Breaking bad news: the SPIKES protocol in teaching
Table of contents
The practical exam station has a door, two chairs and a three-line instruction: the biopsy result has arrived, and you need to tell the patient. The student knows the pathology by heart. Even so, their hands sweat before going in, because no one ever taught them how to open that conversation, how to wait through the silence after the news or how to respond when the patient cries.
NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.
Breaking bad news is a skill, and skills are taught. The SPIKES protocol is the most used script for this. This guide is about teaching: what the six steps are, what reviews show about training and how to put together an activity with simulation, examples and feedback in a medical school, a student league or a residency program. The clinical management of each situation is left out, because that is another subject.
Key points
- SPIKES organizes the conversation into six steps: setting, perception, invitation, knowledge, emotions and strategy with summary.
- The protocol has four objectives: gathering information from the patient, conveying the medical information, offering support and building the next steps together with the patient.
- A meta-analysis found a large improvement in skills assessed by observers and a moderate improvement in the confidence of those who were trained.
- Simulated patients played by actors are the most common format, and virtual patients appear as an alternative that has proved comparable in a few studies.
- A trial with oncologists showed that the effect of an intensive communication course persisted one year later.
What the SPIKES protocol is
A six-step script
SPIKES was described in 2000 by a group at MD Anderson Cancer Center as a practical protocol for communicating unfavorable information to patients with cancer (Baile et al., 2000). The name comes from the initials of the six steps in English: Setting, Perception, Invitation, Knowledge, Emotions and Strategy and Summary (Baile et al., 2000).
The protocol has four objectives: gathering information from the patient, conveying the medical information, offering support and obtaining the patient's collaboration to define the next steps (Baile et al., 2000). The authors report that oncologists, oncology residents and medical students trained in the protocol said they were more confident about communicating unfavorable information (Baile et al., 2000).
Beyond oncology
The protocol was born in oncology, but the script works for other difficult news: a chronic diagnosis, a complication, a change in prognosis. Disclosing an error to the patient is a similar conversation and has its own particularities, which deserve a separate guide.
Breaking the news and deciding together
Breaking the news is different from choosing the management. Shared decision-making, discussed in the guide on clinical decision-making, comes later, when the patient has already understood the situation. SPIKES prepares the ground for that conversation.
The six steps, one by one
S: setting
Prepare the place and yourself: privacy, chairs for everyone, the phone on silent, reserved time and the presence of whoever the patient wants by their side. In teaching, it is the easiest step to train and the most forgotten in exams.
P: perception
Before telling, ask what the patient already knows or imagines. "What have you understood so far about the tests?" The answer shows where to start and whether there is any wrong idea to correct.
I: invitation
Ask how much the patient wants to know and in what form. Some people want every detail; others prefer the essentials and ask that the family receive the rest.
K: knowledge
Give the news in plain language, in small parts, with a warning beforehand ("unfortunately, the result was not what we expected"). Avoid jargon and check understanding at each part.
E: emotions
Recognize and respond to the patient's emotion: notice it, name it, understand the reason and show that you understood. It is the step that most requires empathy, a topic that has its own guide in this series.
S: strategy and summary
Summarize what was said and agree on the next steps, asking whether the patient is ready for this conversation. In teaching, what matters is that the student closes the conversation with a summary and an agreement, not that they master the conduct.
What studies show about teaching
Training works
A systematic review with meta-analysis included 17 studies on interventions to improve the communication of bad or difficult news by physicians, students and residents, totaling 1,322 participants in the main analysis (Johnson and Panagioti, 2018). The interventions were associated with a large improvement in skills assessed by observers, with a standardized mean difference of 0.74, and a moderate improvement in confidence, of 0.60 (Johnson and Panagioti, 2018).
Only one study in the review measured the effect on depression or anxiety reported by patients, and the authors call for more research on the impact on patients and on the best components and ideal duration of training (Johnson and Panagioti, 2018).
The effect that lasts
In a randomized trial in the United Kingdom, 160 oncologists from 34 centers were assigned to a three-day intensive course, written feedback, both or neither, and consultations with 2,407 patients were filmed (Fallowfield et al., 2002). The course included structured feedback, video review, role-play with simulated patients and group discussion; among those who took the course, the use of focused questions rose 34%, expressions of empathy 69% and appropriate responses to patient cues 38% (Fallowfield et al., 2002).
At the 12-month follow-up, the improved skills were maintained, and others appeared, such as 81% fewer interruptions; expressions of empathy, however, declined from their earlier peak (Fallowfield et al., 2003). The study was conducted with experienced physicians, and the authors concluded that clinical experience and time alone do not solve communication problems (Fallowfield et al., 2002).
Who plays the role of the patient
A review on simulation in teaching bad news to students screened 2,117 publications and included 29 (Dale MacLaine et al., 2021). The models included actors as patients in 65.5% of them, colleagues in 7.0% and people who had cancer in 3.5% (Dale MacLaine et al., 2021). The impact was described as positive in all formats, but good-quality comparisons between them are lacking (Dale MacLaine et al., 2021).
Virtual patients
A rapid review found three studies on virtual patients in teaching bad news (Kang, 2024). The results suggest they are better than no intervention and comparable to simulated patients, and video recording appeared as an unexpected advantage (Kang, 2024). The lack of affect and interaction was the main barrier, and the author concludes that virtual patients still complement, rather than replace, existing formats (Kang, 2024). The guide on virtual patients covers the format in general.
Worked examples with markings
Two randomized trials with 147 fourth-year students tested an online module on SPIKES before the encounter with simulated patients (Schmitz et al., 2020). The same worked example was presented in text or video, with or without markings indicating each step; only the markings made a difference, and the students who received them communicated the news more appropriately, whatever the format (Schmitz et al., 2020).
