A table, two chairs, a fake patient and a future doctor… In France, some pioneering establishments call on actors professionals to train future caregivers in difficult announcements. An innovative teaching approach.
It’s a sort of initiation rite which some one hundred and sixty students in the fourth year of the Faculty of Medicine of Montpellier indulge in each year. During one afternoon, they leave the school benches and the corridors of the hospital – where they are external –, heading for the National School of Dramatic Art in Montpellier. “You are trained in the relationship to the body, but not sufficiently in the human relationship. We are going to bring you that extra soul that medicine lacks”, announces the director Serge Ouaknine to the students. “The most difficult part of your career will be the relationship with patients and their families,” continues Marc Ychou, professor of oncology and director general of the Montpellier Cancer Institute (ICM). Four years ago, the two men1 imagined a theatrical workshop to train future doctors in an exercise that many dread: difficult announcements. To put them in situation, three professional actors play the role of patients and their relatives.
A consultation room equipped with a desk, three chairs and a bed: the staging is intended to be sober. “We have received the results of your latest exams. The cancer has recurred… We will have to adopt a new strategy with him, with you…”. Hugo, 34, is the first to launch under the gaze of his comrades. Facing him, Lison, 26, plays the role of a 35-year-old woman affected by a brain tumor. The actress was specifically trained in the exercise. “I was afraid of not being able to play my role sincerely, testifies Hugo. But the actress was so involved that, in just a second, I forgot it was “for fakes”. How do you tell parents that their child has cancer? Or to an elderly and isolated woman the entry into palliative care of her husband? How to get out of “medical jargon” and find the right words? When and how to name the disease?
In turn, the students take their places at the desk. Bursts of violence, silence, denial, disarray, distress… The actors go through the whole range of emotions. “Am I going to die, doctor? Some students, caught off guard, panic. When others shine with their maturity and adaptability. Like this student, who prefers a simple drawing to a long speech: “There, it’s your right breast. Here, these are the cancerous cells…” In the room, the tension is palpable. “We did not expect such a level of emotion,” comments Katia, 22, with tears in her eyes. According to an American study, an oncologist will have to announce nearly twenty thousand “bad news” during his career2. “We tend not to think about it too much,” continues Katia. This training forces us to open our eyes. »
The doctor, an actor in spite of himself
“The human is the soil of your profession, maintains Serge Ouaknine facing the assembly of students. Place your voice, speak softly while articulating, ask your patient: what does he feel? What did he pick up? Does he have any questions? And above all, take the time to listen to it… Act as if you have this time! “During the announcement, marking times of silence is important, underlines Isabelle Moley-Massol, psychoanalyst and psycho-oncologist (see p. 148). They will help the patient to mentalize the information, to integrate it little by little and at his own pace. »
A doctor with shifty eyes or riveted on the screen of his computer who shakes hands timidly or hastily; an interview that is constantly interrupted by phone calls… The two professionals will draw the students’ attention to the importance of all these elements relating to non-verbal communication. “You are a public figure, says Serge Ouaknine. Stand straight. Verticality is ethics! “The doctor is constantly on representation in front of the patients and their families, continues Professor Ychou. The slightest gesture, the slightest word is interpreted, sometimes dramatized. He is an actor in spite of himself! »
The students are then made aware of the repercussions of certain inappropriate formulations (“How are you?”, “I understand”) and others that are particularly harmful for the patient. “Unfortunately, we can no longer do anything,” says a student, immediately addressed by Professor Ychou: “That’s a mistake you won’t make again!” » « It is essential that the patient does not feel abandoned, that he knows that we can still do something for him, even if we can no longer obtain a cure, that he is still in a project of care: stabilizing the disease, relieving it, improving its quality of life…”, warns Isabelle Moley-Massol.
This training session is compulsory for all students in their fourth year of medicine at the faculties of Montpellier and Nîmes. Other universities (Nantes, Nice, Angers, etc.) have also turned to theater in order to train their future doctors through interactive workshops called “Théâtre forum”. On stage, professional actors interpret announcement situations, in the mode of counter-example. In the audience, about fifteen students decipher these sketches with their teachers. Train “communicating” physicians? “It’s anything but a communication course,” says Professor Ychou. Above all, it is important not to fall into the standardized announcement. We teach students to first listen to their patients and their relatives, to perceive these people they have in front of them in order to adapt their attitude, their speech, their position…”
A state-of-the-art method… abroad
“Hollywood invades the faculty of medicine! “, headlined in 1965 the Los Angeles Herald Examinerin reference to the pioneering work of Dr. Howard Barrows3. To train his interns in announcing a diagnosis, this American neurologist had the idea of calling on actors. He is now considered the father of the so-called “simulated” (or “standardised”) patient.
