Berek and Hacker's Gynecologic Oncology, 5th Edition

23

Communication Skills

Robert Buckman

Walter F. Baile

 

In gynecologic oncology, as in all branches of medicine, the clinical encounter with the patient (and often the family) has four specific aims. The first is to gather information from the patient (essential for determining the clinical diagnosis); the second is to transmit information to the patient (necessary to communicate the treatment plan); the third is to build a relationship (necessary to establish rapport and trust); and the fourth is to support the patient and her family through the crisis of her illness. When accomplished successfully, these aims will achieve the overarching goals of producing objective improvement in the patient's medical condition (“helping the patient get better”), if that is possible.

The last two aims take on particular significance because as a result of the increased survival rates of many cancers, the relationship with the oncologist and the clinical team now can extend over many years and encompass a progression of disease crises. The median survivals for women with advanced-stage ovarian cancer has increased substantially over the past 20 years, and it is not uncommon today for patients to experience remission and recurrence four or five times during the course of their cancer (1). However, each disease recurrence can be a crisis in which the patient receives bad news again and must endure the rigors of a new round of treatment, uncertainty about the outcome, and the threat of death. In these instances, the application of supportive communication skills in the context of a long-standing relationship with the patient can reduce anxiety, facilitate patient coping, and assist in providing the patient with hope (2,3,4,5).

Regardless of whether medical improvement is possible, accomplishment of these goals can produce amelioration of the patient's subjective symptoms (“helping the patient feel better”). Communication skills are essential for both. This chapter sets out a basic and practical approach to acquiring and improving effective communication skills.

Why Communication Skills Matter

Good communication skills facilitate the clinician's ability to take an accurate clinical history and therefore to make a correct diagnosis and formulate an appropriate plan of management. Hence, communication skills are a central component of every clinician's management skills. In addition, however, good communication skills change the patient's attitude to the entire medical intervention.

Effective communication changes the way a patient feels about the clinical outcome. Communication skills may affect what the patient perceives has happened to her, as well as her assessment (and feelings) about her management, her treatment, and her health care team (6). Communication and interpersonal skills matter greatly to patients and are an important determinant of satisfaction with care (7). In fact, the literature suggests that patients are both likely to choose and to change physicians based on how they perceive their physician communicates and interacts with them (8).

An important and related issue is one of medicolegal implications. Communication skills have been shown to be a determinant of more objective outcome measures, such as litigation. Approximately three-fourths of complaints against medical practitioners are caused not by matters of medical management but by failures or obstacles in communication.Levinson and Chaumeton (9) further showed that communication skills were a major factor in distinguishing those clinicians who were sued from those who were not.

Patients are very sensitive to communication messages from their oncologists. Using samples of dialogue from interactions between surgeons and their patients, Ambady et al. (10) were reliably able to predict those surgeons more likely to be sued. Those whose voice communicated lack of empathy and concern toward the patient were more than twice as likely to have had a malpractice claim filed against them. Furthermore, many insurance companies in North America now reduce their malpractice premiums for physicians who have attended specific programs in communication skills.

Communication skills are essential for ensuring informed consent, enlisting the family in the care of the patient, reducing the uncertainty associated with a new or recurrent illness, and increasing accrual to clinical trials (11,12).

Communication Skills as Learnable Techniques

Why Communication Skills Are So Difficult to Learn

Most oncologists have had little preparation in communicating with patients (11,13,14). Almost none have had any formal course work, and a fair number have learned by observing other clinicians (certainly no guarantee that anything useful will be learned!). Moreover, many clinical encounters, such as breaking bad news and making the transition to palliative care, are highly emotionally charged. The clinician is challenged not only to address the patient's feelings, but also his or her own, which can be characterized by the sense of helplessness and frustration in the face of incurable disease, or self-doubt about having done everything possible for the patient (12,15). Sometimes these feelings may cause the doctor to offer false hope to the patient, avoid discussing issues important to the patient such as disease prognosis (16,17), or offer treatment when there is little or no chance of success (18).

Acquiring Communication Skills

Since the late 1970s, clinicians have become increasingly aware of the need for improved communication skills, but it has been difficult to define and test techniques that can be acquired by practitioners. In the late 1970s and early 1980s, it was widely believed that communication skills were intuitive—almost inherited—talents (“You've either got the gift or you haven't”). This was coupled with the belief that somehow the physician would be able to feel or sense what the patient was thinking and to divine what the patient wanted, and would then be able to respond intuitively in an appropriate way. This belief alienated a large proportion of health care professionals who found the whole topic (as taught at that time) excessively “touchy-feely,” intangible and amorphous, with no guidelines that could lead even a highly motivated practitioner to improve his or her skills.

Since the mid-1980s, researchers and educators have shown that communication skills can be taught and learned (and retained over years of practice), and that they are acquired skills, like any other clinical technique, and not inherited or granted as gifts from on high (19,20,21,22,23).

