Difficult Conversation Case: Missed Testicular Cancer
Correspondence should be addressed to Joshua Ginsburg, MD at joshua.ginsburg@utsouthwestern.edu
DOI: https://doi.org/10.21980/J8.52336
ABSTRACT:
Audience: We administered this case to senior emergency medicine (EM) residents, but it is appropriate for senior medical students and EM residents at all levels of training.
Introduction: The practice of emergency medicine regularly requires navigating challenging conversations and delivering difficult news. The way physicians interact with patients in these cases can significantly influence outcomes, including the patient’s understanding of their diagnosis and treatment plan, satisfaction with care, and willingness to follow medical advice. It is therefore imperative that emergency medicine residency training emphasizes communication skills, which will also be tested on the new American Board of Emergency Medicine (ABEM) Certifying Exam.1
Educational Objectives: This difficult conversation case is intended to assess the examinee’s ability to disclose sensitive, unexpected information to a patient regarding a missed diagnosis of testicular cancer. By the end of this session, learners should be able to, 1) demonstrate effective communication, including establishing rapport, acknowledging a prior misdiagnosis, and disclosing a revised diagnosis of cancer, 2) elicit and react to the patient’s emotional and informational needs in an empathetic and professional manner, and 3) convey a patient-centered plan of care, including appropriate next steps and coordination with specialist services.
Educational Methods: We created a 10-minute case in the style of an Objective Structured Clinical Exam (OSCE) requiring resident examinees to break bad news. The case was revised after pilot testing on two additional faculty members. Materials included a task sheet for examinees based on example Certifying Exam materials provided by ABEM, a script for examiners with specific attention to eliciting elements of the SPIKES and NURSE frameworks, and a scoring sheet. The faculty who created the case then served as examiners during a Mock Certifying Exam Day for PGY-3 Emergency Medicine residents; alternatively, this case can be run with a standardized patient. For the remainder of this case, we will refer to the person playing the role of patient as “examiner.”
Research Methods: Residents were evaluated using a 15-point rubric, with a score of 11/15 (73%) required to pass. The rubric, which was developed based on the objectives for Difficult Conversations Cases published on the ABEM website, included the following categories: establish rapport, determine baseline knowledge, disclose information, respond and react appropriately, and provide closure. Consistent with our program’s usual OSCE workflow, each resident was evaluated by a single faculty examiner. After completing the case, each resident completed an anonymous two-item evaluation: The first item, “This case increased my understanding of the certifying exam format,” was scored on a 5-point Likert scale from “strongly disagree” to “strongly agree.” The second item, “How would you rate the overall quality of this case?” was scored on a 5-point Likert scale from “poor” to “excellent.” The survey and protocol were reviewed by our institutional IRB on 12/3/2024, and this project was determined not to meet the definition of human subjects research.
Results: Seventeen PGY-3 emergency medicine residents completed the case, with a mean score of 13.35/15. Seventeen residents (100%) completed the post-case evaluation. When asked if this case increased understanding of the certifying exam format, 17 (100%) agreed or strongly agreed. When asked about the overall quality of the case, 17 (100%) said either very good or excellent. The case received a score of 4.82/5 for overall quality.
Discussion: This case was effective, as evidenced by the results that all residents agreed or strongly agreed that the case increased their understanding of the certifying exam content, and all residents considered the case quality to be very good or excellent. Residents overall performed well on the case but may benefit from additional instruction on disclosure of sensitive, unwanted, or unexpected information. Specifically, residents should be taught to use the SPIKES (Setting, Perception, Invitation, Knowledge, Emotions/Empathy, Strategy/Summary) or GRIEV_ING (Gather, Resources, Identify, Educate, Verify, Give Space, Inquire, Nuts and Bolts, Give) frameworks for breaking bad news and NURSE (Naming, Understanding, Respecting, Supporting, Exploring) statements for responding to emotions.2-4 This case and its grading rubric could easily be adapted to other difficult conversation scenarios to prepare emergency medicine residents or graduates for their certifying exam. However, because each resident was evaluated by a single examiner within one residency program, inter-rater reliability could not be assessed, and generalizability may be limited.
Topics: Difficult conversations, breaking bad news, communication, certifying exam preparation.
