A survey of Italian Physicians self-efficacy regarding communication skills and its correlation with a measure of "Burnout"

Background: The majority of practising physicians experience burnout. One of the factors most frequently advocated to increase such risk is breaking bad news (BBN). Several reports, by showing alteration of physiological indices, have empirically suggested that BBN may stress physicians, ultimately contributing to burnout. However, the association between the way serious news is broken and burnout has not been explored yet. In this study we investigated the correlation between burnout and physicians' self-efficacy regarding communication to patients. Methods: A 23-item questionnaire exploring attitudes and practice regarding BBN and the Maslach Burnout Inventory test were administered to 379 physicians from two University Hospitals. Associations were assessed by means of logistic regression models. Results: 226 (60%) returned the questionnaires. 76% of physicians acquired communication skills by observing mentors or colleagues, 64% considered BBN as discussing a poor prognosis, 56% reported discussing prognosis as the most difficult task, 38% and 37% did not plan a BBN encounter and considered it stressful. The overall burnout rate was 59%. At the multivariable analysis considering BBN as discussing a poor prognosis and a stressful task were related to high level of burnout (OR 2.42, p=0.042; OR 3.56, p=0.005); whereas planning the encounter and mastering communication skills even by just by means of reading relevant literature were correlated to low level of burnout (OR=0.43, p=0.037; OR=0.19, p=0.034). Conclusions: Our study identifies some physicians' BBN attitudes and knowledge of conceptual frameworks which may influence the risk of burnout and support the notion that increasing knowledge about communication skills may protect clinicians from burnout.

professions, characterised by 3 core dimensions: physical and emotional exhaustion (PEE), cynicism and depersonalization (CD), and low personal accomplishment (PA). [1,2] Recent studies have reported that more than 50% of medical doctors suffer from burnout. Such an epidemic negatively affects patient care, professionalism, physicians' health and safety, and the viability of health-care systems. Numerous individual and work-related factors contribute to develop the burnout of clinicians. [3] One of the most frequently advocated stressor is breaking serious news (BBN). [2,3] BBN, such as discussing diagnosis, disclosing a poor prognosis or discussing the transition to palliative care with patients and their families, is a core communication task in medicine. [4] The way BBN is conveyed may seriously affect patients and families. [5] However, BBN have consequences also for physicians, who may experience strong emotions and distress. By harnessing simulation methodologies and measuring physiological indices, such as heart rate and sweating indices, several studies have empirically demonstrated that BBN may provoke fear, anxiety, discomfort and burden of responsibility in physicians. All these causes of distress may ultimately lead to burnout, with detrimental consequences on clinical effectiveness. [6][7][8] Nonetheless, the association between the way serious news are broken and burnout has not yet been explored. [9] To that end, we have sought to determine the correlation between the frameworks and professional development opportunities physicians utilise regarding healthcare communication (HC) and how that relates to a metric linked with burnout.

Aim of the study
We have sought to determine the correlation between the frameworks and professional development opportunities physicians utilise regarding healthcare communication (HC) and how that relates to a metric linked with burnout.

Characteristics of the study
The study is a prospective observational study enrolling physicians working in two tertiary care hospitals (AOU-Policlinico di Modena and AOU-Ospedale Civile di Baggiovara) in Modena, Italy. The study was approved by the local Ethical Committee (CE protocol n°2 44/16). An informed consent was obtained from physicians participating to the study.
Participation was voluntary and no incentive was offered.

Study Population
The physicians enrolled into the study were 379. Of them, 226 (60%) completed the survey [ Figure 1A [4,10,11] The questionnaire was strictly confidential and anonymous. The following steps and key aspects of a clinician-patient encounter were investigated: 1) plan the encounter, 2) BBN, 3) discussing prognosis, 4) shared decision making process, 5) tracking and responding to emotions, 6) communication skill training (CST), 7) self-evaluation about communication skills. 16 out of 23 items were multiple choice and 7 had only one possible answer.

