Robert A. Buckman, M.D., Ph.D.
Adjunct Professor, Behavioral Science
The University of Texas MD Anderson Cancer Center
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Our objective here is to offer you some practical guidelines that can be of value as you approach several difficult but actually quite common situations. What you're going to see is a number of scenarios that illustrate communication situations that we often encounter in oncology. Now, in all of those scenarios we use some basic techniques that we think you're going to find helpful, no matter what you encounter. So, what I'd like to do to start is to give you a brief overview of those, sort of like to introduce you to the main concepts. In a nutshell, there are basically four useful plans or strategies that I think we all will find useful in clinical communications. We call those CLASS, SPIKES, CONES, and EVE.
The first of this is the CLASS protocol and that's basically the fundamental structure underlying all clinical interviews, the ancestor of all of them. When you have to break bad news though, you use the SPIKES variant of that CLASS protocol. When you have to disclose an error, then you use the CONES variant of the CLASS protocol. And then, finally, there's a sort of a sub-protocol that we call the EVE, which we use inside any encounter when there are emotions present, for emotions use EVE. So let's look at each of those in a bit more detail.
The first then, is this basic fundamental structure of all clinical interviews and it stresses the five main components or ingredients and we call that the CLASS protocol. And that acronym, CLASS, stands for the following five principles. 'C' is for Context meaning the physical setting, the physical context in which you hold the interview. It's actually quite important to get that right at the start.
Then the 'L' stands for Listening Skills, switching on your listening skills. And there are several of these that you can put into practice very easily. By far, the most important is silence. You maintain silence when the patient is talking. We also, as well as silence, we've got several strategies for responding when the patient starts talking to let the patient know that you are listening and to roll the interview along, to facilitate it. And of those techniques, repetition is the most important, repetition of one word. You repeat one word from their last sentence in your first sentence and that simply lets the patient know that they have been heard, that you've been listening, that the circuit is complete. You'll hear us talk a lot in this program about ways to acknowledge what you have heard when the patient had said something.
And so next, in CLASS, is the 'A' for Acknowledging Emotions and Addressing Emotions. 'A' for both of those things and we're going to show you lots of ways to do that. That's the 'A'.
Then after the 'A', the 'S' for Strategy where you outline your, as it were, your medical plan, your plan for medical management, the diagnosis, the treatment, what you're going to do, and how you're going to investigate it. And then, finally, the second 'S' is for Summary where you wrap up with a summary of the main points that you have discussed and offer to discuss important issues.
So that's CLASS. Make sure the Context is right. Invoke your Listening Skills, switch them on. Acknowledge or/and Address Emotions. Outline your Strategy, and then provide a Summary. And we're going to show you, we're going to provide details and examples about how you can actually, in real life, in practice, do all of those things. So CLASS is the basic structure for all clinical interviews. It's a way, an aid memoir, it's a way of remembering that what you're trying to do is to prepare an interview and carry it out in order to foster trust and rapport, to elicit information, and to respond to the patient's responses or reactions and particularly their emotions to develop a management plan.
But when the major objective of the interview is to break bad news to the patient, the task is slightly different and it's helpful to think along the lines of a variant of the CLASS protocol which we call the SPIKES Strategy. In brief, SPIKES, that acronym, stands for these points. 'S' is for Setting and that includes the physical setting and switching on as we mentioned above, your Listening Skills. Then a pivotal point, 'P' is for Perception. Find out their perception. Before you tell, ask. Find out what the patient knows or suspects or perceives about their condition. Then, another pivotal point is 'I' for Invitation. Get an invitation from the patient to go ahead and share the information if that's what the patient wants. Having gotten that invitation then go ahead with the 'K' for Knowledge, giving the medical facts which starts at the level of the patient's understanding as you heard it in their response to the 'P' for Perception. And then, the all important 'E' is for Emotions. It is very important that emotions are addressed at the time they occur, as they occur. We're going to show you how to do that effectively, very important. Then the 'S' for Strategy and Summary, as before, you outline your plan to the patient and then wrap up with a recap of what's been discussed and then offer for any other questions.
So that is the SPIKES protocol. Now, there are certain clinical situations in which you are compelled to give the information. You have to give the information. You have to tell. You have to share the news whether the other person wants to hear it or not. For example, in disclosing an untoward medical event such as a sudden deterioration in the patient's medical condition or, of course, when you're talking to a relative about bereavement, and a sudden, a death, or of course, when a medical error has occurred. These are all examples when you have to give the information. We've got a slight variant of the SPIKES strategy for doing that and we call that variant the CONES strategy.
CONES is for when you have to tell. 'C' is for Context, as above. Get the setting right first. Then 'O' which stands for Opening Shot. Establishing what it is that you're going to talk about. It alerts the patient or the other person that you have got important news. "Let's talk about your clinical condition" or "I want to tell you what's been going on with your father" or whatever it is. We're going to show you ways to do that. Then after the opening shot, 'N' stands for a process that we call the Narrative Approach which is a usual way of explaining the chronological sequence of events. And we're going to show you how to do that. Then there is the 'E'. The all important 'E' for addressing Emotions is something we have to do in every single interview and finally, in CONES, the 'S' for Strategy and Summary, an effective way to close the interview.
So let me just recap. The fundamental structure of all clinical interviews is the CLASS structure. But when you have to break bad news, use the SPIKES variant of CLASS to do that. When you have to disclose clinical errors or sudden untoward events, the CONES variant is very useful.
And finally, there is a sort of sub-protocol, whenever an emotion erupts into the interview, that we use inside all of these protocols. Inside basically any situation where you encounter an emotion that that sub-protocol is a part of the 'A' in CLASS, the Acknowledging and Addressing Emotions. It's part of the 'E' for the Emotions in SPIKES and its part of the 'E' in CONES. But here is a very important point. This sub-protocol, the EVE sub-protocol, is something you must do at any point, at any moment in an interview where an emotion erupts. Stop right there, no matter what it is you were saying or they were saying and address that emotion. And you do that with this EVE sub-protocol. And here is how it works.
You should respond to any emotion that occurs in the interview with at least one of the three following elements. If you don't know what the emotion is, Explore. The first 'E' is for Exploration. Find out more about what the emotion is and what's causing it. 'V' is for Validation in which you show the patient that the emotion they have expressed is intelligible and understandable and/or 'E' is the third, the second 'E', the third point of the EVE protocol is for the Empathic Response showing that you have seen the emotion and that you can understand its course or origin. It acknowledges and automatically validates as well. And we're going to show you effective ways to do that. EVE, basically, therefore, includes what we call the empathic response which is, without gilding the lily, perhaps the most important technique in the whole of clinical interview.
So you'll see lots of illustrations of this and we're going to illustrate it time and time again during this program. Now, why are these protocols and techniques so important? And the answer is that, very often, we in the healthcare professions think that somehow communication is a factor of just having the right personality. It isn't. It's not something you're born with. It's not basically intuitive. You can learn it. It's a matter of tuition not intuition. The fact is that anybody can adopt these techniques or behaviors. You can practice them. You can learn them and you can teach them. And the quality of every clinical encounter when they are used is enhanced, I promise.
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