The experience of breaking bad news among undergraduate medical students a qualitative analysis in North African context

Abstract

Post-colonial medical education systems face systematic barriers when French-taught curricula encounter vernacular patient care, creating linguistic power imbalances that impede communication competency development. This study develops a Triple Burden Theoretical Framework to understand how linguistic hierarchies, cultural taboos, and emotional labor intersect in breaking bad news (BNN) training in Tunisia. Using constructivist grounded theory, we conducted a qualitative-dominant mixed-methods study with 45 third-year medical students at Tunisia's National Cancer Center (September–November 2024). Participants engaged in standardized Tunisian Arabic simulated cervical cancer disclosure scenarios. A theoretically informed rubric assessed four competency domains, while thematic analysis captured experiential barriers. Data triangulation through observational notes, reflections, and quantitative assessments enabled framework development (COREQ guidelines; κ = 0.84; member checking validation). The Triple Burden Framework revealed three interconnected constructs: (1) Linguistic Displacement—systematic barriers requiring French-to-Arabic medical terminology translation (22.2% unable to translate "cervix" to vernacular); (2) Cultural Silencing—institutional avoidance of fertility and intimacy topics; and (3) Emotional Abandonment—profound student distress without institutional support. Mean communication scores were 6.4 ± 2.0, with significant gender disparities (females 7.0 ± 1.8 vs. males 5.4 ± 1.9; p = 0.029). Session closure was the weakest performance area (0.9 ± 0.7), and students reported feeling emotionally overwhelmed and unprepared for clinical responsibilities. The proposed framework suggests that linguistic power dynamics may function as systematic barriers to communication training and may warrant consideration in ongoing discussions about decolonizing medical education. While developed in Tunisia, the framework may be transferable to other Francophone African contexts that share similar language‑of‑instruction and language‑of‑practice tensions, although this requires empirical testing.