Burnout Questionnaire
Burnout was measured using the validated Italian version of the Maslach Burnout Inventory -Human Services Survey (MBI-HSS), 22-items. [1,12] The standard scoring for health care workers was used. Burnout syndrome was considered present if at least one of the three dimensions was severely abnormal, according to criteria proposed by Grunfeld et al. [12] Statistical Analysis Descriptive statistics of the study sample were calculated; mean and standard deviation were used for continuous variables, whereas absolute and percentage frequencies were used for categorical variables. Results were expressed in terms of odds ratios (OR) with 95% confidence interval (95% CI) and associated p-values, comparing each modality with the reference modality. Association between our observed covariates and the presence of burnout was assessed by means of logistic regression models. First, a single-item analysis was performed, where the dependent variable was the presence of burnout and the independent variables were all the separate answers to the same item of MBI-HSS. The single-item analysis was carried out for all the 22 items of MBI-HSS. Finally, a   multivariable analysis was also performed considering the presence of burnout as the   dependent variable and 12 items of the communication skills questionnaire at authors' choice and being a resident or a consultant as the independent variables. The 12 items, for a total of 34 covariates, were the following: 1, 2, 4, 7, 9, 10, 13, 14, 16, 17, 19, 20. These items were chosen because, in authors' opinion, they summarize the most important aspects of a clinician-patient encounter. Goodness-of-fit of our multivariable

Communication Skills Questionnaire
A full report of the results is included in Table 2 (table provided at  Among the most notable answers, there were the following: in the "plan the encounter" section, 139 physicians (62%) considered important to have a plan before BBN encounter.
However, only 86 (38%) admitted preparing one, while 87 (39%) reported not to have a plan for the encounter, providing lack of time (N = 76, 34%) and the idea that planning may not be necessary (N = 58, 26%) as the main causes.
When asked about "definition of BBN", 145 (64%) and 120 (53%) physicians answered that BBN means discussing a poor prognosis or talking about the end of disease-modifying treatment, respectively. Discussing prognosis and transition to palliative care were considered to be the most difficult tasks of BBN by 125 (56%) and 87 (39%) physicians. 168 (75%) of interviewees described BBN as emotionally engaging and 83 (37%) stressful.
The most difficult part of BBN was balancing hope with honesty for 162 (75%) physician. 59 (26%) reported this was dealing with patients' emotions.
As to "discussing prognosis", 139 (62%) physicians would be in favour of informing both patients and families about prognosis, mainly because they believe it promotes patients' coping skills and empowerment. Nevertheless, 125 (56%) physicians acknowledged that they disclose prognosis only by talking about the rates for cure and response of treatment options.
When asked about "sharing decision making", 167 physicians (74%) revealed they do not usually ask patients how much information they want to know before BBN, mainly because they think that it is already felt by patients as worrisome, and patients may get scared simply by such question [84 (37%)]. As to discussing treatment options, 157 (70%) physicians just recommended the best treatment, in their opinion for the patients, while 89 (40%) attempted to share the decision making. Only 81 (36%) declared to check the patients understanding at the end of every visit.
Regarding to "tracking and responding to emotions", 164 (73%) physicians thought fear to be the most common emotion showed by patients. Overall, 145 (64%) reported to address patients' emotions with empathic responses.
The vast majority of respondent (170, 76%) based their HC professional development by observing colleagues and/or relied on experience. Only 15 (7%) and 14 (6%) physicians, respectively, reported attended CS training courses or receiving this training in Medical Schools. 14 (6%) relied on learning CS from textbooks or the scientific literature. 188 (84%) physicians considered themselves to be at least fair at BBN and 130 (61%) to be empathic and professional, while 45 (21%) acknowledged themselves to be unskilled for the task. Three quarters of the sample admitted not having an evidence based approach and that a strategy to BBN would be helpful in their clinical practice.

Associations between physicians' communication skills and burnout
Single-item analysis In our single-item analysis, the following variables were related to high levels of burnout: 1) physicians believing that BBN means discussing a poor prognosis (p = 0.039); 2) physicians self-assessing BBN to be a stressful task for themselves (p = 0.001); 3) discussing prognosis only including the rates for cure (p = 0.036); 4) feeling unskilled at patient-physician relationship (p = 0.029) and 5) being a resident (p = 0.049). On the contrary, the following variables were found to be related to low levels of burnout: 1) considering BBN an emotionally engaging task (p = 0.042); 2) having a consistent plan for communicating with patients (p = 0.040); 3) responding to patients' emotions with empathic responses (p = 0.017); 4) discussing prognosis with the goal of promoting awareness of illness trajectory, therapeutic choices and to optimize patients' coping (p = 0.010); 5) sharing decisions with patients (p = 0.019); 6) developing CS by using textbooks and scientific literature (p = 0.011); 7) feeling to be good or very good at CS (p = 0.000); 8) graduation within the last 6 to 16 years (p = 0.003) [ Table 3A -(table provided at the   end of the manuscript)].

