During COVID19 pandemic, tele-health and telephone encounters to provide information about the patient’s condition have increased substantially. Communication is recognized as the pillar of patientcentered care and often included in performance evaluations; the skills are often learned by trial and error during the actual encounters without prior training. A phone call can affect the future patient-physician relationship, therefore a tool for phone communication is necessary. Multiple communication tools are available to provide a framework to best approach a conversation with patients or families, and designed to break bad news, one of the most difficult tasks in medicine. After reviewing communication models used for in-person encounters, and based on the lack of such protocols for telephone communication we developed a guideline to provide information over the phone including but not limited to delivering bad news.

In 1999 Kaiser Permanente described a new approach to the medical interview, “the four habits model”: 1, invest in the beginning of the encounter, creating rapport quickly, eliciting the patient’s concerns and planning the visit. 2, evaluate the patient’s perspective, 3, create empathy and respond to the core of the patient’s concerns, and 4, focus on the end of the meeting delivering clear information to allow shared participation in decision making and treatment plans (1).

The Cleveland Clinic developed the R.E.D.E, model to teach relationship-centered communication to their healthcare providers based on 3 principles: 1 establish the relationship with a supportive environment to create connection (“the first impression matters”). 2, know the patient as a person. 3, engage in the relationship with agreement on treatment plans based on patient’s goals (2).

An easy and widely applicable model is the Ask-Tell-Ask. Ask open-ended questions oriented to the goals of the encounter to evaluate how much the patient understands already and how much wants to know. Tell the patient what they want to know with the most important message first using simple language. Finally, ask the patient to provide their understanding of the new information and then clarify misunderstandings. Similarly, the teach back method 3 asks patients to explain in their own words what they have just being told.

The most common model to communicate bad news is the SPIKES (six step protocol) (3), developed for cancer patients but validated in encounters involving delivering difficult news. Step 1, S: Setting up the interview in the right place and being prepared for the meeting with adequate information. Step 2, P:

Assessing patient’s perspective, evaluate how much they want to know and their understanding. Step 3, I: obtaining patient’s Invitation to have the conversation and sharing news. Step 4, K: giving the Knowledge (information) after a “warning shot”, provide information in a simple and empathic way and at the patient’s level of comprehension. Step 5, E: Addressing the patient’s emotions with empathic responses, observing any reaction and respond accordingly to the emotions, giving time to process the information, Silence is fundamental to allow the patient to fully respond. Step 6, S: Strategy and Summary, ask for their understanding, summarize and establish next steps based on their goals.

Finally, the other communication model included was the AAMC Critical Care Communication Skills training for Internal Medicine Residents (4). 1, Focus your attention on the patient and family. 2, Introduce yourself and make connection. 3, Establish agenda (based on patient s goals. 4 Find out what they know and expectations. 4, Explain the illness in clear, simple, terms. 5, Respond to emotion with empathy and show support. 6, Listen actively and look for cues. 7, Understand patient’s goals. Finally, 8 summarize, check in and establish the next steps emphasizing the patient is not alone.

All these models agree on centering the conversation on the patient as a whole person, understanding their values, goals, making a connection while learning how to read the room and using non-verbal and verbal empathic communication. Knowing the expectations will improve patient’s satisfaction and provide better outcomes. It is important to ask questions and never assume what the patient is thinking or feeling; misunderstandings are common and can lead to problems in future medical care.

Privacy is fundamental; being close to the patient in a non-threatening way, allowing eye contact and healing touch if culturally appropriate is beneficial. If possible, allow everyone to sit down maintaining eye contact avoiding interruptions. Moments of silence are vital and one of the most difficult tasks during these encounters.

During tele-health visits, responding with empathy can be difficult because most of the physical and nonverbal clues are easily missed. Especially when communicating with older adults the encounter can be challenging and need extra attention on the patient’s perceptual capabilities such as hearing, vision, cognitive, motor and technological skills (5).

Prepare

Planning phone call ahead decreases emotional impact in the clinician and facilitates the conversation.

Review most relevant data and last conversations documented.

Have the chart available.

Be prepared for a possible long and emotional call.

Hello

Introduce yourself (name and role), where you are calling from and everyone present in the call

Clarify the identity of the person contacted and whether you have talked to that person before and if so, when it happened.

Assess if the moment is right

Suggest the person moves to a safe, private place

If need to leave a message, identify your role and where you can be contacted (Don’t leave patient’s details or bad news in a message or text)

Obtain information

Slow your speech

Establish an agenda for the phone call

Assess what they already know and how much they want to know

News update

Warning shot

Share medical relevant information in pieces and with pauses

Add something personal if you can from your encounter with the patient

Evaluate quietly and respond to the emotion

Use words that feel comfortable in response to their emotions

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Pause

Recap, repeat if needed

 

Investigate for understanding, questions, and expectations

 

Next steps

Treatment plan, goals and time for the next communication)

Go to the chart and document

 

Our recommendation to give information over the phone is based on the same principles for in person encounters but paying extra attention to the lack of cues provided by nonverbal communication. Telephone encounters to break bad news should be avoided when possible and ideally done by the attending physician or someone from the team that knows the patient and treatment plans. Our recommendation are summarized by the mnemonic “PHONE-RING”.

Communication with patients and their relatives is fundamental in any setting of care and delivering bad news is a skill that needs training and practice, even more now when the encounters have changed and different technologies are being used in daily practice.