The finding has a practical consequence: a written example, with the steps marked, prepares as well as a video, and takes less work to produce (Schmitz et al., 2020).
How to set up a teaching activity
Before: a marked example
Start with a worked example, in text or video, with each SPIKES step indicated in the margin. The student reads it, identifies the steps and writes down one sentence for each that they could use. The preparation can be done at home, in an active learning format.
During: a short simulation
Set up ten-minute stations with an actor, a colleague or a virtual patient. Each station has a script with the situation, what the patient knows and the emotion they will show. The clinical encounter simulation guide has the step-by-step for organizing stations.
A format that works well in a small group:
- One student leads the conversation.
- A colleague observes with a grid of the six steps.
- The actor or the teacher can pause the scene and ask for another attempt at a section.
- Roles rotate until everyone has led.
Afterwards: structured feedback
Feedback is the heart of the training, as the design of the British course shows, combining structured feedback and video review (Fallowfield et al., 2002). Start with what the student noticed, go through what the observer noted at each step and end with one sentence they will change next time. The feedback in clinical cases guide helps give this feedback in a useful way.
Assess on more than one level
Self-reported confidence is easy to measure, but it says little. A better assessment includes observing the conversation with a grid, as the studies in the meta-analysis did (Johnson and Panagioti, 2018), and, when possible, repeating it months later.
Look after those who train
Difficult conversations affect those who practice. Set aside time for the group to talk about what they felt, especially when the scene recalls a personal experience. Care is part of teaching.
Common mistakes among learners
Skipping perception
The student walks in and delivers the news right away. Without knowing what the patient imagines, they may repeat what the patient already knows or ride roughshod over a wrong idea that needed correcting first.
Talking too much after the news
The silence after the news bothers the person delivering it, and many fill it with technical details. Training teaches you to wait and let the patient react first.
Answering emotion with information
When the patient cries, the student explains more. The emotions step calls for the opposite: acknowledge what the patient feels before moving on.
Ending without a summary
The conversation ends and nobody knows what was agreed. A short summary and a question about doubts close the meeting.
Treating the script as a checklist
The steps are a guide, and the order can change depending on the patient. Anyone who memorizes the sequence and follows it to the letter tends to sound mechanical. Metacognition helps the student notice when they are following the script instead of following the patient.
Cases for group discussion on NEXO
NEXO works on diagnostic reasoning: the case of the day arrives in up to six clues, and each guess receives its proximity in ICD-10 across five levels. The cases are fictional with a real clinical presentation. Once solved, a case can become the starting point for a communication activity: the group reached the diagnosis, and now someone has to tell the patient.
The game handles the diagnosis part; the conversation with the patient is trained in simulation. The what is NEXO guide explains the whole match, and how the modes are unlocked is on the NEXO economy page.
If you coordinate a medical school, a student league or a residency and want to use cases in group activities, see NEXO Closer. Researchers in medical education can propose studies through NEXO Researcher. Doctors who review cases take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.
Frequently asked questions
What is the SPIKES protocol?
It is a six-step script for breaking bad news, described in 2000 by a group at MD Anderson Cancer Center (Baile et al., 2000).
What does each letter of SPIKES mean?
Setting, Perception, Invitation, Knowledge, Emotions and Strategy and Summary.
Does training in breaking bad news work?
A meta-analysis found a large improvement in observed skills and a moderate one in confidence (Johnson and Panagioti, 2018).
What is the best simulation format?
Actors are the most common format, but good-quality comparisons between formats are lacking (Dale MacLaine et al., 2021).
Can a virtual patient be used to train breaking bad news?
A few studies suggest it is comparable to a simulated patient, though it does not yet replace one (Kang, 2024).
How to start with little time?
With a written example with the steps marked and a short simulation station with colleagues, followed by feedback.
Checklist for teaching SPIKES
- Present a marked example with the six steps.
- Set up short stations with a script for situation and emotion.
- Use an observer with the grid of steps.
- Allow pausing and repeating parts of the scene.
- Give structured feedback right afterwards.
- Assess the observed conversation, beyond confidence.
- Set aside time for the group to talk about what they felt.
Want a case to discuss in a group? Play the case of the day on NEXO.
References
- Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000. https://pubmed.ncbi.nlm.nih.gov/10964998/
- Johnson J, Panagioti M. Interventions to Improve the Breaking of Bad or Difficult News by Physicians, Medical Students, and Interns/Residents: A Systematic Review and Meta-Analysis. Acad Med. 2018. https://pubmed.ncbi.nlm.nih.gov/29877913/
- Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. Lancet. 2002. https://pubmed.ncbi.nlm.nih.gov/11879860/
- Fallowfield L, Jenkins V, Farewell V, Solis-Trapala I. Enduring impact of communication skills training: results of a 12-month follow-up. Br J Cancer. 2003. https://pubmed.ncbi.nlm.nih.gov/14562015/
- Dale MacLaine T, Lowe N, Dale J. The use of simulation in medical student education on the topic of breaking bad news: A systematic review. Patient Educ Couns. 2021. https://pubmed.ncbi.nlm.nih.gov/33926808/
- Kang W. The use of virtual patients for breaking bad news: A rapid review. Clin Teach. 2024. https://pubmed.ncbi.nlm.nih.gov/37860892/
- Schmitz FM, Schnabel KP, Bauer D, Woermann U, Guttormsen S. Learning how to break bad news from worked examples: Does the presentation format matter when hints are embedded? Results from randomised and blinded field trials. Patient Educ Couns. 2020. https://pubmed.ncbi.nlm.nih.gov/32303364/