College of Medicine

Community And Family Medicine

Dr. Beesan Maraqa , MD,MPH , SQIL, PBFM,

Family Medicine specialist
[email protected]

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 Communications Skills, Why?
- FOR DOCTOR: HELPS YOU COMMUNICATE WITH
YOUR PATIENTS (CONSULTATION).

- RELATIONSHIP WITH OTHERS & COLLEAGUES.

- RELATIONSHIP WITH YOUR PARTNER.

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Communication
Pillars of communications skills
1- Listening.

A- Involves asking, clarifying questions.

- Rephrasing.
- Summarizing.
- To insure understanding.
- Active listening.

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Pillars of communications skills
B- active listening

- Nodding your head

- That is interesting
- Maintaining eye contact
- Smiling
- Pauses: avoid risk of interrupting
- You show the other person that you are
giving careful consideration to what
they have to say.
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Pillars of communications skills
2- non verbal communication

- Body language
- Posture
- Eye contact
- Hand gestures
- Tone of voice: silence, timbre, pace, pitch, volume.

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Pillars of communications skills
3- clarity & concision

- Verbal communications means saying just

enough
- Think of what you wants to say clearly
- Avoid excessive talking.
- KISS: Keeping It Short & Simple
- KILL: Keeping It Long & Lengthy

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Pillars of communications skills
3- clarity & concision

- HAIL:
• H: honesty, clear & straight
• A: Authenticity: be your self, standing in your
own truth.
• I: Integrity: be you word.
• L: love: wishing people well.

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Pillars of communications skills
4- friendliness & assertiveness (self assured & confident)

- Through a friendly tone (greetings)

- Ask personal question or simply smile
- Assertive, insistent, persistent, you can be assertive without
being aggressive
- Involves respect the boundaries of others.
- Affirms their rights & points of view

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Pillars of communications skills
5- confidence

- Firm
- Expressing feelings forthrightly
- Know your rights
- Have control over your anger
- Willing to compromise with others.

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Pillars of communications skills
6- Empathy

- I understand where you are coming from.

- Respect others opinion
- Creates common ground
- Cooperative dynamics

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Pillars of communications skills
7- open mindedness

- Flexible & open mind

- Be open to understand the other person’s
point of view even with people you disagree
with.

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Pillars of communications skills
8- Respect

- To people & their ideas

- Using a persons name.
- Making eye contact
- Actively listening when a person speaks

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Pillars of communications skills
9- feed back

- Be able to give & receive feed back

- Giving praise: good job, thanks for taking care of that
patients.

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Pillars of communications skills
10- picking the right medium

- Breaking bad news: what you need

- Choosing the right words
- Be brief & clear e.g. E-mail

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 Is There a Good Way to Break Bad News?
Utilization of the SPIKES Protocol

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Communication
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Objectives

⚫ To define “bad news” in a medical setting

⚫ To understand the barriers to physicians delivering
bad news effectively
⚫ To introduce and break down the six components of
the SPIKES Protocol
⚫ To position the palliative care social worker as an
advocate and teacher for junior medical staff

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Definition of Bad News

“…any information which adversely and seriously

affects an individual’s view of his or her future.”

⚫ Recipient’s expectations and level of understanding

have an important bearing on the impact of bad
news.

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What Constitutes Bad News in a
Medical Setting?

⚫ New diagnosis of a potentially life-threatening

illness
⚫ Patient’s condition suddenly changes or is rapidly
declining
⚫ Curative treatments are no longer effective or not
an option
⚫ Devastating/disappointing test results
⚫ Limited or poor prognosis
⚫ Shift toward comfort care and hospice

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What Do Patients Want?

⚫ Most patients want the truth

 Survey results (1982):
⯍96% wished to be told their cancer diagnosis
⯍85% wanted realistic estimate of life expectancy
 Assists patients with quality-of-life decision making

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How We Deliver Bad News Matters

⚫ Because it can affect the patient’s:

 Understanding of information shared by MDs
 Satisfaction with medical care
 Level of hopefulness
 Psychological/emotional adjustment

⚫ In a qualitative study, surviving family members judged

the most important features of delivering bad news to be:
 Attitude/manner of the person who gave the news
 Clarity of the message
 Privacy
 Having their questions answered

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Barriers to Breaking Bad News

⚫ Why it can be hard for MDs to deliver bad news:

 Lack of training; inexperience
 Anxiety

 Burden of responsibility/inadequacy
⯍ Going back on your word; sense of failure
 Fear of negative responses and strong emotional
reactions
 Uncertainty about patient’s and family’s expectations
 Fear of destroying patient’s sense of hope

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The Six Steps of S-P-I-K-E-S Protocol

Step 1: S - Setting Up the Interview

Step 2: P - Assessing the Patient’s Perception
Step 3: I - Obtaining the Patient’s Invitation
Step 4: K - Giving Knowledge and Information to
the Patient
Step 5: E - Addressing the Patient’s Emotions with
Empathic Responses
Step 6: S - Strategy and Summary

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S – Setting/Set-up

⚫ Privacy
 Interview room (close door)

 Patient’s room (draw curtain)

⚫ Involve significant others

 Ask patient who she’d like to have present
⯍ Important: Who will take on role of spokesperson?
⯍ “Family” = Blood relatives, friends, neighbors, co-workers, clergy

⚫ Book interpreter, if needed

⚫ Have tissues available!
⚫ Pre-meeting, check in with participating health care
providers (IDT) to identify roles and discuss objectives
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S – Setting/Set-up (con’d)

⚫ Manage time constraints

 Allow adequate time for meeting
⯍ Establish boundaries!

