The Good News About Delivering Bad News

When her partner, Mickey Barron, was diagnosed with breast cancer in 2001, Dr. Rhonda S. Fishel accompanied her to the oncologist’s office. As an experienced surgeon, Fishel was no stranger to the delivery of bad news. She was the one who jotted notes furiously as the doctor discussed treatment options, while Barron’s mind struggled just to get past the word “cancer.”

“He was going on about treatments, and I was gone,” Barron recalled. “I was too stressed out.”

Four years later, when Fishel was diagnosed with a rare cancer called uterine sarcoma, it was Barron’s turn to listen carefully as her partner sat numbly.

“I never understood what it felt like physically until I had to go through it. It’s like a pain in your chest,” said Fishel, 51, who has reduced her hours as associate chief of surgery at Baltimore’s Sinai Hospital and director of its intensive care unit since being diagnosed and treated.

Fishel is convinced that patients often remember more about how their doctor broke bad news than they do about their diagnosis.

“You go into these rooms knowing that you’re going to destroy people’s lives,” Fishel said. Yet she has heard of colleagues who deliver bad news from the doorway of a patient’s hospital room and then quickly back out.

It’s a concern shared by other physicians who have developed a protocol for delivering news that they know will be devastating. “It acknowledges the fact that giving bad news is very hard and doctors aren’t taught those skills,” said Dr. Walter Baile, chief of psychiatry at the University of Texas MD Anderson Cancer Center in Houston.

Earlier in his career, he was director of consultation-liaison psychiatry at Johns Hopkins Bayview Medical Center. Five years ago he joined with Dr. Robert Buckman, an oncologist at Princess Margaret Hospital in Toronto, in creating the technique for cancer patients. They now teach it to professional oncologists and fellows throughout the country.

Known as SPIKES, which stands for “Setting, Perception, Invitation, Knowledge, Empathy and Strategy/summary,” it emphasizes skills that Buckman and Baile say are useful for physicians who have to deliver bad news.

As part of the six-step process, Baile says, physicians should take their time when delivering news to ensure that patients understand what is being said. Too many doctors, he says, toss too much medical terminology at their patients.

Baile said it also was critical to choose a location that was comfortable for the patient and to pay attention to the patient’s emotions as he received the information.

“The most important thing is to make an empathetic statement, to say something like, ‘I can see that you weren’t expecting bad news,’ or ‘wish’ statements like, ‘I wish there was something I could do.’ That’s very different from saying, ‘There’s nothing I can do,’ because that’s abandonment,” he added.

Fishel relies heavily on the SPIKES philosophy in a presentation she gives to young doctors and medical students titled, “Giving and Receiving Bad News: Lessons I’ve Learned.”

Fishel learned of SPIKES from a friend, an oncologist using it with her own patients. Fishel developed her talk after a nephew in medical school asked her to speak to his class last summer.

Having received her own cancer diagnosis by this time, she decided to develop something more substantive than the usual jargon-filled lecture accompanied by the gory pictures that medical students love.

“I thought a more relevant talk for young, upcoming physicians was bad news,” she said.

Here she parts company with Baile, who says he’s reluctant to give presentations to young medical students who don’t have the experience to put SPIKES into context.

“If you teach it too early in the medical career, before they’ve had patients, it really doesn’t make much sense to them. I think that students can learn it, but whether they retain it is the question,” Baile said.

Jay Bhatt, president of the American Medical Student Assn., disagreed. “I don’t think that it’s ever too soon to understand human interactions, human emotions and how that impacts people’s health,” he said.

In fact, the student group sponsors the End of Life Education Fellowship, a six-week program that matches medical students with doctors, nurses and social workers dealing with end-of-life issues.

Another supporter of teaching medical students how to deliver bad news is Dr. Jacek J. Mostwin, who teaches a training course titled “Patients, Physicians and Society” at Hopkins’ School of Medicine.

“I think the initiative should expand across the entire spectrum of physicians,” he said. “You need to introduce it at all levels, but it needs to be proportionate to the experience that people have.”

Mostwin’s course devotes two to three weeks to the topic of delivering bad news. During that period, students participate in simulated doctor-patient encounters that are evaluated by practicing physicians and watched by the class.

At the University of Maryland School of Medicine, Dr. Douglas Ross, an oncologist and professor who specializes in hospice care, says students are introduced to end-of-life issues within the first two years of their program. They begin visiting hospices during the junior year through a program funded by the National Cancer Institute.

However, they are only formally trained to use processes such as SPIKES once they are residents. “Our philosophy is that the medical students will often be taught by the residents, and we will not graduate residents unless they complete this training,” Ross said.

When she spoke to her nephew’s class at the Kirksville (Missouri) College of Osteopathic Medicine, Fishel said that the medical students were interested in hearing her advice on delivering bad news.

“The response was incredible,” she said. “None of the students left, even though it was exam week.”

Two weeks ago she brought the presentation home to an audience of nearly 100 at Sinai. The message combined humor, personal anecdotes and stories involving some of her breast cancer patients who have recovered from hearing the bad news and lead full lives.

She also joked about her now-hairless head (covered by a baby-blue bandana) -- the result of her own cancer treatments.

“This is what I call a hair-distribution problem,” she said. “When it falls off your head, it grows on your legs and your face.”

She wrapped up the talk with a three-minute photo presentation set to Celine Dion’s “I’m Alive,” finishing with an image of a triumphant, post-cancer Lance Armstrong winning the Tour de France.

After months of chemotherapy, Fishel’s cancer is in remission. Likewise for her partner, Barron, 51, a nurse practitioner.

“People would make plans like ‘Can you give this talk?’ And I’m like, ‘Well if I’m alive,’ ” Fishel recalled. “Now I have my energy back, which is one of the best things that you can have. I find myself using words like ‘grateful.’ ”

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(BEGIN TEXT OF INFOBOX)

This is the protocol developed by oncologists and psychiatrists for delivering bad news to patients:

Spelling out SPIKES

S Setting. Pick a private location.

P Perception. Find out how the patient views the medical situation.

I Invitation. Ask whether the patient wants to know.

K Knowledge. Warn before dropping bad news.

E Empathy. Respond to the patient’s emotions.

S Strategy/summary. Once they know, include patients in treatment decisions.

Source: The Baltimore Sun