The Complete Guide to Communication Skills

in Clinical Practice© including:

• Breaking Bad News
• Addressing Emotions
• Discussing Medical Errors
• Cultural Competence
• Challenging Emotional Conversations
with Patients & Families
• Effective Communication in Supervision

Walter F. Baile, M.D.

Professor, Behavioral Science & Psychiatry
Director,
Interpersonal Communication And Relationship Enhancement
(I*CARE) Program
 Many clinicians have not had the opportunity to develop their skills in managing difficult
patient encounters where there are strong emotions, stressed families or uncomfortable
conversations. This may be more so when transitioning a patient to palliative care or
discussing end of life. This pocket guide was created to help you hone your communication
skills in clinical practice.
The protocols (step-wise modules) in this guide can be used in many situations and were
created and developed by the late Robert F. Buckman, MD, PhD, Medical Oncologist and
myself and in collaboration with other communication skills experts (Antonella Surbone, MD,
PhD, FACP, Daniel Epner, MD, and Rebecca Walters, MS, LMHC, LCAT, TEP). Creative
contributions and editing were provided by the Interpersonal Communication And Relationship Enhancement
(I*CARE) Program Project Director, Cathy Kirkwood, MPH. The guide is designed to be used as a quick reference
and can be carried in your lab coat so you can review the information quickly before you begin a challenging
conversation. It is our hope that the information provided will assist you in extending your role beyond treating
disease to establishing a therapeutic and supportive alliance with the patient and family members.

Walter F. Baile, M.D.

Professor of Behavioral Science and Psychiatry
Distinguished Teaching Professor
Director, Program for Interpersonal Communication
And Relationship Enhancement (I*CARE)
Department of Faculty & Academic Development
Table of Contents
C-L-A-S-S A protocol for all medical interviews 2

S-P-I-K-E-S A protocol for breaking bad news to patients and family members 8

C-O-N-E-S A protocol for discussing a medical error with patients and family members 14

E-V-E A sub-protocol for any encounter when there are emotions present 18

B-U-S-T-E-R A protocol for challenging conversations with patients and family members 20

B-A-L-A-N-C-E A protocol for cultural competence 24

T-I-M-E-R A protocol for effective communication in supervision 28

1
 CLASS
Clinical Interview
The C-L-A-S-S Protocol
The C-L-A-S-S Protocol
Five Key Steps for Clinical Interviews

C - CONTEXT The physical set up of the area you choose for the interview

L - LISTENING SKILLS How to be an effective listener

A – ACKNOWLEDGE How to validate, explore and address emotions and concerns

S - STRATEGY How to provide a management plan that the patient can understand

S - SUMMARY How to summarize and clarify the conversation ensuring

comprehension

2
 C-Context (setting)
A private area with no distractions
Physical Space
• Choose an area where you can have a private conversation.
• Your eyes should be at the same level as the patient and/or family member
(sit down if you need to).
• There should be no physical barriers between you.
• If you are behind a desk, have the patient and/or family members sit across the corner.
• Have a box of tissues available.
Family Members/Friends
• The patient should be seated closest to you.
Body Language
• Present a relaxed demeanor.
• Maintain eye contact except when the patient becomes upset.
Touch
• Only touch a non-threatening area (hand or forearm).
• Be aware of cultural issues that may not allow touching.

3
L - LISTENING SKILLS
Be an effective listener.

Open Ended Questions

• “How did you manage with the new treatment?”
• “Can you tell me more about your concerns?”
• “How have you been feeling?”
Facilitating
• Allow the patient to speak without interrupting them.
• Nod to let the patient know you are following them.
• Repeat a key word from the patient’s last sentence in your first sentence.
Clarifying
• “So, if I understand you correctly, you are saying…”
• “Tell me more about that.”
Time & Interruptions
• If there are time constraints, let the patient know ahead of time.
• Pagers and phone calls – don’t answer, but if you must, apologize to the patient before answering.
• Try to prepare the patient if you know you will be interrupted.