⚫ Avoid interruptions
 Silence/turn off beepers and cell phones
⚫ Sit down (close to patient, if possible)
 Avoid barriers between patient and you
⚫ Make connection, look attentive
 Maintain eye contact
 Use “active listening” skills
⯍ Allow forsilence
⯍ Show respect by not interrupting or overlapping
⯍ “Moscow technique” – slight delay in responding
⯍ Repetition – reflecting and restating patient’s words

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S – Setting/Set-up (con’d)

⚫ Introductions = good icebreaker

 Names

 Relationship to patient

⚫ Explain what palliative care is

 “Most people don’t know what palliative care is. May I explain
that to you?”
⚫ Check in with patient and family
 “How is everyone doing”

 “How are you all holding up?”

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P – Perception

“Before you tell, ask”

⚫ Explore how patient (and family) perceives his/her
medical condition, and how serious it is, with open-ended
questions:
 “What’s your understanding of your current medical condition?”
 “What have the doctors told you so far?”
⚫ Reflect patient’s language and vocabulary in your
responses
 Creates alignment with patient
⚫ Gauge patient’s (and family’s) level of medical literacy to
tailor your presentation of bad news

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P – Perception (con’d)

⚫ Opportunity to correct misinformation

⚫ Identify/note signs of denial in patient
 Denial is a coping mechanism that may present as:
⯍Wishful thinking
⯍Omission of unfavorable medical details
⯍Unrealistic expectations of treatment
 May increase in direct proportion to the severity of the
illness

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I - Invitation

How much does the patient want to know?

⚫ Obtaining permission from the patient to report medical
information respects his/her right to know or to choose
NOT to know. Explore with Qs:
 “How much information would you like me to give you about your
diagnosis and treatment?”
 “Would you prefer I speak with your family alone and then come
back to share with you what we discussed?”
⯍ Patients may need loved ones to filter the info for them

⚫ Consider issues of race, ethnicity, culture, religion,

and socioeconomic status
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K - Knowledge

⚫ “Warning shot” can be helpful to prepare

patient/family members for bad news
 “I’m so sorry to have to tell you this…”
 “I’m afraid I have some bad news to share…”
 “Some of the news we have to share today may be difficult
to hear.” (pause, allow silence)
 “I wish the news was better.”

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K – Knowledge (con’d)

Five Helpful Guidelines for Delivering Bad News:

1) Use language that matches (“aligns”) with patient’s
level of education, comprehension, and vocabulary
2) Avoid technical, scientific jargon and acronyms –
keep it simple (Use “spread” rather than “metastasized”)
3) Deliver the information in a sensitive, but direct
manner
4) Give information in small chunks and then stay quiet for a
few seconds (pause frequently)
5) If prognosis is poor, avoid statements that express futility
(e.g., “There is nothing more we can do for you.”)

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E – Empathy/Emotions

⚫ Emotional responses can include:

 Crying (tearfulness to sobbing); anger/rage; sadness; anxiety;
relief; denial; shock; disbelief; grief; isolation/withdrawal;
fear; blame; guilt; shame; silence; numbness; the need to flee
the room
 Some may intellectualize as a form of denial

⚫ Patient’s reaction may be impacted by his/her

psychosocial context
 Financial/relational/practical problems
 Timing of life events (e.g., weddings; births; graduations)

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E – Empathy/Emotions (con’d)

“The Empathic Response” – 4 Steps:

1) Observe the emotion by listening quietly and attentively (use
active listening skills)
 “Bearing witness” – a powerful therapeutic tool
2) Identify and acknowledge the emotion
 “I can see this news is very upsetting to you. Can you tell me about
what you’re feeling?”
3) Identify the cause/source of the emotion
 Usually connected to the bad news, but it may center on other
concerns (e.g., “What will happen to my children?”)
 If not sure, explore with open-ended questions (e.g., “What worries
you most about what I’ve told you?”)
4) Show the patient that you have made the connection between
the emotion and the reason behind it
 Move closer to patient; use touch if it feels right

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E – Empathy/Emotions (con’d)

⚫ Validate and Normalize patient’s emotions

⚫ Combining empathic, exploratory, and validating
responses allows you to “join” with the patient
and expresses solidarity and support
⚫ Resist the temptation to make things better
 Often a physician's reaction to his/her sense of
helplessness or feelings of failure
 Avoid platitudes
⚫ Don’t ignore your own feelings

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S – Strategy and Summary

⚫ Summarize the clinical information and ask if the patient

understands it
 Ask questions to uncover discrepancies in comprehension and clarify
them if there are
⚫ Ask patient if he/she is ready to discuss treatment options
(revisit “Invitation”)
⚫ If so, make the patient a partner in the decision-making
process
 Honors right of self-autonomy and patient’s “voice”
 Inquiring what the patient’s goals/wishes are can engender hope in
the patient

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S – Strategy and Summary (con’d)

⚫ Don’t pressure the patient to make a decision on the spot, but

encourage him to take some time
⚫ Identify goals of care with open-ended Qs:
 “What is most important to you right now?”
 “What are your greatest concerns/fears/hopes?”
⚫ Reframe goals using “wish” statements
⚫ Identify patient’s support system; sources of
emotional/practical support
⚫ Ask if a follow-up meeting would be helpful
⚫ Establish a plan for “next steps”
 What treatment plan will focus on:
⯍ Pain/symptom control
⯍ Reliefof emotional distress
⯍ Concrete services for family
⯍ Discharge (e.g., hospice/palliative care services)

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Questions?

Thank you

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