	When my alarm goes off at 5:30 am, I wake up prepared to play many roles. Juggling family life with 2 young children, caring for my patients as a fellow, and pursuing scholarly activities leaves little free time. One of the joys of being a fellow at an academic institution is that I really do not have a “typical” day. Each workday brings a different combination of patient care and research, both of which can be challenging and exciting.

	By 7 am, there has already been a lot of activity in my home. Changing diapers, feeding bottles, and searching for my elder daughter’s favorite pink dress consume my early morning. Afterward, I rush to work so that I arrive on time for rounds.

	If I’m on an inpatient service, by 7:30 am my rounds are starting. The residents and interns are busy gathering patients’ vital signs and orders, and I am preparing chemotherapy orders. As a fellow on rounds, I enjoy leaving issues such as uncomplicated diabetes and hypertension to the internal medicine residents while I focus on the oncologic care of the patient. After our attending hurries off the wards to clinic, I am in charge of the service and our patients. Most days on service I spend much of the morning going over plans with the residents and—most importantly&mdash;teaching the students what they must know about our oncology patients. I try to focus less on specific chemotherapeutics, which I am still learning myself, and more on treatment of complications and communication with patients. Even though I am still acquiring these skills, one of the most useful things I can teach the students is how to deliver difficult news to our patients. Medical schools and residency programs do an excellent job of teaching facts, treatment algorithms, and disease management, but the oncology ward is the ideal place for students to learn the art of communication.

	If I am the hematology or oncology consult fellow during a given month, by 7:30 am my pager has already gone off a couple of times. In my experience, the busiest times in fellowship are consult services, when you never seem to be in enough places at once. On the positive side, however, this fast-paced work helps me learn the most about a wide variety of cases.

	If I am not on service, which is typical now that I am a senior fellow, my morning is somewhat more relaxing. After many months of busy service as a first-year fellow, when I became a senior fellow I welcomed the opportunity to do clinical research in the comfort of my office. I can now spend my time reading and focusing on GI research. More specifically, I am working on a review article about pancreatic cancer and a clinical protocol for neuroendocrine cancers. I’m always working on multiple projects at once in hopes that at least some get published, or funded in the case of a grant. Even as a senior fellow, it is easy to be caught up in patient care at the hospital because there is always a need for a bone marrow biopsy, intrathecal chemotherapy, or orders to be written. It’s very important, though, that I make enough time to pursue scholarly activities that will help me in my career and to become a better oncologist.

	By noon, I have left the residents to manage the oncology service and I squeeze in a lecture. As a fellow, finding time to attend a lecture is a daily struggle. Between clinical work and research, it is very tempting to skip it so that I can catch up on work. Most days I do try to avoid this temptation, as the lectures are essential to my learning as a fellow.

	After a quick bite to eat, it’s off to clinic for the remainder of the afternoon. Now that I’ve been in clinic for a couple of years, the patients are familiar to me because I’ve had the opportunity to follow many of them as they progress through their treatment. Although my attending is in clinic with me, many of my patients now view me as their oncologist. Each afternoon in clinic is usually a mix of emotions as I share both good and bad news with them. It is not uncommon that in 1 hour of clinic I have rejoiced with one patient at the completion of her chemotherapy course and in the next visit have consoled another after learning that his malignancy has recurred. For me, each of these encounters is equally fulfilling, and I always leave clinic feeling privileged to have shared in these experiences with my patients, whether joyful or sad.

	By 5 pm, although I am tired, I am excited about one of the best parts of my day. After finishing at least some of my clinic notes, I hurry down the street to pick up my kids from day care. The look on their faces when they see me is always reenergizing and is a much-needed break from the hospital. Although sometimes it is impossible, I try not to do any more work when I am at home. During fellowship, the time with my husband, kids, and friends is a precious thing. My evenings consist of tea parties with my daughter, rocking my son to sleep, and catching up with my husband. I have to admit that it is not always easy balancing my family with fellowship. It is difficult to completely keep family life and work separate in oncology because many of our patients depend on us even when it is not between the hours of 8 am and 5 pm. Although I value keeping my family life the highest priority, I also hope that the dedication and time commitment I have shown to my patients and research will be a good example for my children.

	By the end of the evening, fatigue has set in and I begin to prepare for the next day. There is always a recent article or textbook chapter to be read that oftentimes needs to wait until the next day. My clinic notes need to be finished too, but they will also need to wait until the next day. The beauty of oncology training is that tomorrow will offer new challenges to find enough time in the day as well as opportunities to learn more about how best to help our patients.

Articles

When my alarm goes off at 5:30 am, I wake up prepared to play many roles. Juggling family life with 2 young children, caring for my patients as a fellow, and pursuing scholarly activities leaves little free time. 

Day in the Life of an Oncology Fellow

	How do you tell a 45-year-old mother of 2 that not only has her breast cancer returned but it is now incurable? Or how do you explain to a 22-year-old student that despite intensive chemotherapy and a 6-week hospitalization, he still has acute leukemia and is not eligible for a bone marrow transplant? Even for an experienced oncologist, walking into a room and initiating a conversation that will change the life of someone who sought your help can be a daunting challenge.

	Early in your oncology training, learning the biology and treatment of a dozen malignancies was a task that seemed overwhelming. For many oncologists, knowing how to compassionately deliver bad news—something that is often learned through trial and error&mdash;is less important than absorbing and understanding an avalanche of cancer-related information. But just as you need to know how to discuss the efficacy and side effects of a chemotherapeutic agent whose name at first you could barely pronounce, you must learn to disclose the truth with sensitivity for patients’ concerns. This is a vital skill that all oncologists must hone.