A -ACKNOWLEDGE EMOTIONS
Explore, identify, and respond to the emotion.
The Empathic Response
• Identify the emotion.
• Identify the cause of the emotion.
• Respond by showing you have made the connection between the emotion and the cause.
“That must have felt terrible when...”
“Most people would be upset about this.”
• You don’t have to have the same feelings as the patient.
• You don’t have to agree with the patient’s feelings.

S –STRATEGY
Propose a plan that the patient will understand

The Plan
• Appraise in your mind or clarify with the patient their expectations of treatment and outcome.
• Decide what the best medical plan would be for the patient.
• Recommend a strategy on how to proceed.
• Evaluate the patient’s response.
• Collaborate and agree on the plan.
5
S -SUMMARY
Closing the interview
Final Thoughts
• Summarize the discussion in a clear and concise manner.
• Check the patient’s understanding.
• Ask if the patient has any other questions for you.
• If you don’t have time for further questions, suggest that they can be addressed
at the next appointment.
• Make a clear contract for a follow up visit.

6
7
 Breaking Bad News
The S-P-I-K-E-S Protocol

SPIKES


The S-P-I-K-E-S Protocol

S Setting Up the Conversation
P Perception

I Invitation
K Knowledge
E Emotions

S Strategy and Summary

8
 S – SETTING - Secure an appropriate area for the discussion.
• Have the conversation in a quiet undisturbed area.
• Prepare for what to say and anticipate the patient/family reaction.
• Have the key people (whom the patient wants) in the room.
• Seat the patient closest to you and have no barriers between you.
• Sit down, try to be calm, make eye contact.

P – PERCEPTION - Assess the patient’s understanding of the

seriousness of their condition.
• Ask what the patient and family already know.
“Tell me what you understand about your condition so far.”
“What did the other doctors tell you?”
“I’d like to be sure we are on the same page with understanding your condition,
so can you tell me…”
• Assess the patient and family members’ level of understanding.
• Take note of discrepancies in the patient’s understanding and what is actually true.
• Watch for signs of denial.

9
I – INVITATION - Get permission to have the discussion.
“ASK BEFORE YOU TELL.”
• Set goals for the discussion - ask the patient if they want
to know the details of the medical condition/treatment.
“I’d like to go over the results, would that be ok?”
“Today my plan is to discuss…is that okay?”
• Accept the patient’s right not to know.
• Offer to answer any questions the patient/family member may have.

K – KNOWLEDGE - Explaining the facts

• Avoid medical jargon by explaining the facts in a manner that the patient will understand.
NOT: “You have a nuclear grade 1ER/PR positive spiculated 4-centimeter lesion.”
BETTER: “You have a fairly good sized tumor in your breast.”
• Fill in any gaps that were evident in the “Perception” stage.
• Present the information in small chunks.
• After each chunk, verify the patient’s understanding.
“Are you with me so far?”

10
 E – EMOTIONS - The Empathic Response – Be Supportive
• Deal with emotions as they occur
(patients who are very emotional will not comprehend what you say).
• Use open-ended and direct questions to explore what the patient is feeling.
“Can you tell me more about how you feel?”
“Did that make you angry?”
• Respond to emotions with empathic and affirming statements.
“I can see you weren’t expecting this.”
“Most people would be upset finding this out.”
• Use “tell me more” statements.
PT: “I don’t know how I’m going to tell my kids.”
MD: “Tell me more about that.”
• Try to keep your own emotions from taking over.
• AVOID responding with false reassurance such as:
“Everything will be fine.”
“I’ve seen lots of miracles happen.”

Note: You don’t have to have the same feelings as the patient
nor do you have to agree with the patient.

