Breaking bad news – 99% invisible list of antiemetic medications

When a doctor reveals a terminal diagnosis to a patient — that process is as delicate a procedure as any surgery, with potentially serious consequences if things go wrong. If the patient doesn’t understand their prognosis, for example, they could end up making uninformed decisions about their treatment.

That’s why many medical schools now offer training for students on how to break bad news, bringing in actors to help them learn how to navigate this critically important and very high-stakes moment. And that’s not the only connection between acting and this particular facet of medicine.

It turns out that one of the first doctors to recognize the challenges of this particular kind of doctor-patient communication wasn’t just a physician — he was also a comedian. And he drew on that experience to transform the way that doctors break bad news.

His name was Dr. Rob Buckman, and his very unusual life experiences prepared him to tackle what might be the hardest part of a very hard job. Radio reporter and part-time medical school videographer John Fecile went back to trace the strange journey of this comedic doctor, and discovered unexpected connections along the way.

In 1969, Kubler-Ross published a book based on her research called On Death and Dying — the famous five stages of grief were first described in the volume, which became an international bestseller and brought conversations about dying into the home. Kubler-Ross also encouraged doctors to speak more frankly with their patients about death.

Historically, doctors hadn’t addressed mortality directly. The original code of ethics established by the American Medical Association in 1847 said it wasn’t the role of doctors to make, “gloomy prognostications.” Instead, they should be ministers of hope and comfort.

In 1951, the Journal of the American Medical Association actually published methods for deceiving cancer patients and their families. They recommended giving evasive answers or using confusing euphemisms, like calling cancer an “ulcer” or an “infection.”

But slowly, medical culture started to change. Radiation and chemotherapy led to more hope for patients who might otherwise have been given a terminal diagnosis. Meanwhile, palliative care emerged as a concept in medicine, as well as the hospice movement. Death became less fearful to people. Doctor Comedian

These developments — along with the work of Elizabeth Kubler-Ross — all started to change the way our culture talked about death and dying. And it was in this context that Rob Buckman became more than just a doctor, but someone who would also help transform the profession.

In a TV documentary he made about his illness titled Your Own Worst Enemy, Rob can be seen growing ever sicker. He had dermatomyositis, an inherited autoimmune disease that causes the body to reject muscle tissue. Slowly, Rob began to waste away. Married with two daughters, the documentary reveals him in his weakened state, unable to lift his own girls. “What happens,” he recalled, is that “the color drains out of everything.”

For a time, Rob’s condition was so bad that his doctors thought he might not survive — and the experience of being that close to death was profound. Years later, Rob would recall an especially important encounter with this one of his physicians who told him “it must be awful for you, I am sorry.” Rob nearly burst into tears and hugged him, because the doctor gave him permission to feel ill.

Little by little, Rob started getting better. He was having blood plasma replacement therapy and a new drug he was taking started to work. “The last four weeks have been like a gift,” he said, on the path to recovery. “I can drive my car … straighten my elbows … dress myself.”

In Canada, Rob had to restart his life completely, but it was there that he would end up making his most lasting contributions to the field of medicine. He started studying the way that doctors communicated with the people they were treating. Specifically, he was interested in how doctors interacted with dying patients, because he himself had recently been a dying patient.

“The great thing about being ill from my point of view,” he said in an interview in the late 1990s, “was that I found out that I could tolerate … a fair amount of pain and handicap … I didn’t collapse, and I didn’t turn into a different person.” His big realization was that doctors didn’t need to hide information from their patients and tiptoe around tough subjects. Sick people could withstand a lot and deserved to know about their conditions.

In Toronto, Rob met and married Dr. Patricia Shaw, a cancer researcher at the same hospital. “He was told that I had the best microscope,” she recalls. “I had the newest microscope. And so he came in to see me. And that’s how we really met, our first conversation.”

Around the same time, Rob began writing more. His first book was called I Don’t Know What To Say: How to Help and Support Someone Who is Dying. It’s a very frank but easy-to-read book that covers everything from basic listening skills to survivor’s guilt after someone has passed.

Rob drew on his vast experience as an oncologist who had to break bad news several times a week. He understood the process could be broken down into a series of steps, which eventually became the basis of the SPIKES protocol — an acronym standing for Setting, Perception, Invitation, Knowledge, Empathy, Strategy and Summary. It’s a mnemonic device that doctors can use as they prepare to give bad news, and then during the actual conversation with the patient.

Soon Rob and his collaborator Walter Baile were giving presentations on SPIKES at hospitals all over the world. They made videos for medical schools, which demonstrated how SPIKES could help doctors navigate these difficult conversations. In some of the videos, Rob performs improvised scenes with actors playing patients or family members.

At about midnight, a police officer knocked on his wife Pat’s door. “He talked a bit of nonsense … and then eventually got got around to saying that Rob had passed away.” Rob had died in his sleep on the plane from an undiagnosed heart condition.

Beyond Rob’s death, SPIKES has endured. It’s been absorbed into the mainstream of American medicine. The American Society of Clinical Oncology now recommends that doctors use a protocol when giving bad news. They offer SPIKES as a good example. And SPIKES is taught in many medical schools in the U.S. and Canada, as well as schools in Europe, Asia, and South America.

SPIKES isn’t the only set of guidelines for breaking bad news, and it may not apply to every bad news situation. But throughout the course of their careers, many doctors will have to break bad news over and over again. SPIKES can help make this challenging task easier for doctors and also better for patients, many of whom are facing one of the most difficult experiences a person can go through.