The main part of this chapter describes two practical protocols that can be used by any health care professional to improve her or his communication skills. They are (i) a basic protocol, the CLASS protocol, that underlies all medical interviews; and (ii) a variation of that approach, the SPIKES protocol, for breaking bad news.

Illustrations of Practical Techniques

The CLASS and SPIKES protocols are summarized briefly using simple and practical guidelines or rules. Both protocols have been published in greater detail elsewhere as a textbook (24), a booklet (25), and in illustrated form using videotaped scenarios of interactions between standardized patients (26). Review of this video material can enhance the understanding of these communication techniques.

 

CLASS: A Protocol for Effective Communication

There are probably an infinite number of ways of summarizing and simplifying medical interviews, but few (if any) are practical and easy to remember. The five-step basic protocol for medical communication set out in the following sections, which has the acronym CLASS, has the virtue of being easy to remember and to use in practice. Furthermore, it offers a relatively straightforward, technique-directed method for dealing with emotions. This is important, because one study showed that most oncologists (more than 85%) believe that dealing with emotions is the most difficult part of any clinical interview (27).

Trust and rapport are especially important to patients at times of illness crisis, and communication skills such as exemplified in the CLASS protocol underpin the establishment of confidence and a working relationship with the patient and her family.

In brief, the CLASS protocol identifies five essential components of the medical interview. They are Context (the physical context or setting) and Connection (or building rapport), Listening skills, Acknowledgment of the patient's emotions, Strategy for clinical management, and Summary (Table 23.1).

C—Context (or Setting) and Connection (or Building Rapport)

The context of the interview means the physical context or setting, and connection means the steps that are necessary to begin building rapport or a relationship with the patient.Both of these steps are important because they encourage trust on the part of the patient and family, an essential ingredient of any collaborative endeavor. They are especially important in the first encounter, during which often the most lasting impressions are formed. The essential components are listed in Table 23.2. The first component is to arrange the space optimally. The second is to get your own body language right. It is important to pay attention to eye contact, to whether touch is helpful, and to making introductions.

A few seconds spent establishing these features of the initial setup of the interview may save many minutes of frustration and misunderstanding later (for both the professional and the patient). These rules are not complex, but they are easy to forget in the heat of the moment.

Spatial Arrangements

The Setting

Try to ensure privacy. In a hospital setting, if a side room is not available, draw the curtains around the bed. In an office setting, shut the door. Get any physical objects out of the way—e.g., move any bedside tables, trays, or other impediments out of the line between you and the patient. Ask for the television or radio to be turned off for a few minutes. If you are in an office or room, move your chair so that you are adjacent to the patient, not across the desk. There is evidence that conversations across a corner occur three times more frequently than conversations across the full width of a table (28).

Table 23.1 The CLASS Protocol

C—Physical context or setting and connection

L—Listening skills

A—Acknowledge emotions and explore them

S—Management strategy

S—Summary and closure

Table 23.2 The Elements of Physical Context

Arrangement

Sitting down, placement of patient, appropriate distance.

Body language

Drop shoulders, sit comfortably and attentively.

Eye contact

Maintain eye contact except during anger or crying (“not when hot”).

Touch (optional)

Touch patient's forearm if you and the patient are comfortable with touch.

Introductions

Tell the patient who you are and what you do. Introduce others.

 

Clear any clutter and papers away from the area of desk nearest to the patient. If you have the patient's chart open, make sure you look up from it and do not talk to the patient while reading the chart. If you find any of these actions awkward, state what you are doing (“It may be easier for us to talk if I move the table/if you turn the television off for a moment”).

Then—the most important rule of all—sit down. This is an almost inviolable guideline. It is virtually impossible to assure a patient that she or he has your undivided attention and that you intend to listen seriously if you remain standing up. Only if it is absolutely impossible to sit should you try and hold a medical interview while standing. Anecdotal impressions suggest that when the doctor sits down, the patient perceives the period of time spent at the bedside as longer than if the doctor remains standing. Thus, not only does the act of sitting down indicate to the patient that he or she has control and that you are there to listen, but it saves time and increases efficiency. Before starting the interview itself, take care to get the patient organized if necessary. If you have just finished examining the patient, allow or help her to dress to restore the sense of personal modesty.

Distance

It is important to be seated at a comfortable distance from the patient. This distance (sometimes called the “body buffer zone”) seems to vary from culture to culture, but a distance of 2 to 3 feet between you usually serves the purpose for intimate and personal conversation (28). This is another reason why the doctor who remains standing at the end of the bed (“six feet away and three feet up,” known colloquially as “the British position”) seems remote and aloof.

The height at which you sit can also be important; normally, your eyes should be approximately level with the patient's. If the patient is already upset or angry, a useful technique is to sit so that you are below the patient, with your eyes at a lower level. This often decreases the anger. It is best to try to look relaxed, particularly if that is not the way you feel.

Positioning

Make sure that whenever possible, you are seated closest to the patient and that any friends or relatives are on the other side of the patient. Sometimes relatives try to dominate the interview, and it may be important for you to send a clear signal that the patient has primacy.