	The Importance of Compassionate Communication

	Difficult conversations between oncologists and patients about prognosis, disease progression, and death are a crucial part of the treatment process. Whereas physicians may not recall all the difficult conversations they have had, despite how painful they seemed at the time, patients and their families will remember them word for word. They will remember whether you approached this juncture with truth and compassion, or whether it was awkward, rushed, and filled with medical terms they could not understand. They will remember if they left this life-changing visit with a sense of clarity and understanding or with fear and hopelessness.

	Good communication can help clarify patients’ understanding of their disease, ease adjustment, and lessen physical and emotional pain. It can also leave them more satisfied with their care.

	Many people believe that effective communication skills are not something that can be taught or learned and that some physicians are just better or more natural at it. Though it may be true that some may have an innate facility for conversation, you can develop the necessary tools to communicate clearly, effectively, and compassionately.

	Fellowship is an excellent time to begin developing your skills. Just as you study the algorithms of the National Comprehensive Cancer Network to treat lung cancer, you can learn a framework for how to approach a difficult conversation that will make the task less daunting while offering deeper value to your patients.

	The literature has proposed a number of models for effective communication, but the most widely accepted is “SPIKES,” a 6-step protocol developed by Dr Walter Baile and colleagues at The University of Texas MD Anderson Cancer Center.

 The individual letters represent the following: (1) setting up the interview, (2) addressing the patient’s perception, (3) obtaining the patient’s invitation, (4) giving knowledge and information to the patient, (5) addressing the patient’s emotion with empathic responses, and (6) strategy and summary.

	According to Baile and his team, the goal of SPIKES is to allow you to fulfill the following 4 important objectives of the interview in which you deliver bad news

		Provide intelligible information in accordance with the patient’s needs and desires.

		Support the patient by employing skills to reduce the emotional impact and isolation experienced by the recipient of bad news.

		With the patient’s input and cooperation, develop a strategy in the form of a treatment plan.

	Meeting these 4 goals can be accomplished by completing the steps of the SPIKES protocol. Although all 6 steps are not always needed, when they are it is important that you follow them in order:

	"You will ultimately develop your own style of delivering bad news to patients."

 You should be sensitive to the patient’s surroundings as she receives life-changing news. Be sure that you are in a private room and that she is accompanied by a family member, if desired. One of the most challenging aspects of having difficult conversations is the time involved. But even if you feel rushed, you should sit down and maintain eye contact with the patient to help her relax and show her that she is your priority. You should tell her in advance of any time constraints or expected interruptions.

Step 2: Addressing the patient’s perception.

 Before launching into a detailed conversation, ask open-ended questions to get an accurate picture of how the patient perceives her medical situation. Th is not only gives you a glimpse into whether she is experiencing denial, wishful thinking, or unrealistic expectations, but it allows you to tailor your discussion based on what she already knows.

Step 3: Obtaining the patient’s invitation.

 To you as an oncologist, it may seem obvious that the patient is in your office and therefore is prepared to hear full information about her diagnosis, prognosis, and treatment. But some patients do not want all this information. Asking a patient, “Would it be okay to go over the details of your test results?” or “Shall we spend more time discussing the treatment plan?” will let you know how she wants to receive the information.

Step 4: Giving knowledge and information to the patient.

 Th is is the part of the conversation we tend to focus on and likely have the most experience with. When giving medical facts, start at the level of comprehension and vocabulary of the patient. If necessary, use words such as “spread” instead of “metastasized” and “sample of tissue” instead of “biopsy.” Do not forget to repeatedly check in with the patient to ensure that she understands what you are saying.

Step 5: Addressing the patient’s emotion with empathic responses.

 Responding to strong emotions is one of the most difficult challenges in breaking bad news. Patients’ emotions may vary from silence to disbelief, crying, anger, or denial. Physicians often feel uncomfortable addressing these strong emotions and may compensate by providing more information about the disease or treatment. An empathic response is one in which you not only recognize the emotion that the patient is experiencing (such as anger, sadness, or denial) but directly name it back to her. For example, after hearing that her metastatic colon cancer has progressed, the patient is surprised and angry. An empathic comment would be, “I can tell that this news is not the news you expected and that it makes you very angry. I also wish that the news were better.” A comment like this lets the patient know that you understand how she feels and validates that such thoughts are normal and expected.

 Before discussing the treatment plan, it is important to determine whether the patient is ready. If she is still experiencing strong emotion, it is unlikely that she will be able to move on to discuss a treatment plan or prognosis. Isolation, fear, and uncertainty are common feelings that patients may have, and letting them know that you will be with them on this journey is reassuring. Once you determine that the patient is ready to discuss the treatment plan, you must understand her treatment goals, such as symptom control. You can then frame hope in terms of what is possible to accomplish.

	You will ultimately develop your own style of delivering bad news to patients, and this model is just 1 tool that can be used as a beginning framework for enhancing your communication abilities. The patient benefits, plus you are rewarded by learning skills that transform the dreaded task of delivering bad news into a skill that can be mastered with practice. Also, you will probably find that your self-confidence increases over time. Armed with this knowledge, you will soon find that the words will flow easier, your connections to your patients will become stronger and more meaningful, and you will become better able to understand their disappointments, fears, and hopes for the future.

Sheetal M. Kircher, MD, is a second-year oncology fellow at Northwestern University’s Feinberg School of Medicine in Chicago, Illinois.

	1. 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. 

How do you tell a 45-year-old mother of 2 that not only has her breast cancer returned but it is now incurable?

Sheetal M. Kircher, MD

Articles

Day in the Life of an Oncology Fellow

Learning to Deliver Bad News