This study investigated the self-reported take-home messages of medical students after an early training module in breaking bad news (BBN). The findings will aid the discussion on how to teach BBN. Methods: We asked 592 second year medical students at two Dutch medical schools to write down what they had learned, right after their first communication skills training in BBN. We analysed these self-reported take-home messages using a hybrid form of qualitative content analysis using SPIKES as a

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... nceptual frame. Results: The most important take-home messages reported by students in both schools were: how to inform the patient (24,5%), how to deal with emotions (20,6%), and how to prepare for a BBN-consultation (16,9%). Additionally, students reported the professional quality "being patient-centered". Conclusions: Early communication skills training on BBN, including true stories and examples of doctors and their BBN-experiences, does not only give the students the knowledge how to break bad news to patients, but also which underlying professional qualities are needed to successfully break bad news. Good role models and realistic examples are therefore important. We propose a new mnemonic PRINSE (PReparation-INformation-Silence-Emotions) for novice learners in the design of a helical curriculum. with emotions?) and promoting reflection on one's behaviour. How learning methods influence learning outcomes and which teaching approach is more cost-effective is a topic of interest for further research. Strength and limitations Strength of this study is that it investigated for the first-time student's take-home messages after an introduction to BBN early in the medical studies. It also yielded an unusually high response rate, even for an anonymous data collection. Reasons for this were, in our opinion, the close connection of the data collection to the time and place of the teaching and the students' anticipated high relevance of adequate BBN for their future career. Furthermore, based on the study aims, a worldwide influential framework (SPIKES) was used to categorize the take-home messages. This framework was not able to fit all mentioned take-home messages, and thus we had to use open coding to describe the remaining learning outcomes. This could have made it possible that the individual teacher's favourite topic regarding breaking bad news was reflected in the mentioned messages in school 2, instead of student's selfformulated take-home messages. It might have been possible that an open coding strategy on the whole dataset had brought different findings. Another limitation of this study is, that we investigated the take-home messages immediately after finishing the workgroup or e-learning. We do not know, how the take-home messages change over time, when students had time to digest the new information about BBN. Furthermore, we were not able to observe student's actual performance on BBN after this first teaching, which could have taught us more about the possible gap between 'knows how' and 'shows how'. However, this study is a starting point for further investigation. . He is past president of the World Organization of Family Doctors WONCA. Research expertise is in long-term outcome of patients with chronic morbidity. Evelyn van Weel-Baumgarten MD PhD is an associate professor in medical communication, emeritus at the and president of EACH: International Association for Communication in Healthcare. Her interests include research and teaching of communication skills, including faculty development and implementation issues.