Have Tissues Nearby

In almost all oncology settings, it is important to have a box of tissues nearby. If the patient or relative begins to cry, offer them tissues. This not only give overt permission to cry, but allows the person to feel less vulnerable when crying.

Your Body Language

Try to look relaxed and unhurried. To achieve an air of relaxation, sit down comfortably with both your feet flat on the floor. Let your shoulders relax and drop. Undo your coat or jacket if you are wearing one, and rest your hands on your knees. (In psychotherapy, this is often called “the neutral position.”) Pay attention to your nonverbal behavior because it may communicate that you are listening or concerned. For example, if you are listening with your arms folded in front of you, the patient may feel that you have already made up your mind about things and are not open to further discussion.

Eye Contact

Maintain eye contact for most of the time while the patient is talking. If the interview becomes intense or emotionally charged—particularly if the patient is crying or is very angry—it is helpful to the patient for you to look away (to break eye contact) at that point.

Touching the Patient

Touch may also be helpful during the interview if (i) a nonthreatening area is touched, such as the hand or forearm; (ii) you are comfortable with touch; and (iii) the patient appreciates touch and does not withdraw.

Most clinicians have not been taught specific details of clinical touch at any time in their training (29). They are, therefore, likely to be ill at ease with touching as an interview technique until they have had some practice. Nevertheless, there is considerable evidence (although the data are somewhat “soft”) that touching the patient (particularly above the patient's waist to avoid misinterpretation) is of benefit during a medical interview (30). It seems likely that touching is a significant action at times of distress and should be encouraged, with the proviso that the professional should be sensitive to the patient's reaction. If the patient is comforted by the contact, continue; if the patient is uncomfortable, stop. Touch can be misinterpreted (e.g., as lasciviousness, aggression, or dominance), so be aware that touching is an interviewing skill that requires extra self-regulation.

Starting Off

Introductions

Ensure that the patient knows who you are and what you do. Many practitioners, including the author, make a point of shaking the patient's hand at the outset, although this is a matter of personal preference. Often the handshake tells you something about the family dynamics as well as about the patient. Frequently the patient's spouse also extends his hand. It is worthwhile making sure that you shake the patient's hand before that of the spouse (even if the spouse is nearer) to demonstrate that the patient comes first, and the spouse (although an important member of the team) comes second. The “white coat syndrome” is a well-known phenomenon that describes how the medical setting induces anxiety in many patients (often even leading to blood pressure increases!), so that a friendly greeting may go a long way at putting the patient at ease. Also remember to introduce others in the room (e.g., medical students, nurse) that the patient may not know.

L—Listening Skills

As dialogue begins, the professional should show that she or he is in “listening mode.” For a general review of interviewing skills, see Lipkin et al. (31). The four main points to attend to are covered in the following sections. They are the use of open questions, facilitation techniques, the use of clarification, and the handling of time and interruptions(Table 23.3).

Open-Ended Questions

Open questions are simply questions that can be answered in any way or manner of response. In other words, the question does not direct the respondent or require her to make a choice from a specific range of answers. In taking the medical history, of course, most of the questions are, appropriately, closed questions (“Do you have swelling of the ankles?” “Have you had any bleeding after your menopause?”). In therapeutic dialogue, when the clinician is trying to be part of the patient's support system, open questions are an essential way of finding out what the patient is experiencing as a way of tailoring support to the patient. Hence, open questions (“What did you think the diagnosis was?” “How did you feel when you were told that …” “How did that make you feel?”) are a mandatory part of the “nonhistory” therapeutic dialogue.

Facilitation Techniques

Silence

The first and most important technique in facilitating dialogue between the patient and clinician is silence (32). If the patient is speaking, do not talk over her. Wait for the patient to stop speaking before you start your next sentence. This, the simplest rule of all, is the one most often ignored, and it is most likely to give the patient the impression that the doctor is not listening.

Table 23.3 Fundamental Listening Skills

Switch onyour listening skills and techniques to show that you are an effective listener.

1.

Open Questions

 

Questions that can be answered in any way (e.g., “How are you?” "“How did that make you feel?”)

2.

Facilitating

 

Pausing or silence when patient speaks. Try not to interrupt. Nodding, smiling, saying “mm hmm,” “tell me more about that,” and the like repetition (i.e., repeating one key word from patient's last sentence in your first sentence)

3.

Clarifying

 

Making overt any ambiguous or awkward topic

4.

Handling Time and Interruptions

 

With pagers and phones: acknowledge the patient who is with you as you answer Tell patient about any time constraints and clarify when discussion will resume

 

Silences also have other significance: they can be—and often are—revealing about the patient's state of mind. Often, a patient falls silent when she has feelings that are too intense to express in words. A silence, therefore, means that the patient is thinking or feeling something important, not that she has stopped thinking. If the clinician can tolerate a pause or silence, the patient may well express the thought in words a moment later.

If you have to break the silence, the ideal way to do so is to say “What were you thinking about just then?” or “What is it that's making you pause?” or something to that effect.