11
S – STRATEGY & SUMMARY - Closing the interview
Strategy
• Decide what the best medical plan would be for the patient.
• Appraise in your mind or clarify with the patient their expectations of treatment and outcome.
• Recommend a strategy on how to proceed.
• Collaborate and agree on the plan.
• Ask the patient to repeat to you their understanding of the plan.
• Have a clear treatment plan in writing for the patient to take home with them.
Summary
• Summarize the conversation.
• Offer to answer questions. (be prepared for tough questions):
PT: “Does this mean I’m going to die?”
MD: “Tell me more about what concerns you?”
PT: “Can I be cured?”
MD: “I’m sorry to say that it is unlikely. Our goal is to keep it in check.”
PT: “How long do I have to live?”
MD: “I can discuss that with you, but first tell me why you ask?”

References
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. The Oncologist 5(4):302-11, 2000.
12
13
The C-O-N-E-S Protocol

Medical Error
CONES
The C-O-N-E-S Protocol
When You Have to Tell

C Context
O Opening Shot
N Narrative
E Emotions
S Strategy & Summary

Use the C-O-N-E-S Protocol when:

• Disclosing that a medical error has occurred
• There is a sudden deterioration in the patient’s medical condition
• Talking to the family about a sudden death

NOTE: The news should be delivered by the most senior person on the patient’s treatment team.
14
 C – Context
• Prepare for what to say and anticipate the patient/family reaction.
• Have the conversation in a quiet undisturbed area.
• Seat the patient closest to you and have no barriers between you.
• Sit down, try to be calm, maintain eye contact.
• Have a box of tissues available.

O – Opening Shot
• Alert the patient/family member of important news.
“This is difficult. I have to tell you what I found out about why your mother is so ill.”
“This is hard, but I have some information to give you that is important.”
“I must talk to you about your condition.”
“Thanks for coming in. I must tell you what is going on with your father.”

15


N – Narrative Approach
• Explain the chronological sequence of events.
“As you know, your mother came in back in…”
“Then, we gave her… and there was little improvement.”
“Last night we….and I just found out that …”
“In other words, she received too much chemotherapy.”
• Avoid assigning blame and/or making excuses.
• Emphasize that you are investigating how the error occurred.
“We started investigations and by the end of today I hope to be able to answer your questions
as clearly as possible.”
“I hope by the end of today she will turn the corner and start improving.”
• Offer a clear apology.
“I am really sorry that this has happened.”

E – Emotions
• Address strong emotions with empathic responses.
• Use the E-V-E protocol as soon as strong emotion occurs.
“I know it’s upsetting for you and it’s awful for me too.”
16
 “I know this is awful.”
“It’s very rare, but it does happen and I’m sorry to say that it did.”
• Beware of being pushed into making promises you can’t deliver.
• Avoid reassuring the person that there’s going to be a good outcome or that no harm was done.

S – Strategy & Summary

• Summarize the discussion and make specific plans for follow up.
• Let them know the situation is a priority.
“I am the doctor responsible for your mother so it is important that I found out what happened.”
“I’ll be open and honest with you when I have all the facts.”
“I can guarantee we will do our best.”
“Here is what I propose we do.”
“Let’s meet at the end of today or I can call you when I know more.”
• If you don’t know the answer, say so and that you will attempt to find out.
• Disclosing medical errors is now a standard. It’s not optional.
• Sensitive disclosures have a favorable impact on malpractice claims.

17
The E-V-E Protocol

Emotions
EVE
The E-V-E Protocol
Three elements to use any time strong emotion occurs

E Explore the Emotion

V Validate the Emotion

E Empathic Response

18
 E – Explore
• Explore and identify the emotion (anger, sadness, etc.).
• Find out more about the emotion and what is causing it.
“Can you tell me more about how you feel?”
• Acknowledge the emotion.
“I can see that made you very angry.”

V – Validate
• Let the person know you understand the emotion was appropriate.
“I can understand how that would make you angry.”
“Most people would feel that way.”

