Delivering 'Bad' vs 'Serious' News to Patients

Neil Chesanow


January 27, 2016

In This Article

Showing Patients Empathy

The E in the SPIKES protocol is for empathy. "Patients very commonly are upset or ticked off or have some other kind of emotional reaction" after receiving an unwelcome diagnosis, Dr Back says. "It's important for doctors to realize that this is a normal experience. The pitfall that I see is doctors reacting by giving a mini-lecture about the medical problem, with patients upset the whole time, and they don't hear anything else. As a result, the doctors just wasted their time."

Dr Back emphasizes the "show" in "show empathy." Physicians, he says, often feel empathy, and assume that because they feel it, patients will recognize that the doctors are empathic. Not so. Empathy must be displayed for it to register. There are a number of techniques for doing this. In one, called "naming," the doctor articulates the emotion the patient is expressing. For example, "It sounds like you are angry." In another, "exploring," the doctor draws the patient out by asking a focused question: "Could you say more about what you mean by that?"

"Some physicians perceive a danger," Dr Back says. "If they don't feel confident about using these kinds of empathy statements, they have all kinds of ideas about what's going to happen."

The fear is that by showing too much empathy, the self-protective paradigm for physician/patient interaction—detached concern—will crumble, leaving the doctor vulnerable to being overwhelmed by the patient's powerful emotions.

"The reality is that most doctors are pretty well emotionally regulated," Dr Back observes. "It's rare that I see doctors who are completely overwhelmed. Most doctors are pretty well-defended. They'll be able to deal with it."

The final step in SPIKES is to summarize and strategize. In this, you summarize the patient's clinical picture to ensure understanding and make a plan for the next step, which may be further testing or a discussion of treatment options. At the conclusion of the visit in which the serious news is delivered, Dr Back says, doctors should be able to answer three questions: "Does the patient understand what's next?" "Is the patient engaged in the right problem?" And, "Have I helped the patient understand that my concern is not just about the next appointment but also about the patient's ability to take care of his or her own health?"


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.