Other Simple Facilitation Techniques

Having encouraged the patient to speak, it is necessary to prove that you are hearing what is being said. The following techniques enhance your ability to demonstrate this.

In addition to silence, you can use any or all of the following simple facilitation techniques: nodding, pauses, smiling, saying “Yes” “Mmm hmm,” “Tell me more,” or anything similar.

Repetition and Reiteration

Repetition is probably the second most important technique of all interviewing skills (after sitting down).

To show that you are really hearing what the patient is saying, use one or two key words from the patient's last sentence in your own first one (“I just feel so lousy most of the time.” “Tell me what you mean by feeling lousy.”). Reiteration means repeating what the patient has told you, but in your words, not hers (“Since I started those new tablets, I've been feeling sleepy.” “So you're getting some drowsiness from the new tablets.”). Both repetition and reiteration confirm to the patient that she has been heard.

Reflection

Reflection is the act of restating the patient's statement in terms of what it means to the clinician. It takes the act of listening one step further and shows that you have heard and have interpreted what the patient said (“If I understand you correctly, you're telling me that you lose control of your waking and sleeping when you're on these tablets.”).

Clarifying

Patients often have concerns about treatment or other issues related to their care. When not asked about them directly, they may hint or express them in nuances, protests, or questions that are not clear. Listed below are some examples of how important information may be indirectly communicated.

Statement: “I don't know how my family can take any more of this.”

Patient means: “I really feel guilty.”

Statement: “I just couldn't stand another round of chemo.”

Patient means: “I felt so awful when my hair fell out.”

Statement: “Doctor, how long do you think I have to live?”

Patient means: “I wonder if I'll see my grandson graduate.”

Statement: “What will the end be like?”

Patient means: “How much will I suffer?”

As the patient talks, it is very tempting for the clinician to go along with what the patient is saying, even when the exact meaning or implication is unclear. This may lead very quickly to serious obstacles in the dialogue.

It is important to be honest when we do not understand what the patient means. Many different phrases can be used (“I'm sorry—I'm not quite sure what you meant when you said …” “When you say …do you mean that … ?”). Clarification gives the patient an opportunity to expand on the previous statement or to amplify some aspect of the statement, now that the clinician has shown interest in the topic. The key to addressing questions is to use clarifying statements that get at the issue underlying the concern.

 

Table 23.4 Acknowledgment of Emotions: The Empathic Response

Acknowledging the emotional content of the interview is the central skill of being perceived as sensitive and supportive.

The central technique is the empathic response.

1.

Identify the emotion

2.

Identify the cause or source of the emotion

3.

Respond in a way that shows you have made the connection between (i) and (ii) (e.g., “that must have felt awful,” “this information has obviously come as quite a shock”)

The empathic response is a technique or skill—not a feeling. It is not necessary for you to (i) experience the same feelings as the patient, or (ii) agree with the patient's view or assessment.

Handling Time and Interruptions

As clinicians, we seem to have a notorious reputation for being impolite in our handling of interruptions—by phone, pager, or other people. Too often, we appear abruptly to ignore the patient we are with and go immediately to the phone or respond immediately to the pager or to our colleague. Even though we may not realize it, this appears as a snub or an insult to the patient we are with.

If you cannot hold all calls or turn off your pager (and most cannot), at least indicate to the patient that you are sorry about the interruption and will return shortly (“Sorry, this is another doctor that I must speak to very briefly—I'll be back in a moment.” “This is something quite urgent about another patient—I won't be more than a few minutes.”). The same is true of time constraints (“I'm afraid I have to go to the O.R. now, but this is an important conversation. We need to continue this tomorrow morning on the ward round …”).

A—Acknowledgment (and Exploration) of Emotions

The Empathic Response

The empathic response is an extremely useful technique in an emotionally charged interview, yet is frequently misunderstood by students and trainees (Table 23.4).

The empathic response has nothing to do with your own personal feelings. If the patient feels sad, you are not required that moment to feel sad yourself. It is simply a technique of acknowledgment, showing the patient that you have observed the emotion she is experiencing. It consists of three mental steps:

  • Identifying the emotion that the patient is experiencing.
  • Identifying the origin and root cause of that emotion.
  • Responding in a way that tells the patient that you have made the connection between steps 1 and 2.

Often, the most effective empathic responses follow the format of “You seem to be …” or “It must be …” (e.g., “It must be very distressing for you to know that all that therapy didn't give you a long remission” or even “This must be awful for you”). The objective of the empathic response is to demonstrate that you have identified and acknowledged the emotion that the patient is experiencing, and by doing so, you are giving it legitimacy as an item on the patient's agenda. In fact, if the patient is experiencing a strong emotion (e.g., rage or crying), you must acknowledge the existence of that emotion or all further attempts at communication will fail. If strong emotions are not acknowledged in some way, you will be perceived as insensitive, and this will render the rest of the interaction useless.

