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‘The human element’: Creighton medical students take part in simulation on breaking bad news

Twenty fourth-year School of Medicine pediatrics students, a month from their minting as M.D.s, took part in a simulation on breaking bad news to the parents of children who have experienced severe trauma or a difficult diagnosis. She knew she had just delivered devastating news.

She felt the tension in the room. She heard the stifled sobs. She beheld the tear-streaked face.

And yet, winding down the conversation in which she had just broken the news of a Down syndrome diagnosis to the mother of a days-old, beautiful baby boy, Caitlin Jacowski did what she usually always does, what any person of polite bearing would do.

“Have a good morning,” she quietly told the crying mom.

The face-palm came later, but Jacowski held it together enough to continue soothing the “mother” — Omaha actress Melissa Rotolo, who has been a standardized patient in simulations for the Creighton University School of Medicine for the past nine years — and walk her through the veil of this difficult revelation.

In April, Jacowski was one of about 20 fourth-year School of Medicine pediatrics students who, a month from their minting as M.D.s, took part in a simulation on breaking bad news to the parents of children who have experienced severe trauma or a difficult diagnosis. While simulated, the exercise is far from fake, as the standardized patients — specially trained by simulation lab staff for these situations and some of whom, like Rotolo, are actors from the Omaha area — provide visceral reactions to the worst news a parent can get.

For 15 intense minutes, Jacowski had been spot on. She sat Rotolo down, put a hand on her knee and gave her tissues. She went through the diagnosis in layman’s terms, she assured the mother none of this was her fault, she told the mother her baby would live a happy, wonderful life with a loving mother. Jacowski even took ownership of a misstep the medical team had made in running a test without the mother’s knowledge.

“All your warm and fuzzy stuff was right there,” Rotolo said in providing some feedback for Jacowski after the session. “I really felt the empathy. You put a hand on my knee and looked into my eyes. But I’m definitely not going to have a good morning.”

“It just popped out,” Jacowski said afterwards. “Oh, I tried to eat those words the second I said them. It was just… It’s what I always say. It’s how you end a conversation politely, isn’t it? Obviously not that conversation. But that’s why we do this. We practice this and practice this, knowing that it will never be easy, but the feeling is very real as we do it and it reminds you: your patients are real human beings. This exercise is invaluable.”

In a few months, Jacowski and her fellow pediatrics students will be residents at hospitals across the country and, more than likely, broaching difficult conversations is a job that will fall to them at one time or another.

Under the mentorship of Terence L. Zach, M.D., a neonatologist and professor of pediatrics at Creighton, students take to the Clinical Education and Simulation Center on the fifth floor of the Creighton University Medical Center and, as they do in the classroom, work on their technique.

“As a neonatologist, by definition, I do this just about daily,” Zach said. “Some news is worse than other news — sometimes it’s just that the baby has to stay in the NICU for a few days, in other cases, the baby died — but on a fairly regular basis, this is something we do. We want the students to be able to have the experience before it really happens. It’s the old saying: ‘Tell me, I forget; show me, I may remember; involve me and I understand.’”

Students in the simulation learn to have a communications plan before breaking the news, learn how much words matter, how much body language matters, how even a brief mental rehearsal can help. The authenticity of the simulation was underscored by the standardized patients, who convincingly cried, broke down, raised their voices and provided a range of the perplexed emotions doctors face in such situations.

“When a student has a high level of empathy, I cry harder,” said Stacy Jolley, another standardized patient in the breaking bad news simulation. “But I try to run through the litany of responses, just to see how the student will respond.”

Typically, Zach said, not many medical schools offer a simulation like this one. But Creighton’s emphasis on treating the whole person, combined with educating the whole person, makes this one of the most poignant lessons many of the students will take away from their time in the School of Medicine.

The run-up to the actual simulation involves the students doing advanced preparation for breaking bad news, including reviewing video of other students and residents who participated in previous simulations. The students are also able to review their own performances on video and, when the simulation wraps up, there’s a group debriefing.

“I think they learn a lot from what is a very moving, emotional day,” Zach said. “When we’re talking about seeing the human element, they learn it’s OK to touch a shoulder or a knee, to pray with a family. They learn the best thing is often to deliver the news and just be quiet. They learn it’s OK to say ‘I don’t know.’”

The main takeaways from those sessions were succinctly illuminated by Jan Stawniak, BSN, RN, education director at the Clinical Education and Simulation Center, who provided the students with bits of last-minute advice.

“Don’t focus so much on the medical,” Stawniak said. “Leave that at the door and remember that this is a human being, going through human emotions. Connect with them on that plane.”

Fourth-year pediatrics student Tim Evans had the task of informing a mother her son had fallen out of a second-floor window and had a massive bleeding on the brain.

“Just trying to put yourself in the patients’ shoes and asking yourself, ‘How would I want a doctor to talk to me?’ makes this very worthwhile,” Evans said. “I think it’s an underutilized tool in medical education, so what we’re doing emphasizes how Creighton prepares us to care for the whole individual and the family. It says something about what’s valued at Creighton.”

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