The hidden curriculum of breaking bad news: Identification of three dimensions and four communication patterns

Objectives: To explore students' observations in the hidden curriculum of physicians' breaking bad news interactions and identify dimensions and patterns within them. Methods: We qualitatively analyzed 156 written narrative descriptions of bad news encounters in the clinics written by senior medical students. Results: The analysis identified three dimensions within the encounters: providing information, dealing with emotions, and discussing treatment plans. These dimensions were observed in different proportions, identifying four communication patterns. Half of the encounters focused solely on presenting a treatment plan. Within them, the news was communicated abruptly while neglecting to share information or address emotions. Conclusions: Compared to the main literature on breaking bad news that focuses on two dimensions—the present study identified a third, prominent dimension—discussing the treatment plan. Half of the hidden curriculum experiences contradict the taught protocol, paying little/no attention to emotion and information. Practice implications: When teaching breaking bad news, it is essential to address the day-to-day practices students' observe. Students exposed to these encounters might misinterpret the physician's reliance on a single dimension as best practice. To mitigate this and help recognize their and others' tendency to focus primarily or solely on one dimension, we suggest a simple reflective prompt.