base study was conducted in Atbara, Ad-damer, and Alsalam teaching hospitals from the 1st of December 2018 to the 8th of January 2019. The information was gathered using a closedended questionnaire and analyzed with a statistical computer program (SPSS) version 21.

Results: The study revealed that 54% of doctors were not trained in breaking bad news, and only 46% of doctors were trained. The main age group whom they trained was between 25 and 30 years old. Also, more males were trained than females, with 56.7% and 41.4%, respectively. The study showed that the registrars were more trained than medical officers and house officers, with 63.2%, 36%, and 50%, respectively. 74% of doctors didn't hear about the global policy of breaking bad news. There was an association between certain factors and the level of training of doctors as conducted through the chisquare test as follows: age p value (0.0059), gender p value (0.014), clinical position p value (0.0024) and specialty p value (0.0019).

Conclusion: We concluded that half of doctors were not trained, and the majority of doctors didn’t hear about the policy of breaking bad news.

Keywords

Breaking Bad News; Doctors; Perception; Sudan

Breaking Bad News articles; Doctors articles; Perception articles; Sudan articles

Article Details

1. Introduction

Bad news is defined as "any news that adversely and severely affects an individual's view of his or her future, providing serious case disclosure to anyone who needs expertise, experience, and compassion" [1]. It is also defined as (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 established lifestyle, or where a message is given which conveys to an individual fewer choice in his or her life) [2]. The bad news may be a devastating diagnosis such as metastatic cancer with a poor prognosis and a high mortality rate. It may also include treatment failure or developing drug side effects. There is a wide variety of what can be considered bad news, for example: fetal congenital anomalies, disabilities after trauma, fertility problems, chronic illness, neoplastic disorders, a loved one's death, contagious diseases, or any other conditions that may negatively alter the patient's views of his or her life, hopes, and dreams. Regardless of the content of the bad news, breaking it to the patient and his/her family or guardian is not a simple mission at all. As a result, in medical practice, a global policy and excellent communication skills are required. Despite many articles and theories that have addressed this topic, there are a very limited number of studies with small sample sizes from both medical staff and recipients. There is increasing awareness regarding the importance of breaking bad news in medical societies [3]. Unfortunately, this part of medical practice has not received enough training in the past because medical schools are focused on the scientific part only, whereas communication skills are supposed to be acquired by postgraduates through observation. Breaking bad news is one of the most important and difficult responsibilities in the practice of medicine, although virtually all doctors in clinical practice encounter situations entailing bad news at some point in their medical practice.

2. Methods

2.1 Study Design

Cross-sectional, descriptive hospital-based study.

2.2 Study Area

The study was conducted at Atbara, Ad-damer, and Alsalam teaching hospitals. Atbara teaching hospital is situated in the western north of Atbara town. It's about 14292 meters. It was built in 1904 during the period of the English government. Furthermore, it has wards and referral clinics for surgery, medicine, pediatrics, and obstetrics, as well as a dialysis and diabetes center, casualty, and newly built CCU and ICU. There are about two laboratories and three pharmacies, and other services such as x-rays and ultrasound. Ad-damer teaching hospital is situated in the western south of Ad-damer town. It was built in 1967. It consists of wards and referential clinics for surgery, medicine, pediatrics, and obstetric specialties, a center for dialysis, casualty, and ICU. There is about one laboratory, three pharmacies, and other services such as x-rays and ultrasound.

2.3 Study Period

From the 1st of December 2018 to the 8th of January 2019.

2.4 Study Population

All house officers, medical officers, and registrars work at Atbara, Ad-damer, and Alsalam teaching hospitals during the period from December 1st, 2018 to January 8th, 2019.

2.5 Sample Size

100 doctors.

2.6 The Tool and Technique of Data Collection

Data were gathered through direct interviews with doctors using a closed-ended questionnaire.

2.7 Data Analysis

The data were analyzed by using the statistical computerized program for social sciences, SPSS (version 21).

2.8 Data Presentation

Frequency and percentage descriptive statistics. A formal letter from the department of community medicine to the medical director of Atbara, Ad-damer, and Alsalam teaching hospitals from whom we received verbal consent to conduct the research. We also received verbal consent from the responders after explaining our research objectives.

3. Results

In a descriptive cross-sectional hospital based study, 100 doctors were enrolled to assess their perception toward BBN, fulfilling all inclusion criteria, SPSS version 25 was used for analysis and obtaining the following results. The study revealed that (79%) of participating doctors were younger than 30 years and only (4%) were older than 35 years.70% were females, only (22%) had passed SMSB part 1exam, (73%) were graduated after the year 2015 and only (7%) graduated before the year 2011. The majority of them (47%) were medical officers, (34%) house officers and (19%) registrars. There were participants from several departments: Internal Medicine (28%), Pediatrics (26%), Obstetrics & Gynecology (24%), Surgery (19%) and Family Medicine (3%). Most of the participants (70%) were working at Atabara Teaching Hospital, (23%) in Aldamer TH and (7%) in Alsalam TH, as shown in Table 1.

