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Patient-centred communication

Fostering understanding

Uncomfortable situations

When the news is bad

Side view of young male with mohawkNot all medical news is good news. Bad news needs to be delivered with compassion and empathy. Physicians can make it easier by using the SPIKES format [REF]
Baile WF et al. SPIKES—A six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist 2000;5(4):302-11.
  • Setting — private and calm
  • Perception — what does the patient think?
  • Invitation — how much does the patient want to hear?
  • Knowledge — after explaining, what does the patient understand?
  • Empathy — acknowledge every emotion that arises
  • Strategy — set out the next steps

When there's disagreement

Patients may sometimes have expectations that can't be met. They may be disappointed or angry, and may become aggressive and threatening.

Case: A demanding and concerned mother
Male physician speaking with mother who is holding a child


A woman attends the emergency department with her 18-month-old child, who has a cough. She states at the outset that she wants a prescription for antibiotics.

The exam reveals a healthy-looking child with an occasional cough, no fever, and an otherwise completely negative exam. The doctor explains this to the mother, and says that antibiotics are not indicated.

The mother becomes angry and insists that her child needs the antibiotics. Other modalities for treatment are suggested, but finally the mother says she will sue the doctor and have his medical licence revoked. She refuses further examination or assessment by a colleague and storms out. The doctor writes a note in the medical record.


The College notifies the doctor of a complaint. The College reviews the medical record and the response from the doctor. It concludes the doctor has given medically sound advice and has treated the patient and the mother politely. The complaint is considered groundless and is dismissed.

Physicians have a professional responsibility to stay above the fray:

  • Keep calm.
  • Explain the facts and situation rationally.
  • Offer possible solutions.
  • Do not try to intimidate the patient or allow yourself to be intimidated.
  • Consider asking your supervisor or a colleague to help defuse the situation.
  • If there is no way to resolve the issue, end the interview politely.
  • Record the facts objectively and without emotional language.