E – Empathic Response
• Respond in a way that shows you have seen the emotion and that you can understand it.
“I’m sorry this has happened and I understand how it would make you feel that way.”
“I hear what you’re saying. That must have been very difficult.”
“I get your point. It was obviously very upsetting.”
19
 Challenging Conversations
BUSTER
Challenging Emotional
Conversations with
Patients & Families
 “Emotional Labor is the mental work
used to recognize and minimize
emotions so they don’t rule the
conversation.”
When you feel like saying “Hey Buster,
Challenging Emotional this is how it is,” take a step back and use
the protocol below instead.
Conversations with
Patients & Families Be prepared
A guide to forming a therapeutic
Use non-judgmental listening
alliance with patients and families
Six second rule
Walter F. Baile, MD
Rebecca Walters, MS, LMHC, LCAT, TEP
“Tell me more” statements
Empathize and validate
Respond with a wish statement

20
 Be Prepared Use Non-Judgmental Listening
• Expect emotions (your own and • Remember it’s not about you, but about
theirs) to come your way. the other’s disappointments, fears, anxiety,
• Have a plan for how you will do it etc. which often underlie the anger, blame
(especially if you have to give bad or denial on the surface.
news). • Maintain eye contact.
• Monitor what you think and feel • Listen without interrupting only making
(awareness of your communication clarifying statements and paraphrasing.
can make you more effective). “So let me see if I understand…”
• Practice self regulation – Keep your “What I hear you saying is…”
own emotions in check when your • Put your own agenda aside until the
buttons are pushed. other person is finished.
• Aim to turn the confrontation into • Avoid trying to make a situation better
a conversation. when it is grave.
• Know when NOT to have “I’m sure things will not be as bad as
conversation (when emotions are you think.”
too intense).

21
Six Second Rule Empathizing and Validating to
Avoid escalation of conversation. acknowledge and diminish emotions.
• When your own emotions start to Acknowledge emotions by empathizing:
boil (especially in response to anger “I can see you weren’t expecting this.”
or blame), wait at least 6 seconds or “This isn’t easy to talk about, is it?”
more if needed for them to calm “It’s very stressful, isn’t it?”
down. “It must be hard to come here every week.”
• Avoid being defensive/blaming “I can see how difficult it is for you.”
“Well it didn’t work because you
waited too long to get help.” Respond with a Wish Statement
• Gather your thoughts and use Let the other person know you hear them and
skills such as “tell me more” or acknowledge that the goal may be desirable, but…
empathic/validating responses.
“I wish I had better news…”
“I wish I didn’t have to tell you this…”
Tell Me More “I wish we had a more effective treatment.”
Invite the person to expand on what they “I wish things had worked out better.”
are saying.
“Tell me more about your husband.”
“What happened after that?”
“What other concerns do you have?”

22
 Walter F. Baile, M.D.,
Professor of Behavioral Science
Important Tips Director, Interpersonal Communication
• Stay calm. And Relationship Enhancement
(I*CARE) Program
• Avoid phrases such as:
Department of Faculty &
“I know how you feel.” Academic Development
“I feel your pain.” The University of Texas
“It’s going to be alright.” MD Anderson Cancer Center
• When emotions/behaviors escalate
Rebecca Walters, MS, LMHC, LCAT, TEP
and you feel threatened/unsafe,
Director, Hudson Valley Psychodrama Institute
end the interaction.
I*CARE Faculty
“This conversation is making me
feel uncomfortable right now.” Cathy Kirkwood, MPH
I*CARE Project Director
“I don’t feel safe right now and can’t
Department of Faculty &
continue this conversation.”
Academic Development
The University of Texas
Resources
MD Anderson Cancer Center Email:
The six-second rule [email protected]
Goleman D. Emotional Intelligence 1995, For video demonstrations of these techniques,
Bantam Books please visit our Web site at:
www.mdanderson.org/icare
Free online CME available
23
 Cultural Competence
Culturally Competent

BALANCE
Communication
 Fundamental Principles:
• Cross-cultural medical encounters are increasing
in multi-ethnic societies.
• Cultural factors influence cancer survival rates and

patient/family quality of life.
• Cultural competence is a set of attitudes, skills and
Culturally Competent knowledge that can be acquired.
Communication • Respecting cultural diversity is key to delivering
comprehensive cancer care across the illness
Antonella Surbone, MD, PhD, FACP and trajectory.
Walter F. Baile, MD
• Cultural competence promotes patient-centered
care through sensitive negotiation of therapeutic
goals.

