Competence in Breaking Bad news tasks: A curriculum review of teaching and assessment at Moi Teaching and Referral Hospital Eldoret Kenya.

Purpose: The objectives of this study was to determine the adequacy of the medical training curriculum content and methodologies utilized in training doctors in breaking bad news tasks at MTRH. Methods: A mixed methods approach used to collect data. Qualitative data, focus group discussions and in-depth interviews; quantitative data; resident’s perception of the adequacy of the curriculum using a questionnaire. Study participants were postgraduate doctors and lecturers of communication skills. Data was collected using questionnaires and analysed in SPSS version 22, descriptive statistics and inferential statistics utilized in reporting the data. Qualitative data was analysed and presented thematically. A p-value of <_ 0.5 was set as significant for all tests. Results: Curriculum content and structure; 33% adequacy, teaching methodologies; 28.5% adequacy, Residents perception of various aspects of curriculum: helical or spiral with competence levels; n=70 (87.5%) No, 12.5% (10) yes, theoretical basis of communication skills covered n=46 (57.5%) No, 34 (42.5%) yes, breaking bad news training using task approach with task process n=51 (63.5%) No, 29 (36.25%) yes, Challenging situations in breaking bad news were addressed n=56 (70%) No, only 24 (30%) yes, Reflective approach in coping with the effects of breaking bad news 58 (72.5%) No, 22 (27.5%) yes. Conclusions: Overall, this study found that curriculum content and methodologies in breaking


Introduction
Breaking bad news (BBN) is a medical interview whose purpose is to pass unfavourable medical information to a patient: diagnosis of cancer, transition to palliative care and death were the main bad news in this study.
For doctors bad news is viewed objectively as diagnosis of potentially terminal disease, poor prognosis, failure of treatments and impending death (Heyse-Moore, 2009). These changes in the continuum of death and dying requires communication between the healthcare worker

Moi University, Kenya
Corresponding author: Dr. David Chumba Email: dchumba@yahoo.com and the patient, who on one hand is apprehensive of where he/she is going and the doctors treatment options which promises to reverse the trajectory. This conversation is difficult for anyone not only the doctors who are mandated by their profession not only to give the good 'all is well' but also the bad news of terminal illness.
Studies show that key communication skills elements in breaking bad news have been identified (Engel, 1990) (Nadelson, 1993) and can be taught using conventional and experimental methods (Spiro H. , 1992) (Spiro H. M., 1996) Despite evidence based training and inclusion in curricular, competence in this skill remains low and poor performance in BBN especially with cancer patients, has been shown to be associated with worse clinical and psychosocial outcomes, including worse pain control, worse adherence to treatment, and confusion over prognosis and dissatisfaction at not being involved in decision making (Hanratty, 2012). In other words, harm to patients which is against the norms of medical practice. The current study was therefore to review the curriculum content and methodology to determine its adequacy in making doctors competent in breaking bad news tasks.

Material and Methods
The study was approved Institutional Research Ethics Committee (IREC), at the CHS Moi University (FAN:IREC 1716) year 2016.

Research paradigm
The study was positioned within pragmatism paradigm where researchers focus on the 'what' and 'how' of the research problem (Creswell, 2007).

Research design
A Mixed methods study approach was used to gather data in this sequential explanatory mixed study. The primary quantitative data was produced using self-administered questionnaires related to questions about the adequacy of various aspects of the and qualitative data using focus group discussion (FGD) and in-depth interviews with the teachers (Creswell 2007).

Research question
Is the content and training methodology utilized in training doctors in BBN tasks adequate to make them competent?

Data production
Quantitative data was collected using the three questionnaires. After analysis of quantitative data, qualitative data; themes were generated after further scrutiny of data to complete analysis. (12.5%), family medicine 5 (6.3%) and reproductive health oncology 1 (1.3%). There were more men than women male 44 (55%) and female 36 (45%). All except 1 of the participants had worked below five years after graduation. The mean age of the participants was 37.4 years.

Various aspects of curriculum No Yes
Curriculum structure is helical or spiral with competence levels 70 (87.5%) 10 (12.5%)

Discussion
The main findings in this study as indicated above is that the content and methodologies utilized in training of doctors are not adequate. This similar to other studies where curriculum content has been found to be the main issue in competence. Maguire and co-workers concluded that specific content would lead to an advantage over those without. Aspergen in one study found that the skills are easily forgotten if not maintained by practice, supporting the spiral structure of the curriculum. (Aspergen, 1999) (Laura, 2019) The curriculum allocates a total of nine units in the training of communication skills in year one and two and the amount of time allocated to these course seem justifiable as many studies have shown that these skills though short lived can still be effective in improving leaners Other studies have documented that training in clinical clerkships is more effective than in a pre-clinical courses; two high-quality studies from Maastricht (Kraan, 1990) (Bogels, 1996. Studies show that early in the program leaners have not yet been exposed sufficiently to clinical experiences for them to be able to effectively transfer their learning (McCarthy, et al. 2008.) The Canadian consensus statement (Donald, 1992), British General Medical Council has developed a helical approach to curriculum structure for undergraduate medical education (Martin, 2008).
Students moved to the clinical years without having been able to comprehend the connection between breaking bad news communication skills and clinical practice, this leads to theory-practice gap which has been extensively discussed in literature as source of significant deficiency in training of doctors (Chant, 2002) (Aspergen, 1999 Aspergen recommend for medical students to utilize the knowledge in communication skills, they should be given during clinical years and reinforced in practice. (Shulei, 2012) Shulei, looking at the status quo in humanistic education recommend horizontal "relevance" where the process of teaching, humanistic courses should be mutually penetrated with natural science and medical courses, overlapped with each other and Longitudinal "sequence" where humanistic courses should be set up at the preclinical stage, but are not finished at the preclinical stage and are extended to the entire process of teaching.
On paper this methodology included lectures, role plays, overviews, video and audio presentation, group work and simulated  et al., 2007).

Limitations of the study
Purposive sampling, self-reported subjective responses which lack objectivity, potentially put bias in the findings of this study hence the findings may not be generalizable to the larger population of residents