“When I first started as a pediatric oncologist, I’d be shaking going into the room if I knew I had to deliver bad news to a family,” says Timothy P. Garrington, MD. Here we talk with Dr. Garrington about his process of learning to communicate difficult and sometimes devastating news to patients, and about his efforts to teach these skills to residents and fellows at the University of Colorado School of Medicine.
C3: You’ve been involved in changing how doctors communicate with patients— specifically in how doctors deliver bad news. When you started your work, how was this skill taught?
Garrington: The short answer is that it wasn’t. Forty years ago, medicine was very paternalistic and we didn’t even tell patients they were dying. Now we teach communication skills at the medical student level, but in my opinion communication skills training needs to continue beyond medical school into residency and fellowship, where trainees need these skills in real settings. As far as residents and fellows, there really wasn’t much of anything when I was in training, and I don’t think people had a sense of how to go about it—you learned by doing and developed whatever habits you developed.
C3: And were some residents and fellows developing better habits than others?
Garrington: Well, yes. Some are naturally better at communication than others, and the belief has been that you’re either good at it or you’re not. But what we found is that the ability to deliver bad news and communicate well with patients is related to a specific set of skills that can be taught to anyone.
C3: Like what?
Garrington: First, there’s a model we follow and teach. And then there are some important things we’ve learned from our experience along the way, too. The model is called SPIKES, which stands for Setting (you can’t be in a busy hallway or have your beeper going off), Perception (what do the families already know and what are they worried about?), Invitation (you invite patients and families to tell you the kind of information they want—how much or how little, test results or just big picture), Knowledge, (this is where you deliver the bad news in an organized and straightforward way and provide the time and space to answer all of their questions), Empathy (you show the patient you empathize with their feelings of sadness or even anger) and Steps (the plan moving forward).
C3: But you said there are also things you’ve learned from experience?
Garrington: Yes, absolutely. We help residents and fellows work with real patients, and we even did a study, led by Gee Mei Tan, a pediatric anesthesiologist at Children’s Colorado, using actors to play the part of patients. One huge thing we see is that after communicating the information—the “K” step of knowledge—doctors want to jump in and fill the space that inevitably comes after. There’s a basic human need to make other people feel okay. And so a doctor might tell a family that a scan came back bad, but then jump right into what we’re going to do about it and why everything’s going to be okay. Giving space allows time for patients to process the information and lets the next step happen, which is empathy.
C3: I can see why it would be hard for doctors to allow themselves to empathize day in and day out…
Garrington: It’s difficult and uncomfortable and that’s why so many doctors avoid empathy, or even try to avoid the process of delivering bad news altogether. But this is important: What we see from experience is that doctors need this step of empathy too. When a patient starts crying or even when a patient expresses anger, the tendency is to minimize the emotion—to smooth it over. But let me tell you, your doctor is experiencing this emotion too. We know a diagnosis can be unfair and we’re sad and angry right along with you. In the long run, empathizing is essential for the doctor—it makes you more satisfied with what you’re doing. There’s less burnout and less risk of disengagement. Empathy is as critical to the experience of being a doctor as it is to the experience of being human.