S—Management Strategy

There are several useful techniques to ensure that you construct a management plan with which the patient concurs and will follow (Table 23.5). The following are useful guidelines:

  • Determine what you judge to be the optimal medical strategy. In your mind (or out loud), define the ideal management plan.

 

Table 23.5 Management Strategy

A reasonable management plan that the patient understands and will follow is better than an ideal plan that the patient will ignore.

1.

Think what is best medically, then …

2.

Assess the patient's expectations of her condition, treatment, and outcome (summarize this in your mind, or clarify and summarize aloud, if needed).

3.

Propose a strategy.

4.

Assess the patient's response (e.g., what stage of action is the patient in: precontemplation, contemplation, implementation, or reinforcement phase?).

5.

Agree on a plan (as far as possible).

Table 23.6 Summary and Closure

Ending of the interview has three main components.

1.

A précis or summary of the main topics you have discussed

2.

Identification of any important issues that need further discussion (Even if you do not have time to discuss them in this interview, they can be on the agenda for the next.)

3.

A clear contract for the next contact

  • Assess (in your own mind or by asking the patient) what are her own expectations of her condition, treatment, and outcome. Be aware if there is a marked “mismatch” between the patient's view of the situation and the medical facts, because you are going to have to work harder to make the plan appear logical and acceptable.Bearing in mind your conclusions from steps 1 and 2, propose your strategy. As you explain it to the patient;
  • Assess the patient's response. For example, make note of the patient's progress in forming an action plan (the stages are often defined as the precontemplation, contemplation, implementation, and reinforcement phases). Acknowledge the patient's emotions as they occur, and continue in a contractual fashion to arrive at a plan that the patient has “bought into” and that she will follow. Check the patient's understanding by asking her to repeat back to you what you have told her (don't just ask if she understood; most of the time she will say yes, even if she hasn't).

S—Summary

The summary is the closure of the interview. In gynecologic oncology, the relationship with the patient is likely to be a continuing one and a major component of the patient's treatment. The closure of the interview is an important time to emphasize that point.

It is relatively straightforward to cover three areas in the summary (Table 23.6). They are (i) a précis or reiteration of the main points covered in the dialogue; (ii) an invitation for the patient to ask questions; and (iii) a clear arrangement for the next interaction (“a clear contract for the contact”). This part of the interview is not necessarily long, but does require considerable focus and concentration.

SPIKES: A Variation of CLASS for Breaking Bad News

Among the various types of medical interviews, breaking bad news is a special case, and one of exceptional importance for both parties in the clinician-patient relationship (24,33,34).

Bad news can best be defined as “any news that seriously adversely affects the patient's view of her future” (35). In other words, the “badness” of bad news is the gap between the patient's expectations of the future and the medical reality. This is crucially important because what is good news for one patient (e.g., “I'm really glad they could operate on this tumor,”) may be very bad for another (e.g., “I don't think I can take another operation”). In gynecologic oncology, bad news is common at many stages in a patient's history: (i) initial diagnosis; (ii) recurrence or disease progression; (iii) clinical deterioration; (iv) development of new complications; and (v) change from therapeutic to palliative intent. It is necessary to have a protocol that will function in all of these circumstances.

 

Table 23.7 The SPIKES Protocol for Breaking Bad Newsa

S—;Setting = Context, connection and listening skills

P—Patient's perception of condition and seriousness

I—Invitation from patient to give information

K—Knowledge—giving medical facts

E—Explore emotions and empathize as patient responds

S—Strategy and summary

aA variant of the basic CLASS approach.

The SPIKES protocol has been designed specifically for these purposes and allows assessment of the patient's expectations before sharing the information (Table 23.7).

S—Setting (= Context + Listening Skills)

In the SPIKES protocol, for the sake of convenience, we have combined two phases of the CLASS protocol—the context (see Table 23.2) and listening skills (see Table 23.3)—into “setting.”

P—The Patient's Perception of the Situation

The cardinal rule of breaking bad news is to find out what the patient already knows or suspects before going on to share the information. To condense this into a slogan, one might say “Before you tell, ask.”

The exact words used to find out how much the patient already understands are a personal choice (Table 23.8). (“Before I go on to tell you about the results, why don't you tell me what you've been thinking?” “When you first developed that swelling of the abdomen, what did you think was going on?” “Had you been thinking this was something serious?” or “What did the referring medical team tell you about your medical condition?”).

As the patient replies, pay particular attention to her vocabulary and comprehension of the subject. When starting to give information, it is very helpful if one can start at the same level of knowledge as the patient (36).

I—Getting a Clear Invitation to Share News

Next, try to get a clear invitation to share the information (Table 23.9). Most patients want full disclosure. There has been a steady increase in the desire for honest information from Oken's (37) study in 1961, when 95% of surgeons did not disclose to their patients a cancer diagnosis. Twenty years later, a study by Novack et al. (38) showed a dramatic reversal of this proportion. Regarding the proportion of patients who state they want to be informed, Jones's (391) study in 1981 showed that 50% of (British) patients wanted to know. Since then, there have been many studies that all put the proportion of patients who want full disclosure at above 90% (40,41,42).