24
 The following vary across cultures: Where You Need Cultural
• role of autonomy in decision making, Competence
Most
• support available to help patients cope, • Truth-telling about diagnosis,
• role expectations of sick persons, prognosis and risks
• beliefs about cancer causation,
• EOL preferences (AD, DNR, hospice),
• Discussion of death and EOL choices
• patient/clinician/institution relationships. • Issues related to:
- family involvement in information
and decision making
Why Cultural Competence Can Help - use of alternative and
You Plan the Patient’s Care complementary cancer treatments
- reliance on spirituality and religion
• Discussion of cancer is a taboo in some for healing
cultures where the word “cancer” is still - attitudes toward psychological and
associated with death or guilt & shame. behavioral counseling
• Patients from diverse cultures rely on - concerns regarding clinical trials
different healing practices that can
often be incorporated into care plans.
• Ethnic/genetic/cultural differences can
affect treatment response directly or
through lifestyles.

25
7 Areas to Cover in Taking a Cultural Pearls
of Wisdom
History -“BALANCE” • Sensitivity to cultural issues enhances
trust between patients and doctors.
B Beliefs & Values (that influence • Initial time investment avoids later
perceptions of illness) misunderstandings and/or bedside
A Ambience (living situation and ethical conflicts.
family structure) • Personalized cancer care incorporates
patients’ and families’ culture and
L Language & Health Literacy (role of draws on community resources.
interpreters, accuracy of translation, ...................................................................
metaphoric meanings)
• Learn about the cultural groups most
A
Affiliations (community ties, frequently treated at your institution.
religious & spiritual beliefs) • Incorporate cultural into social history.
N Network (social support system) • Be prepared to briefly describe your
own cultural background.
C Challenges (cancer-related risks of
home, work & life conditions)

E Economics (socioeconomic status &

community resources)
26
Pearls
of Wisdom (cont’d.) Resources

• Always clarify your institutional and Cancer, Culture, and Health Disparities:
ethical norms in matters of truth- Time to Chart a New Course?
telling and decision making. Marjorie Kagawa-Singer, Annalyn Valdez
• Recognize your own biases toward Dadia, Mimi C.Yu & Antonella Surbone,
some cultural attitudes and practices. CA Cancer J Clin 2010; 60: 12-39
• Be aware how different families involve For more information visit:
themselves in decision making. www.mdanderson.org/icare
• Be sensitive to different cultural Antonella Surbone, M.D., Ph.D. F.A.C.P.
meanings of suffering and caregiving. Lecturer in Bioethics
Professor of Medicine
• Open your mind to different ways to New York University Medical School
promote health and cope with illness. I*CARE Program Faculty
Walter F. Baile, M.D.,
Professor of Behavioral Science
Director, Interpersonal Communication And Relationship
Enhancement (I*CARE) Program
Department of Faculty & Academic Development
The University of Texas MD Anderson Cancer Center
Cathy Kirkwood, MPH
I*CARE Project Director

27 ©
The University of Texas MD Anderson Cancer Center 2014
Effective Communication
in Supervision

Supervision
TIMER
 Set your TIMER for a Successful Conversation!
• Think Through the Encounter (ahead of time)
• Introduce Issues
• Manage the Discussion
• Establish a Plan and Expectations
• Revisit and Give Feedback

Effective Communication
in Supervision Think Through the Encounter (ahead of time)
Giving Corrective Feedback – • Be sure you have the right information/data you need.
The good, the bad and the ugly
• Run it by others if you need a reality check or advice.
• Have the endorsement of the “one up”
(upper management) to avoid being undermined.
Walter F. Baile, MD • Rehearse what you will say – Don’t let your thinking get
Rebecca Walters, MS, LMHC, LCAT, TEP catastrophic (focused on the worst possible outcome).
• Put on your “Feedback Hat.”
(Strive to help the person improve performance.)

