Post 3: S"P"IKES
Understanding perspectives using Active Listening and Active Reflection
Understanding perspectives is one of the two most important skills in meaningful conversation and SPIKES. This requires Listening and reflection rather active listening and active reflection. I hope you noticed the meaningful conversations logo… There are several things highlighted.
Thought bubbles on both sides of the conversation
Speech bubbles on both sides of the conversations
“Listening” and “Reflection” highlighted
In another post, I will address Patient-Centered Decision Making, and there, we will highlight “patient worldview” and “physician worldview” to highlight that all of us come from different experiences, use different languages, and have different framing of situations.
For us to be successful in helping patients in their quest for good health, we need to listen to them and facilitate them to express their goals and values.
Active Listening
As an oncologist, when I see a new patient, I set up the conversation in the following manner. I tell everyone involved that I want to hear from the patient first and then the rest of the caregivers. This sets the tone for the conversation: “The most important person in that room is the patient.”
When I start asking questions, I address the patient (even when a family member answered the prior questions or even answered all the questions); this reminds all present that my focus is on the patient.
As I ask question(s), I listen to what and how patients/caregivers answer their questions. I listen to what they say and what language and words they use (in my practice in NJ, a melting pot where a large portion of patients use language other than English at home). I also note the words they do not use or avoid (they use “c” word rather than “cancer” or euphemism for death/dying). I listen for what questions they do not ask. It gives me a perspective on the patient/caregiver “world view.”
Active Reflection
When listening to patients and caregivers, I listen to what and how patients/caregivers answer their questions.
Just as above, in addition to listening to what is said and what is not said, I reflect on two things:
1. How the conversation makes me feel
I have learned that many times I feel the emotion that is in the room (I feel down when there is a sense of sadness in the room, or feel anxiety or frustration when those emotions are present in the room).
2. The “why”
Reflection requires us to ask “why?” Why did the patient or caregiver ask a specific question or said a specific thing? Why they did not ask a different question?
A novice learner can just reflect on it and an advanced learner can use an open or leading open-ended question below to explore the why.
Wait, before you go ahead with exploring the why, I would like to share a caveat. When you feel an “emotion in the room,” how to express it is important. Later on, we will discuss the NURSE acronym and Naming an emotion as a way to allow patients to emote. A tip is that we have to do it with hedging strategies — so a phrase like, “I get the sense that …,” “I wonder if…” (Pro tip: no one likes to be told how they feel, and if you are not sure of it, try it home and tell your spouse or loved one about how you think they feel and come back here and share your experience ;).
Some helpful questions to elicit perceptions: I categorize these into two buckets:
Completely Open Ended
What do you know so far?
What is your understanding of your disease (Cancer, DM, HTN, CHF, COPD, CKD)?
What have you looked up online? (almost always at the first visit)
What have your friends and family looked up online? (I almost always get a laughter on this question)
(When it is second or later visit): “Tell me what you remember from our last conversation” and “What question do you have from our last conversation?”
Leading, Open Ended Questions
What are your hopes? What, to you, is the “best case” scenario?
What are you worried about? What, to you, is the “worst case” scenario?
(When it is a second opinion or a person has been through a disease journey) - Tell me about what you have been through.
I want them to tell me about their journey
I will ask pointed questions about their experiences (specifically about their prior toxicities)
I will ask them about what they understood to be the goal of their treatment at each major junction (when it was curable, when it became incurable when cancer treatment stopped working or had to be stopped due to side effects)
I try to elicit how involved they were in these decisions and specifically how they made the decision (how they balanced risks and benefits)
If you are someone with a business background, you might ask, how is this different from successful negotiation where I need to “build rapport” and “trust?” Well, it is not! They are just different words that accomplish the same thing. In the “Setting” and “Perceptions,” we are establishing a good (and hopefully long-term) relationship with our patients and caregivers. We are aligning ourselves to help them on their journey.
What are the biggest takeaways for you?
Mine are:
Lesson 5: Be present and listen to patients’ stories; look for what they are saying and what they are not saying
Lesson 6: Reflect on not just what is said and what is not said, but also start to ask “why” something is said and some things are not…
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Please share your thoughts and what phrases you use to assess the patient’s perceptions. Or if you are reading this and not in medicine, what do you use to “build rapport?”
Biren Saraiya MD