Table 23.8 Patient's Perception of Condition

Ask the patient to say what she knows or suspects about the current medical problem (e.g., “What did you think when …?” or “Did you think it might be serious … ?”).

As the patient replies

Listen to the level of comprehension and vocabulary.

Note any mismatch between the actual medical information and the patient's perception of it (including denial).

 

Table 23.9 Invitation from Patient to Give Information

Find out from the patient if she wants to know the details of the medical condition or treatment (e.g., “Are you the sort of person who … ?”).

Accept patient's right not to know (but offer to answer questions as patient wishes later).

Disguising the information or lying to the patient is highly likely to be unsatisfactory. The phrase one uses to obtain a clear invitation is again a matter of personal choice and judgment (“Are you the sort of person who'd like to know exactly what's going on?” “Would you like me to go on and tell you exactly what the situation is and what we recommend?” or “How would you like me to handle this information? Would you like to know exactly what's going on?”) Once this is determined you can set goals for the interview, e.g., “So now I'm going to explain what the MRI showed.”

It is important to respect cultural norms that may delineate how bad news is discussed. For example, in some Middle Eastern countries, the word “dying” is not used, and in others, bad information is felt to cause the progression of the patient's illness (e.g., in some Native American tribes, giving bad news is felt to make the situation worse) (43).

K—Knowledge (Explaining the Medical Facts)

Having obtained a clear invitation to share information, begin by giving the medical facts and simultaneously be aware of (and sensitive to) the patient's reaction to the information—in other words, giving the information and responding to the patient's emotions should proceed simultaneously.

The most important guidelines for giving the medical facts are shown in Table 23.10.

  • Begin at the level of comprehension and use the vocabulary that the patient indicated (this is called aligning).
  • Use plain, intelligible English (avoid the technical jargon of the medical profession—“medspeak”). Give information in small amounts.
  • Check that the patient understands the information before going further (use phrases such as “Do you follow what I'm saying?” “Is this clear so far?” “Am I making sense so far?”).
  • Use a narrative approach to make sense of what has occurred: Explain the sequence of events and how the situation seemed as events unfolded (“When you became short of breath, we didn't know whether it was just a chest infection or something more serious. So that's when we did the chest x-ray … ”).
  • Respond to all emotions expressed by the patient as they arise (see below).

E—Emotions (Exploration and Empathic Response)

The acknowledgment of emotions is more important in an interview about bad news than it is in most other interviews (see the “A—Acknowledgment” section in the CLASS protocol, previously; Table 23.4).

The doctor can effectively use an empathic response on his or her own feelings if they are becoming intense (“I'm finding this very upsetting, too.”).

The value of all empathic responses lies in the fact that one is making an observation that is almost unemotional in itself about an issue that is heavily charged with emotion(whether the patient's or the doctor's). The fact that this is experienced by the patient as supportive is why an empathic response cools the temperature of a fraught moment and facilitates the exploration of the situation without causing escalation.

Table 23.10 Knowledge: Giving Medical Facts

Bring the patient toward a comprehension of the medical situation, filling in any gaps.

Use language intelligible to the patient, and start at the level at which he or she finished.

Give information in small pieces.

Check the reception: Confirm that the patient understands what you are saying after each significant piece of information.

Respond to the patient's reactions as they occur.

 

S—Strategy and Summary

Close the interview with a management strategy and closure, as described in the “S—Strategy” and “S—Summary” sections for the CLASS protocol (see Table 23.5).

Dealing with Hope and False Hopes

Many clinicians and patients often say “But you can't take away hope.” Frequently this is used by clinicians as an excuse for not telling the patient the truth. Usually, the real rationale behind this is to protect the clinician from discomfort, not the patient.

Clinicians are more likely to create major problems for themselves if they promise cure when that is not possible or hold out unrealistic hopes. Supporting the patient and reinforcing realistic hopes is part of the foundation of a genuinely therapeutic relationship. Setting realistic goals for treatment early on allows the patient to “hope for the best while preparing for the worst” (44,45).

The important thing is not whether to tell the truth (there is a moral, ethical, and legal obligation to do so if that is what the patient wants), but how to tell the truth. Insensitive and ineffective truth-telling may be just as damaging and counterproductive as insensitive lying. In practice, the preceding protocols allow the truth to be told at a pace determined by the patient and in a way that allows recruitment and reinforcement of the patient's coping strategies.

Communication in Palliative Care

In palliative care, communication skills are even more important than in acute care—and may sometimes be the only therapeutic modality available to the clinician (46). In palliative care, communication may have at least three distinct functions: (i) in taking the history; (ii) in breaking bad news; and (iii) as therapeutic dialogue (i.e., support of the patient).

Even when the prognosis is acknowledged to be grave, there may be stages in which some hopedfor improvement or stabilization is not achieved. In these circumstances, the SPIKES protocol can be helpful, even when the clinician and the patient already have a long-standing relationship.

