Medical schools have never been known for providing communication courses that teach physicians to initiate or discuss difficult topics with their patients. How does a provider approach a patient to talk about a serious diagnosis or procedure?
Being comfortable with talking about sensitive topics can be learned. Avoiding topics doesn’t help anyone; in fact, it can give false hope, delay necessary treatment, or impact patient compliance. It can hurt your credibility, too; patients want a provider who is honest and compassionate, as well as knowledgeable and skilled.
To get started, acknowledge that you’re nervous. But remember that your patients are counting on you to help them navigate their situation. Not to decide for them, but to give honest information that allows them to determine how to proceed.
Remember that only 7% of communication is verbal. Your voice is 38% and your body language is 55%. “Think quality, not quantity,” advises clinical supervisor and oncology expert Cyndi Cramer, BA, RN, PCRN. With this in mind, begin by setting the tone of the conversation:
- Remain seated during the appointment. Face the patient.
- Stay in the present. Put away your phone and ask staff not to interrupt.
- Maintain eye contact and use touch if appropriate.
- Keep your voice even. Don’t rush.
One way to start is to prepare the patient by saying something like, “I wish I had good news for you” or “This isn’t easy to talk about…” Now the patient understands that the discussion is a serious one. Use simple words and give small bits of information at a time. Don’t try to fill pauses; allow the patient to absorb what you’ve said and to ask questions.
The SPIKES Protocol
Dr. Robert Buckman, author of “Practical Plans for Difficult Conversations in Medicine: Strategies that Work in Breaking Bad News,” has created useful guidelines for handling sensitive discussions, including the SPIKES Six-Step Protocol, first published in The Oncologist, 2000:
1) Setting up the interview: Review the information to be presented. Also find the best possible way to provide some privacy. Have tissues nearby. Include one or two family members, if the patient agrees. Use the suggestions above to establish the tone of the meeting. Remember that your news may make the patient and family sad, they will be eager to hear any information you can share.
2) Perception of the patient: Before discussing the medical diagnosis and treatment options, take time to find out how the patient views their situation. Buckman suggests asking open-ended questions, such as, “What have you been told so far?” “Has anyone explain the reasons for the tests we’ve done?” Start with what the patient understands to know where to begin your explanation. You can also assess if the patient is ignoring important details or has unrealistic ideas about the prognosis.
3) Invitation from the patient to proceed: Although most patients do, never assume that a patient wants to learn everything. Choosing to receive little information, or to request it a little bit at a time can be a coping mechanism. Ask, “I have your test results. How would you like me to give you the information? Would you like it all now, or shall I give you some details now, and then answer your questions?
4) Knowledge and information for the patient: This is the step when you can warn the patient that you have bad news. “I’m sorry to tell you that…” Use language at the level the patient can understand. Avoid medical terms, as well as describing the situation in a way that leaves the patient with no hope. Even with a poor prognosis, there are other therapeutic actions that you can offer, such as pain control or assistance from a social worker.
5) Emotions and empathetic support: Responding to the patient’s emotions can be the most difficult part of the discussion, partly because it’s impossible to anticipate the range of response. Be prepared for anything from silence to rage, with sadness, disbelief, and crying in between. No matter the response, the physician can use four steps to offer empathetic support:
- Observe the patient’s emotion: shock, tearfulness, or fear are common.
- Verify the emotion with the patient by asking open questions or simply asking what they are thinking or feeling.
- Identify the reason for the emotion. Although it’s probably related to the bad news, it’s okay to ask for verification.
- After the patient talks about their feelings, connect the emotion with its reason. Buckman suggests moving closer and saying, “I know you’re sad (or other emotion) about (the news). It’s not what either of us wanted to hear.”
Until emotions have been acknowledged, it will be difficult to discuss other issues or options. Allow time for emotions and an honest empathetic response. If the patient remains silent, the physician should ask an open-ended question. When a patient makes a comment that sounds angry (“I guess this means more surgery and pain.”) the physician can say, “I can see this is upsetting for you.”) Do not go to the last step without determining how the patient feels and offering support.
6) Strategy and summary: Even in the face of bad news, patients feel less fearful and anxious when given a plan. However, do not launch into a treatment plan before asking the patient if they are ready to discuss it. Offering treatment options gives patients a sense of participation, helps maintain hope, and provides reassurance that their opinions matter. (Buckman also notes that it relieves the physician of some guilt if the treatment is not successful.)
The SPIKES Protocol was first used in oncology settings, but is adaptable for most other clinical situations that include sensitive or uncomfortable conversations. Physicians are already familiar with breaking complicated clinical processes into manageable steps. Using similar guidelines to improve patient conversations should be useful as well.
Although we think that most challenging conversations happen with patients, these conversations may be necessary within your practice, as well. There may be a staff member whose negative attitude is affecting the mood at the office. Another colleague may not be accepting appropriate responsibility. You may have to cut ties with a longtime vendor or business partner. Imtiaz Manji, Chairman of Spear Education, a company dedicated to supporting dental practitioners, says, “how far you get in life will depend a great deal on how willing you are to have difficult conversations.”
About the Author
Suzanne Ball is an experienced Registered Nurse with a Masters Degree in Health Sciences. She has worked in a variety of settings, including acute care, quality improvement, and research. She is a freelance writer who specializes in writing about medical and health topics.