Factor

N

%

 · Age

< 25 years

31

31

25 < 30

48

48

30 <35

17

17

>35

4

4

 · Gender

Male

30

30

Female

70

70

 · Qualifications

MBBS*

78

78

MBBS & SMSB* part 1

22

22

 · Year of Graduation

Before 2011

7

7

2011 – 2012

6

6

2013 – 2014

14

14

2015 – 2016

25

25

2017 – 2018

48

48

 · Clinical Position

House Officer

34

34

Medical Officer

47

47

Registrar

19

19

Specialty

Internal Medicine

28

28

Pediatrics

26

26

Obstetrics & Gyn.

24

24

Surgery

19

19

Family Medicine

3

3

 · Work place

Atabara TH*

70

70

Aldamer TH

23

23

Alsalam TH

7

7

Table 1: Demography, Qualifications and Job description of study participants.

*Gyn. Gynecology, MBBS (Latin Abbreviation of) Bachelor of Medicine and Surgery, SMSB Sudan Medical Specialization Board, TH Teaching Hospital.

Among the 100 participating doctors, only (46%) had been trained about breaking bad news, first person to receive bad news were a patient in only (30%), (50%) family and (20%) were both patient and family. (56%) of participating doctors were comfortable to discuss diagnosis issue with family or patient, (24%) were not and (16%) were not sure. Most of the study participants (77%) told the patients everything about diagnosis, while (18%) didn't and (5%) were not sure about. (26%) informed the patients about diagnosis in single visit. (47%) of participating doctors took patient hope before, while (25%) didn't and (28%) were not sure. (49%) of study participants relied on relatives’ consent to inform patient about diagnosis, (42%) did not rely on, while (9%) were not sure about. (41%) of participating doctors told patient diagnosis and prognosis, (15%) avoided difficult questions from patients, (14%) tell patient truth only if patient ask, (21%) refer the patient to another doctor, while (9%) lied to the patients. (66%) of study participants thought that patients didn't want to know about diagnosis, (16%) of thought the reverse, while (18%) were not sure. Most of participating doctors (77%) were depressed about breaking bad news, while (17%) were not and (6%) were unsure. (81%) of study participants explained bad prognosis but (60%) of them gave false hope and remaining (21%) didn't, (17%) gave false hope to terminal patients. (60%) told patients about their final diagnosis, while (28%) avoided that, and (12%) were not sure about. (21%) of study participants used a multi bed hospital room to deliver bad news, while (64%) didn't and (15%) were not sure. (65%) of participating doctors prepared the patients for bad news, (28%) didn't and (7%) were not sure about. The majority of study participants (89%) gave follow-up plan and hope, the rest either didn't (4%) or were unsure (7%). Only (26%) of participating doctors knew about breaking bad news policy, while (48%) didn't know and (26%) were unsure. As shown in Table 2.

Parameter

N

%

Training about BBN*

Trained

46

46

Untrained

54

54

First person to receive BN*

Family

50

50

Patient

30

30

Both

20

20

Doctors feeling when discussing diagnosis issues

Comfortable

56

56

Not comfortable

28

28

Not sure

16

16

Telling the patient everything about diagnosis

Telling

77

77

Not Telling

18

18

Not sure

5

5

Number of visits to inform the patient about the diagnosis

Single visit

26

26

Partial Information

74

74

Telling the patient according to patient hope and survival lessens

Take their hope

47

47

Not taking

25

25

Not sure

28

28

Relying on the relative consent to inform the patient about the diagnosis

Rely on consent

29

29

Not rely on

42

42

Not sure

9

9

Decision about concealing the diagnosis

Tell the patient

41

41

Take him to another doctor

21

21

Avoid difficult questions

15

15

Tell the truth if the patient asks

14

14

Lie to the patient

9

9

Patients whom want to know about the diagnosis

Patients want to know

16

16

Do not want

66

66

Not sure

18

18

Depressing after breaking bad news

Depressed

77

77

Not depressed

17

17

Not sure

16

16

Stressful situations in breaking bad news

Explaining bad prognosis+ giving false hope

60

60

Explaining bad prognosis

21

21

Giving false hope to terminal patients

17

17

None of above

2

2

Avoid telling the patients about their final diagnosis

Avoid telling the patient

28

28

Do not avoid

60

60

Not sure

12

12

Doctors who used multi-bed hospital room to deliver bad news

Multi-bed hospital

21

21

No multi-bed hospital

64

64

Not sure

15

15

Preparing the patient for bad news among study group

Prepare

65

65

Do not prepare

28

28

Not sure

7

7

Giving follow-up plan and some hope

Give follow-up plan and hope

89

89

Do not give

4

4

Not sure

7

7

Know about breaking bad news policy

Know

26

26

Don’t know

48

48

Not sure

26

26

Table 2: Training, Perception and Practice regarding Breaking Bad News.