At other times, simply listening to the patient and acknowledging the various emotions and reactions she is experiencing is in itself a therapeutic intervention. This is particularly true in discussions about dying. When a patient realizes and acknowledges that she is dying, there is no “answer” the clinician can give. Instead, listening to the questions, issues, and emotions is a valuable service.

Talking to Family Members

Family members are an important component of the psychological context surrounding the patient. Often they may assist the clinician in confirming the medical facts and supporting the patient as she responds to the information. Sometimes, however, individual family members may be at a different phase of acceptance or understanding of the medical information than the patient. This is called discordance, and it can be a serious and additional problem for the clinician. The important guideline is to seek and maintain clarity in talking to the relative. The clinician must stress that he or she is looking after the patient (not the relative), and empathic responses can be used to acknowledge and explore the emotions underlying the relative's state.

This is particularly true in a potential conflict, such as when a relative tells a clinician, “My mother is not to be told the diagnosis.” This is a common and awkward situation, and it requires care and effort to emphasize the primacy of the patient's right to knowledge (if that is what she wants), while at the same time underlining the relative's importance and value as part of the patient's support system.

Another exceptionally difficult situation for the clinician is telling a relative that the patient has died. The central principle is to use a narrative approach to the events, but to be prepared at any instant to respond to the relative if he or she asks whether the patient has died.

 

Communication with Other Health Care Professionals

Medical professionals are only human. Sometimes under great stress, they may become shorttempered, rude, aggressive, or impatient. This is almost unavoidable. With good communication skills, the resulting damage can be minimized.

The two principles that are most useful are (i) clarification and (ii) acknowledgment of the situation (using empathic responses). Whenever one responds to an emotion by acknowledging it with a relatively unemotional empathic response, the dispute will deescalate. It is also worth remembering the old adage that “an ounce of prevention is worth a pound of cure.” Giving information early (a “preemptive information strike”) prefaced as a “for your information” discussion may prevent major disputes or discontent later (“Why didn't you tell me … ?”).

Motivation and Manners

Like any clinical intervention, effective communication requires motivation to be successful. If one is motivated to be a good clinical communicator, it is achievable. Some of it depends on having a basic strategy for the task, and the protocols presented here should be helpful. The rest is largely a matter of having an awareness of the effect of what one says and does on the patient and her family. There is a great deal of courtesy and common sense mixed in with the specific strategies. It is important to be mindful of the fact that if chosen poorly, words can be scalpels, but if chosen carefully, they can be perceived by the patient and family as a source of comfort and support.

Communication tasks are of enormous importance in the relationship between doctor and patient. As has been said, “Do this part of your job badly and they will never forgive you; do it well and they will never forget you.”

References

  1. Armstrong DK. Relapsed ovarian cancer: challenges and management strategies for a chronic disease. Oncologist 2002;7(suppl 5):20-28.
  2. Sardell AN, Trierweiler SJ. Disclosing the cancer diagnosis: procedures that influence patient hopefulness. Cancer 1993;72: 3355-3365.
  3. Zachariae R, Pedersen CG, Jensen AB, Ehrnrooth E, Rossen PB, von der Maase H. Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease. Br J Cancer 2003;88: 658-665.
  4. Kerr J, Engel J, Schlesinger-Raab A, Sauer H, Holzel D. Doctorpatient communication: results of a four-year prospective study in rectal cancer patients. Dis Colon Rectum2003;46:1038-1046.
  5. Dimoska A, Butow PN, Dent E, Arnold B, Brown RF, Tattersall MH. An examination of the initial cancer consultation of medical and radiation oncologists using the Cancode interaction analysis system. Brit J Cancer 2008;98:1508-1514.
  6. Kaplan SH, Greenfield S, Ware JE. Impact of the doctor-patient relationship on the outcomes of chronic disease. In: Stewart M, Roter D, eds. Communicating with medical patients. Newbury Park, CA: Sage Publications, 1989:228-245.
  7. Bredart A, Bouleuc C, Dolbeault S. Doctor-patient communication and satisfaction with care in oncology. Curr Opin Oncol 2005;17: 351-354.
  8. Gandhi IG, Parle JV, Greenfield SM, Gould S. A qualitative investigation into why patients change their GPs. Fam Pract 1997;14: 49-57.
  9. Levinson W, Chaumeton N. Communication between surgeons and patients in routine office visits. Surgery 1999;125:127-134.
  10. Ambady N, Laplante D, Nguyen T, Rosenthal R, Chaumeton N, Levinson W. Surgeons' tone of voice: a clue to malpractice history. Surgery 2002;132:5-9.
  11. Albrecht TL, Ruckdeschel JC, Riddle DL, Blanchard CG, Penner LA, Coovert MD, et al. Communication and consumer decision making about cancer clinical trials. Patient Educ Couns 2003;50:39-42.
  12. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152:1423-1433.
  13. Hoffman M, Ferri J, Sison C, Roter D, Schapira L, Baile W. Teaching communication skills: an AACE survey of oncology training programs. J Cancer Educ 2004;19:220-224.
  14. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist2000;5:302-311.
  15. Wallace J, Hlubocky FJ, Daugherty CK. Emotional responses of oncologists when disclosing prognostic information to patients with terminal disease; results of qualitative data from a mailed survey to ASCO members. J Clin Oncol 2006 ASCO Annual Meeting Proceedings Part 1. Vol 24( 8S):8520.
  16. Taylor KM. “Telling bad news”: physicians and the disclosure of undesirable information. Sociol Health Din 1988;10:109-132.
  17. Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002;325:697-700.
  18. Harrington SE, Smith TJ. The role of chemotherapy at the end of life: “when is enough, enough?” JAMA 2008;299: 2667-2678.
  19. Garg A, Buckman R, Kason Y. Teaching medical students how to break bad news. CMAJ 1997;6:1159-1164.
  20. Baile WB, Kudelka AP, Beale EA, Glober GA, Myers EG, Greisinger AJ, et al. Communication skills training in oncology: description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer 1999;86: 887-897.
  21. Maguire P, Faulkner A. Improve the counselling skills of doctors and nurses in cancer care. BMJ 1999;297:847-849.
  22. Simpson M, Buckman R, Stewart M, Maguire P, Lipkin M, Novack D, et al. Doctor-patient communication: the Toronto consensus statement. BMJ 1991;393:1985-1987.