Since then, the use of this medical simulation technique, still confidential in France, has grown considerably abroad, where medical students practice technical gestures (know-how) on high-fidelity mannequins or virtual, and relational qualities (know-how) thanks to “simulated” patients. Leading countries? The United States, Canada, Israel, Switzerland… “Over there, the simulated patients are actors, members of the hospital staff trained in the exercise and even patients who have become ‘experts’ in their disease. All are paid, says Sylvie Angel4, psychiatrist. This technique is preferred by universities to train their medical students. Hospital centers also use it to ensure continuous training for all medical staff. »
“Never the first time on a patient”, this is the principle laid down in January 2012 by Pr Jean-Claude Granry and Dr Marie-Christine Moll, co-authors of a report for the Haute Autorité de santé (HAS) aimed at promoting the development of technical and relational simulation in France5.
1. Marc Ychou and Serge Ouaknine, authors of New Hippocratic Oath (The manuscript).
2. Source: “Giving bad news”, The Oncologist, August 20, 2015.
3. “The programmed patient, à technique for appraising student performance in clinical neurology”, Journal of Medical Education, 1964.
4. Sylvie Angel, author with Pierre Angel ofAvoid medical errors thanks to simulation (Odile Jacob).
5. “State of the art (national and international) in simulation practices in the healthcare field” by Jean-Claude Granry and Marie-Christine Moll (HAS, 2012).
Put an end to cancers announced by telephone
In 2008, the CHU of Angers was equipped with a simulation center. It is one of the most developed in France. On 1150 square meters, operating theaters, consultation rooms, recovery rooms… “We try to reproduce the hospital environment as well as possible”, explains Professor Granry, who directs it. Announcement of a serious illness, a death, a multi-organ sample… Scenarios have been developed beforehand by doctors trained in pedagogy through simulation. Interviews with professional actors are filmed and broadcast in an adjoining room where a trainer watches them live. The exercise will be followed by a debriefing with the participants and the trainers: what are the positive points? And those to improve? “Too many cancers are still announced by telephone or at the bend of a hospital corridor, calls out Pr Granry. It is unbearable and unacceptable. »
From simulated patient to virtual patient!
At the University of Aix-Marseille, Philippe Blache, CNRS research director at the Speech and Language Laboratory (LPL), and Magalie Ochs, teacher-researcher at the Information and Systems Science Laboratory (LSIS), are convinced that virtual reality can help the doctor-patient relationship. For two years, they have been developing training software for difficult announcements, based on the analysis of video recordings of simulation sessions at the University Hospital of Angers and the Paoli-Calmettes Institute in Marseille.
On his computer, the doctor is transported to a virtual recovery room. Thanks to a keyword recognition system, the virtual patient questions his doctor and encourages him to be clear. The software counts the number of complex medical terms pronounced by the doctor. And sensors make it possible to calculate the time during which he maintained visual contact with his patient.
“There are no right ways to deliver bad news, but some are less devastating”
Isabelle Moley Massol1psychoanalyst and psycho-oncologist
How is this moment of the announcement of the disease essential and founding for the patient?
This moment will forever mark the individual, his psyche, his imagination, his relationship to his being sick and to the disease. The announcement of a serious illness is a shock that can initially manifest itself in a state of stupefaction, that is to say a stupor that freezes the ability to think. This is why, very often, patients do not integrate the doctor’s explanations that follow the announcement of the diagnosis. They are subject to what has just been stated.
Can these announcements cause real trauma?
Some people remain traumatized by the announcement of the disease, even though they are healed in their body. Years later, they relive this moment identically, as if it were current: they feel the same dread, often associated with sensory perceptions, a noise, an image, a smell. There are no good ways to announce bad news, but some are less devastating than others, and can even be structuring when they respect the person’s ability to integrate the information: step by step, everyone’s rhythm, in a relationship of listening and empathy.
1. Author of Sick, illness and loved ones (The Archipelago).