Break It To Me Gently

It’s not been a good week for me. I’ve had to tell two patients that they need a thyroidectomy because their biopsies showed papillary thyroid cancer. It is not an aggressive form of cancer but still … patients know this is bad news. I don’t know how I would do it if I were an oncologist, having to do this all the time.

The SPIKES protocol (Baile et al) for delivering bad news has six steps:

Step 1. S- SETTING UP the Interview

The setting is important. I’ve had the most difficulty disclosing bad news in the medical ward where patients’ beds are too close together to afford privacy. I have a better clinic set-up now but years back, I only had a cramped cubicle. If I sat on my desk and leaned back, my head would already hit the examining table. It was ok except the upper part of this cubicle was open and it was possible for patients in the waiting area to hear the conversation I was having with the patient.

Step 2. P- Assessing the Patient’s PERCEPTION

This step is necessary for the doctor to find out if the patient is in illness denial. On more than a few occasions though, Dr. Google has beaten me to it and the patient only needs me to confirm his worst fears. At other times, I am the bearer of “relatively” good news, because the situation is actually better than what Dr. Google had predicted.

Step 3. I – Obtaining the Patient’s INVITATION

For Filipinos, it may also require asking for the family’s permission to break the bad news. I could be opening the envelope containing the biopsy result and I would catch desperate hand signals from the patient’s daughter warning me not to say anything bad. Another daughter had my secretary pass me a note saying, Please don’t tell him if it’s bad news.

Step 4. K – Giving KNOWLEDGE and Information to the Patient

I’ve learned how to be careful when using the words “POSITIVE” and “NEGATIVE.” Saying for example that a result is “positive” is actually bad news if cancer cells were seen in the biopsy. Conversely, reading “negative for malignant cells” on the biopsy report has sent some of my patients into a panic.

Step 5. E – Addressing the Patient’s EMOTIONS with Empathic Responses

I’ve seen the spectrum of patients’ reactions – from stoic silence, white-knuckled fear, clenched-fist repressed anger to loud sobs. I have the most trouble with crying. On a few occasions, I’ve found myself getting teary-eyed too – which does not inspire confidence in the patient. It must be THAT bad if even my doctor is crying. Mababaw lang talaga luha ko!


It is important to not leave the discussion hanging. Options should be discussed, though I often worry if the patient is too shell-shocked to understand or even remember what I say.

Let’s discuss breaking bad news to patients at the next #HealthXPH tweet chat on Saturday, 7 Oct 9 pm Manila time.

T1. Do you use SPIKES/other protocol when breaking bad news to patients? If a patient, how would you prefer to be told bad news?

T2. What are the barriers to breaking bad news to patients?

T3. What are your tips for breaking bad news to patients?

In the meantime, check out this 1980s song from Angela Bofill.


Artificial Intelligence & Healthcare

Merriam-Webster defines Artificial Intelligence (AI) as the branch of computer science dealing with the simulation of intelligent behavior on computers, or the capability of a machine to imitate intelligent human behavior.

How do you imagine AI in healthcare? Is it more like No. 5 in Short Circuit or Sonny in I, Robot? Let’s talk about AI and healthcare at the #HealthXPH tweet chat on tonight 29 Jul 9 pm Manila time (9 am EST).

Bertalan Mesko has enumerated the ways that AI can redesign healthcare on the

  • Mining medical records
  • Designing treatment plans
  • Assisting repetitive jobs
  • Getting the most out of in-person and online consultations
  • Health assistance and medication management
  • Precision medicine
  • Drug creation
  • Helping people make healthier choices and decisions
  • Analyzing a healthcare system

What do you think? Can you add to this list?

T1. In what ways do you think will AI redesign healthcare?

Pierre Pina enumerated the 7 jobs that will be killed first by robots. These are:

  1. Truckers
  2. Construction workers
  3. Legal advisors
  4. Medical staff and doctors
  5. Accountants
  6. Editors
  7. Sellers

Healthcare workers are on the list because of the excitement surrounding IBM Watson who is getting smarter daily. After all for 1,000 cancer cases, Watson matched the treatment plan of oncologists 99% of the time and even suggested options that oncologists missed in 30%.

While I am willing to concede that Watson can beat a human doctor in intelligence, I’ve always thought though that empathy is something that AI can never replace. But John Brandon thinks that by offering information in the right amount “it knows we need to reduce stress or understand people on a deeper level,” AI can teach us to have more empathy.  Maybe something like Samantha in Her.

T2. Do you think that AI will replace doctors? Why or why not?

Bernard Marr curated the best quotes on artificial intelligence on Two quotes stand out from Stephen Hawking and Elon Musk.

“The development of full artificial intelligence could spell the end of the human race….It would take off on its own, and re-design itself at an ever increasing rate. Humans, who are limited by slow biological evolution, couldn’t compete, and would be superseded.”— Stephen Hawking told the BBC

“I’m increasingly inclined to think that there should be some regulatory oversight, maybe at the national and international level, just to make sure that we don’t do something very foolish. I mean with artificial intelligence we’re summoning the demon.” —Elon Musk warned at MIT’s AeroAstro Centennial Symposium

And now even Mark Zuckerberg has joined the fray calling Elon a naysayer.

T3 Do you agree with Stephen Hawking or Elon Musk that AI will end humanity? Why or why not?

See you at the #HealthXPH tweet chat!