 

  1. Back AL, Arnold RM, Baile WF, Fryer-Edwards KA, Alexander SC, Barley GE, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med 2007;167:453-460.
  2. Buckman R, Kason Y. How to break bad news: a guide for health care professionals. Baltimore: Johns Hopkins University Press, 1992.
  3. Baile W, Buckman R. The pocket guide to communication skills in clinical practice. Toronto: Medical Audio-Visual Communications, 1998.
  4. Buckman R, Baile W, Korsch B. A practical guide to communication skills in clinical practice. CD-ROM or video set. Toronto: Medical Audio-Visual Communications, 1998.
  5. Baile WB, Glober GA, Lenzi R, Beale EA, Kudelka AP. Discussing disease progression and end-of-life decisions. Oncology 1999;13:1021-1031.
  6. Hall ET. The hidden dimension. New York: Doubleday, 1966.
  7. Older J. Teaching touch at medical school. JAMA 1984;252:931-933.
  8. Buis C, De Boo T, Hull R. Touch and breaking bad news. Earn Pract 1991;8:303-304.
  9. Lipkin M, Quill TE, Napodano J. The medical interview: a core curriculum for residencies in internal medicine. Ann Intern Med 1984;100:277-284.
  10. Frankel RM, Beckman HB. The pause that refreshes. Hosp Pract 1988;23:62-67.
  11. Ptacek JT, Eberhardt L. The patient-physician relationship: breaking bad news. A review of the literature. JAMA 1996;276:496-502.
  12. Billings AJ. Outpatient management of advanced cancer: symptom control, support, and hospice-in-the-home. Philadelphia: JB Lippincott, 1985:236-259.
  13. Buckman R. Breaking bad news: why is it still so difficult? BMJ 1984;288:1597-1599.
  14. Maynard DW. On clinicians co-implicating recipients perspective in the delivery of bad news. In: Drew P, Heritage J, eds. Talk at work: social interaction in institutional settings.Cambridge, UK: Cambridge University Press, 1992:331-358.
  15. Oken D. What to tell cancer patients: a study of medical attitudes. JAMA 1961;175:86-94.
  16. Novack DH, Plumer R, Smith RL, Ochitill H, Morrow GR, Bennett JM. Changes in physicians' attitudes toward telling the cancer patient. JAMA 1979;241:897-900.
  17. Jones JS. Telling the right patient. BMJ 1981;283:291-292.
  18. Meredith C, Symonds P, Webster L, Lamont D, Pyper E, Gillis CR, et al. Information needs of cancer patients in west Scotland: cross-sectional survey of patients' views. BMJ1996;313:724-726.
  19. Benson J, Britten N. Respecting the autonomy of cancer patients when talking with their families: qualitative analysis of semi-structured interviews with patients. BMJ1996;313:729-731.
  20. Northouse PG, Northouse LL. Communication and cancer: issues confronting patients, health professionals and family members. J Psychosocial Oncol 1988;5:17-45.
  21. Baile WF, Lenzi R, Parker PA, Buckman R, Cohen L. Oncologists' attitudes toward and practices in giving bad news: an exploratory study. J Clin Oncol 2002;20:2189-2196.
  22. Von Roenn JH, von Gunten CF. Setting goals to maintain hope. J Clin Oncol 2003;21:570-574.
  23. Back AL, Arnold RM, Quill TE. Hope for the best, and prepare for the worst. Ann Intern Med 2003;138:439-443.
  24. Buckman R. Communication in palliative care: a practical guide. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford textbook of palliative care. Oxford: Oxford University Press, 1998:141-156.