28
Introduce the Issues
• Meet on their turf, if possible (being “called • Use the “Six Second Rule” - when your
into the office” may not lead to productive emotions boil, wait 6 seconds or until calm
conversation). before responding.
• Clearly state the issue using “I Statements” • Reaffirm the other person’s issue.
(tends to decrease defensiveness in others). “So what I hear you saying is…”
“I’m worried about your getting to clinic late…”
“I’m concerned about your interaction with…” • Align with the person by acknowledging
“I have something important to discuss about…” and validating emotions with empathy.
• Provide Facts – avoid personal stuff. “I can see you weren’t expecting this.”
“I know this is hard for you to hear.”
“In going over your attendance, I see that…” “I see your point.”
• Maintain eye contact. “This isn’t easy to talk about, is it?”
• Use “Wish Statements”
Manage the Discussion
“I wish I could change that.”
• Try to stay calm. “I wish I had better news.”
• Focus on what the other is saying. “I wish that I did not have to revisit the issue.”
• Try to be nonjudgmental and personal. It’s about
changing behavior.
• Use “Tell me more” to clarify.
“When you say you feel treated unfairly, can you
tell me more?”

29
Establish a Plan and Expectations Revisit and Give Feedback
• When emotions subside, work on the • State purpose of meeting.
problem together. “I wanted to meet with you to follow up on…”
• State your expectations. • Review agreed upon goals/agreements.
“It’s important that we resolve this.” • Get their perception.
• Collaborate/Negotiate/Brainstorm. “How are things going?”
“What are your ideas for how we can…?” • Praise Effort.
• State your goals. “I appreciate the work you put in to…”
“I’d like to see you try to…” • Give Feedback.
• Set SMART Goals: “You’ve really improved on…”
S=Specific “I think you’ve struggled with…”
M=Measureable • Brainstorm to further improve performance.
A=Achievable
“What will it take for you to bump this up a notch?”
R=Resourced
T=Timed
• Summarize
“So this is what we’ve decided.”

30
Feedback Resources

– when things have NOT changed.
Walter F. Baile, M.D.,
• State the problem. Professor of Behavioral Science
“I am concerned that you are still Director, Interpersonal Communication
coming to work late.” And Relationship Enhancement
• Explore the problem. (I*CARE) Program
“I’m wondering what’s gotten in the way Department of Faculty & Academic Development
of your following through with our The University of Texas MD Anderson Cancer Center
agreement?”

• Deal with emotions as they occur. Rebecca Walters, MS, LMHC, LCAT, TEP
“It sounds frustrating.” Director, Hudson Valley Psychodrama Institute
• Restate the need to improve. I*CARE Faculty
“This is really important so let’s brainstorm Cathy Kirkwood, MPH
some more as to how we can fix this.”
I*CARE Project Director
• State consequences. Department of Faculty & Academic Development
“I’m trying to avoid this being The University of Texas MD Anderson Cancer Center
moved to a higher level.” Email: [email protected]
For video demonstrations of these techniques, please
visit our Web site at:
www.mdanderson.org/icare
Free online CME available

31 ©
The University of Texas MD Anderson Cancer Center 2014
NOTES

NOTES
Notes

32
 Notes

33
To view video demonstrations of these protocols and our Telly Award winning program “Crossroads,”
please visit our Web site at: www.mdanderson.org/icare
Free online Continuing Medical Education (CME Ethics & Professional Responsibility) available
To order copies, please contact:
Cathy Kirkwood, MPH
Project Director, Academic Affairs
Interpersonal Communication And Relationship Enhancement (I*CARE) Program
MD Anderson Cancer Center – Faculty & Academic Development
The University of Texas MD Anderson Cancer Center
Mailing Address: PO Box 301407, Unit 1726, Houston Texas 77230-1407
Deliveries: 7007 Bertner Ave., 1MC17.2106, Houston, TX 77230-1407
Tel: 713-745-3138
Fax: 713-794-4236
[email protected]
Designed and Produced by Medical Graphics & Photography 2014