Multivariable analysis
The multivariable logistic regression model confirmed that: a) physicians believing that BBN means discussing a poor prognosis (OR 2.42; 95% CI 1.03 to 5.66; p = 0.042); b) physicians self-assessing BBN to be a stressful task for themselves (OR 3.56; 95% CI 1.46 to 8.71; p = 0.005) were related to high levels of burnout; whereas a) physicians referring to plan in advance before communicating with patients (OR 0.43; 95% CI 0.19 to 0.95; p = 0.037) and b) physicians reporting to have learnt CS from textbooks and scientific literature (OR 0.19; 0.04 to 0.89; p = 0.034) were correlated to low levels of burnout [Table 3B (table provided at

Discussion
This study collects descriptions and opinions of a sample of Italian hospital medical doctors on their own HC, including specific behaviours, thoughts, and feelings they might experience while getting ready for and performing difficult communication tasks.
Moreover, it informs some of the factors and how they might relate to burnout metrics.
Results are consistent with those of previous surveys, mainly focused on the disclosure of the diagnosis, such as that from the American Society of Clinical Oncology. [10,[13][14][15] The majority of our respondents believed that BBN mainly equals discussing a poor prognosis, that discussing prognosis is the most difficult communication task, and that BBN is very emotionally engaging or stressful. Most clinicians admitted not using a consistent evidence-based framework for BBN encounter, not asking the patients the amount of information they want to receive, and checking for understanding only if they think this may be impaired. Fear is generally reported as the most frequently emotion raised in patients while discussing such topics. Respondents rated themselves good or at least fair in BBN and mostly reported acquiring CS empirically by observing colleagues. Of note, they reported very low rates of CS training both at medical school and beyond.
Also the frequency of burnout in our population is similar to that reported in US practising physicians, where nearly 60% of them experience the syndrome at some point in their career. [2,16,17] In Europe, similar rates were documented among French and Swiss physicians, 49% and 70%, respectively. [18,19] Present data also confirm that younger medical doctors or residents have been reported to be exposed to an even higher risk. [20] The other important finding of our study is that, for the first time, it documents significant associations between some self-efficacy patterns regarding communication to patients and the risk of burnout. This study shows that physicians for whom BBN means discussing a poor prognosis and self-assessing BBN as a stressful task are exposed to a higher risk of burnout, from almost 2.5 to more than 3.5 fold, respectively.
Previous researches have so far reported that conversations with patients about prognosis have always been challenging for clinicians, either because many of them are concerned that honest information about prognosis can damage patients' hope or because they feel uncertain in estimating patients' survival. [21] In the last few years, while new therapeutic technologies have progressively enabled patients to live longer with their disease than ever before, this has become even more complex.
[22] Moreover, by demonstrating the increase of several physiological indices (e.g. heart rate, blood pressure, skin conductance, cortisol levels, etc…) during BBN encounters, other studies have empirically confirmed that physicians perceive BBN as a stressful task. [6][7][8] Our report supported by quantitative data suggests that these areas of self-efficacy, related to the distress, deriving from the uncertainty and the emotional burden, are linked to burnout.
Interestingly, clinicians who disclose prognosis only talking about the success rate of therapies find themselves at a higher risk of burnout -although this was detected only in the single-item analysis. This finding suggests that the sole conscious positive estimate of treatment efficacy may have unintended consequences not only for patients, who may be led to seek life-sustaining therapies even in phases where active treatments will not be helpful, but also for physicians, who expose themselves to burnout, by risking losing patients' trust when things get worse. [23] Our data show that an evidence-based theoretical framework for the encounter may be protective of burnout in a statistically significant manner. This is even more important if we consider that the majority of our interviewed physicians admit not to plan a BBN encounter because of lack of time or because they consider this approach to be worthless.
Previous qualitative studies found evidence that simple behavioral training has potential to positively affect physician-patient relationship and are felt beneficial by physician in terms of reducing BBN-related stress.
[24] Our findings supported by quantitative data the effectiveness of this approach, and, together with the data that physicians who delay serious news discussions may experience high levels of burnout, further validate the importance of planning difficult communication tasks as a burnout prevention strategy.
Furthermore, we found that physicians who are aware of communication skills by means of textbooks and scientific literature are exposed to low levels of burnout, in a statistically significant manner. Indeed, although understanding what patients want to know and delivering worrisome information may be stressful for clinicians, it has been reported that standard communication protocol may increase the confidence, the ability of physicians to disclose unfavourable medical information, eventually reducing the BBN related-stress, and may also increase patients' rating of medical professionalism.

Ethics approval and consent to participate
This study was conducted in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the local Ethical Committee (CE protocol n° 244/16).

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
The authors declare that they have no competing interests.