Breaking bad news

The communications skills contribution to this year's program is a series of tutorials on breaking bad news. We are assessed on a video recording of us breaking something to an actor.

The school teaches the SPIKES protocol[1]:

• Setting: make sure you have time, privacy, tissues etc
• Perception: find out what the patient already knows
• Invitation: make sure the patient is ready to receive the news
• Knowledge: pass on the news: diagnosis, treatment, prognosis etc
• Emotion/Empathy: respond to the patient's emotional response
• Summary/Strategy: wrap up, plan where to go next

While having a "formula" for telling someone they are doing to die sounds wrong, it is the only practical way to teach it. The alternative is experience. Experience either means hundreds and hundreds of hours of properly reviewed interactions with actors (for which there is neither time nor money) or lots of bad interactions with real grieving patients before the students get it right.

I hope that, in real life, most of my fellow students get that SPIKES is a framework and not a script. In doing the assessment recording they followed SPIKES slavishly, believing (I think correctly) that this is what was required in order to pass. So students playing the part of a doctor in an emergency department would ask the next of kin of a road accident victim "why do you think you are here?" (because you called me in, you prat!) and "do you want to know your son's condition?" (of course I bloody do!). The actors, to their credit, managed to respond to this inanity without either going out of character and laughing or staying in character and slugging the "doctors".

[1] Buckman, R. (2005). Breaking bad news: The S-P-I-K-E-S strategy. Community Oncology, 138-142