The SPIKES Protocol and Me: How a Doctor’s Bad News Improved My Communication Skills
Have you ever felt deflated, overwhelmed, or just plain weird after someone commented on your writing? Even when the criticism is constructive and well-intentioned, if it’s not communicated in a way that’s clear and empowering, it may cause more damage than good.
As an editor and writing coach–not to mention a writer myself–this is a risk I’m continuously aware of. More than most professions, my job necessitates giving honest–at times highly unpleasant–feedback on work that someone may have spent months or even years on.
So I’m always on the lookout for items to add to my communication toolbox.
The most recent tool I’ve added to my collection was discovered in an unlikely place: the hospital. More specifically, an oncology unit–not a place anyone wants to find themselves in, ever. (Ever!) But it’s also a place where bad news gets delivered every day, virtually all the time.
Observing the strategies and methods physicians used to address difficult topics was an eye-opening experience, one that has changed the way I communicate with clients, particularly when it comes to giving constructive criticism.
But first, the backstory…
The Bad News
In January, we found out my husband’s father’s cancer had come back. In February, tests revealed it had already metastasized. By March, he was in the hospital, where he would fight a courageous, months-long battle before ultimately succumbing in May. We took shifts at the hospital for those months to minimize the time my father-in-law was alone. The experience was life-changing on a lot of levels, and we’re just beginning to adapt to the “new normal” without him.
But back to that season in the hospital… As my father-in-law got sicker, there were countless conversations in which his physicians had to convey bad news or developments–sometimes to him, sometimes to us as a family.
It quickly became evident that while some of these conversations left us feeling negative and disconnected (or just completely confused), others gave us a sense of strength, clear-headedness, and support. From this positive feeling would come hope–not necessarily the hope that my father-in-law would magically get better, but the hope that we could face this and help him face it.
One day I realized something that shocked me: these two outcomes were not really tied to the severity of whatever was being discussed.
In other words, it wasn’t necessarily that “easier” conversations left a more positive impression on us. In fact, in my opinion, the best conversation I witnessed between physicians and my family members occurred on a day my father-in-law was rushed to critical care. Although he ended up pulling through, at that moment, all signs pointed to a swift demise and we were heartbroken.
Then the doctor called a “family meeting.” It was a long conversation that involved sober eventualities and end-of-life directives. By all measures, this should have been the most upsetting conversation any of us had ever had, but it wasn’t. In fact, I almost feel strange saying this, but it was sort of amazing. (The main physician looked fresh out of med school, but his communication abilities were frankly astounding. Even while we were still in the thick of it, I found myself marveling at his skilled use of narrative and ability to address his target audience. #ThingsEditorsThinkAbout)
By contrast, some of the worst conversations revolved around comparably “insignificant” items of bad news–random but inexplicable decreases in blood pressure, a minor infection that seemed to have sprung up. After the doctor would leave, we’d be left confused, defensive, or totally suspicious.
As a communications professional, this baffled me. What was happening in these conversations? What were some doctors doing so well and others doing so poorly? Because there’s so much downtime in a hospital, and because sometimes you just do strange things when a loved one is dying, I immersed myself in the scientific literature about the different methods doctors are trained in to deliver bad news to patients and families. It seems there are multiple strategies out there, and in my amateur assessment, they appeared to correspond to the different communication styles (and outcomes) of the medical professionals I’d observed.
In the “good” conversations, the ones that left us feeling empowered and hopeful, the doctors appeared to be adhering to the so-called SPIKES Protocol or something similar. I’d never heard of this before, but it’s a six-step method for delivering bad news to patients and their families. It was formulated in the early 2000s and is becoming the most widely taught protocol at medical schools for this type of situation.
Despite the jarring name (Is that really the best acronym for something that already involves tragic news?), it’s an incredible formula that dispels the traumatic dynamics of difficult conversations.
It quickly became evident to me how useful this protocol could be if I adapted it to the “tough talks” I face in my own profession. But first, the protocol…
What the *Heck* is SPIKES?
SPIKES is a chronological protocol. Each of the letters in the acronym signifies the next step in a conversation that involves a difficult diagnosis:
- STEP 1: SET UP the Conversation–create and cultivate a calm/appropriate environment for the conversation ahead of time.
- STEP 2: Assess PERCEPTION–begin the conversation by determining the patient/family’s level of awareness of what’s going on.
- STEP 3: Obtain an INVITATION–gain their trust and permission to proceed to the matter at hand.
- STEP 4: Provide KNOWLEDGE and Information–explain the diagnosis or condition; emphasize the patient’s options.
- STEP 5: Address EMOTIONS with empathic responses–leave space to discuss emotions; respond with empathy and understanding.
- STEP 6: Strategize and Summarize–conclude with an overall summary that explains the conversation as though it were a journey; end with next/ initial steps in treatment.
Basically, the steps move all the way through an interaction with a patient or their family–from preparing the environment in which the conversation will take place all the way through to concluding the conversation with action items and strategies.
The most important item to note, here, is that SPIKES is based on a patient-centered approach: doctors begin with where the patient is at and move outward/ forward from there. The diagnosis is given within the context of the patient’s awareness (this will become clearer over the next few blog posts). The protocol also carves out intentional space for the patient to express and discuss emotions.
What all these things seek to do, essentially, is to alleviate the traumatic or crisis-ridden dimension of receiving bad news. “Crisis” comes from a Greek word that means “to separate,” and part of why such conversations are so painful is because they suddenly cut us off from our prior understanding of our lives. (There are few things more blindsiding than the stereotypical, Hollywood depiction of these encounters, in which the doctor plops the patient down and just lays it on them: “I have some bad news to deliver. You have cancer. You have six months to live.”)
The rationale is that when medical professionals begin with where the patient is at (“assess perception”), and after the diagnosis circle back to where the patient is at (“Address Emotions”), they are essentially laying the groundwork for a bridge that will integrate the patient’s new reality with his or her prior experiences and perceptions of life.
Again: I’m aware that getting or giving editorial feedback is nowhere near as life-altering as a serious medical diagnosis. Still, discussing one’s writing IS personal and at times vulnerable–and any time there’s vulnerability, there’s potential for trauma, misunderstanding, and loss of trust.
It’s been two months since I began trying to adapt the SPIKES Protocol to my conversations with clients. I’m still learning, but already it’s shown clear benefits.
This is the first post in an 8-part series that will explains how I’ve adapted each of the six steps in the SPIKES protocol to the interactions I facilitate as an editor. Not an editor or a coach? Keep reading anyway: these strategies apply to a virtually infinite array of encounters, both professional or personal. Who doesn’t have to navigate criticism and confrontation, at least occasionally?
Stick around–next up is the importance of “setting up” conversations!