The most age group trained on breaking bad news was older than 35 years (75%), followed by younger than 25 years (51%), then (25 < 30) years old (44%), and the least trained age group was (30 < 35) years; only (35%). Male participants were more trained with (56%) versus (41%) for female doctors. Registrars were the most trained with (70%) followed by house officers (50%) then medical officers (36%). Study participants from family medicine were all trained (100%) then surgery (51%), obstetrics (50%), pediatrics (46%) and least trained were Participants from internal medicine with (32%). As shown in Table 3.

Parameter

Trained N(%)

Untrained N(%)

P. value

Age

< 25 years

16 (51.6)

15 (48.4)

0.0059

25 <30

21 (43.7)

27 (56.3)

30 < 35

6 (35.3)

11 (64.7)

>35

3 (75.0)

1 (25.0)

Gender

Male

17 (56.7)

13 (43.3)

0.014

Female

29 (41.4)

41 (58.6)

Clinical Position

House officer

17 (50.0)

17 (50.0)

0.0024

Medical officer

17 (36.2)

30 (63.8)

Registrar

12 (63.1)

7 (36.9)

Specialty

Obstetrics & Gyn.

12 (50.0)

12 (50.0)

0.0019

Pediatrics

12 (64.1)

14 (35.9)

Internal Medicine

9 (32.1)

19 (67.9)

Surgery

10 (52.6)

9 (47.4)

Family Medicine

3 (100)

0 (0.0)

Table 3: Correlation of Demography, Clinical Position and Specialty with Breaking Bad News Training.

4. Discussion

To the best of the author's knowledge, this is the first study in the perception of doctors in breaking bad news in the River Nile State and in Sudan as a whole, assessing the perception and experience of the doctors in breaking bad news.

There are few studies regarding this issue in developing countries especially Africa, in one study conducted in southeastern Nigeria regarding breaking bad news in clinical setting between health professionals, they found that only 22.1% of health professionals received formal training about BBN, they concluded that large proportion of respondents in this study were incompetent in BBN, as they showed low level of training and little knowledge about BBN concept and policies [4]. The results of this study demonstrate that more than half of doctors didn't have training in breaking bad news due to lacking of the training programs in Sudan, in contrast to the similar study done at comprehensive cancer center, at King Fahad Medical City, Riyadh, Saudi Arabia [5] which reveled about 70% of their doctors had training in breaking bad news. In a survey conducted among patients in tertiary care hospitals in Pakistan, most respondents (40.5%) stated that it is absolute right to know about breaking bad news [6]. The current study showed about 50% of doctors preferred to discuss diagnosis issues with close relatives rather than the patient because they felt more comfortable and easier to handle it with them, and this finding is in agreement with a similar study performed in the Qassim region and published at Oman Medical Specialty Board [7]. In our study showed 77% of doctors feeling depressed after breaking bad news and describe that's more stressful situation, 60% of study group when explaining bad prognosis, they gave false hope to the patient and their families. More than 60% of our doctors preparing and informing their patients about bad news in multi visits, trying to reduce the psychological impact. Our hypothesis is there may be big limitation in awareness, training and implementation of principles of breaking bad news. The purpose of this study is to evaluate the perception of doctors in breaking bad news in Atabra, Ad-damer and Alsalam teaching hospitals through a cross-sectional descriptive hospital-based study conducted in Atabra, Ad-damer and Alsalam teaching hospitals from December 2018 to January 2019. This study is novel and constitute a basis for further studies and work up concerning breaking bad news in River Nile State and across Sudan.

5. Conclusion

From this cross-sectional study, we concluded that there is good relationship between the level of training and the clinical position of doctors. Also, our study showed that the obstetricians and pediatricians were well-trained rather than other specialties. Half of doctors thought that the family should be told first about bad news. Unfortunately, the majority of doctors didn't hear about the global policy of breaking bad news.

Acknowledgment

The authors are grateful and deeply indebted to their family members, friends, colleagues for their unconditional support and encouragement.

Conflicts of Interest

The authors have no conflicts of interest to declare.

Ethical Statement

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Contributions

(I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

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