Effective communication skills are a must for athletic-training graduates, and something we focus heavily on at the University of Idaho.  While things like injury treatment and prevention are more visible athletic trainer duties, empathetic communication is important also.  Unclear or ineffective communication can easily undermine an athletic trainers’ relationships with their colleagues and patients.  One particular skill we see many athletic training students struggle with is delivering bad news.  No athlete or patient wants to be told that they may have to sit out an entire season or that they have a long and difficult road to recovery ahead of them.   On the other hand, good communication with patients can mean higher adherence to care plans, greater rapport, and more effective treatment.

What is the best way to deliver bad news?  Luckily, there is a mnemonic to help us remember the basic premises.  But before we get into the details, let’s start with the basics.

What is athletic training?

To take it from the National Athletic Trainers’ Association (NATA), “Athletic trainers are highly qualified, multi-skilled health care professionals who collaborate with physicians to provide preventative services, emergency care, clinical diagnosis, therapeutic intervention, and rehabilitation of injuries and medical conditions.”  Visit NATA here to learn more.

While athletic trainers have varying roles in different settings, their training emphasizes the prevention, assessment, and treatment of musculoskeletal injuries and illnesses.  Athletic trainer skills and abilities may emphasize different aspects, but some skills are universal.  One of these universal athletic trainer duties, we believe, is good communication.

Why is communication so important for athletic trainers?

While athletic trainers often also serve as liaisons to other healthcare professionals, advocates, and advisors, their primary communication is with the patient.  Unlike other healthcare professionals, athletic trainers often work longitudinally with patients, over the course of their athletic career, employment, or lifetime.  This fosters the formation of strong working relationships built upon respect, trust, and (you guessed it) clear communication.

There is a perception that all communication in sports involves backslapping and high fives.  While athletic trainers may find themselves sharing a fist-bump or two, they also sit down for difficult conversations.  One of the most difficult times for an athletic trainer (and their patient!) can be the delivery of bad news.  As with any skill, repetition and practice help build mastery.  However, for the new athletic training graduate (or person hoping to brush up their skills), here is the SPIKES mnemonic, developed for oncologists by Walter F. Baile and Robert Buckman.  While developed for cancer situations, Dr. Baile and and Dr. Buckman’s mnemonic can be very easily applied to athletic training scenarios.

What is SPIKES and how can athletic trainers utilize this tool?

SPIKES is mnemonic designed to keep communication lines open and reduce tension.  The letters stand for:

S: Setting

P: Perception

I: Invitation

K: Knowledge

E: Empathy

S: Summary

Let’s go through each in greater detail.

Setting

In some cases, where you have the conversation is a crucial factor in having a difficult conversation. Meeting in-person in a distraction-free environment helps simplify many complicating factors. Having important conversations on a sideline, in a gym, or in a factory may present numerous challenges. Additionally, having privacy can help prevent others, who don’t need to be in on the conversation, from being present. Some patients may prefer one-on-one communication. Others may want to have a trusted family member, friend, or coach present. The same can be said for you! Would it be helpful to have another member of your sports medicine team there? If this is of interest to you, obtain consent from your patient and ensure that they are okay with them being present.

Also, be mindful of your own position when conducting the conversation. Body language can often speak volumes above the words that leave our mouth. Your position (i.e., sitting vs. standing) may unintentionally communicate a conflicting message. Likewise, where you face (i.e., side by side or facing one another) may help communicate additional non-verbal cues.

Perception

Many difficult situations can be created by a genuine misunderstanding by any party.  Make sure you set the stage and establish what your patient’s perception of their injury or condition is.  Knowing where their knowledge sits is going to help you find the appropriate starting place for the conversation.  If a patient is misinformed on their situation, this is a good time to find out.  Some ideas are:

• What brings you in today?
• Do you know why your (coach, parent, supervisor) sent you to meet with me?
• Tell me about what has been going on lately?  What do you know about it?

Invitation

Next, obtains your patient’s invitation to a continuing conversation.  Some people like to know everything possible about their injury or condition and others don’t! After discussing what they already know, make sure to determine what and how much they want to know. This will help you deliver the exact information that your patient wants and/or needs. You may ask questions like:

• Your images have arrived from the lab.  Would you like to look at them?
• Can we discuss your treatment plan?
• Would you like to discuss next steps?

Knowledge

This is often the most difficult part of the conversation – delivering the difficult news. Remember to be clear and concise.  How we lead into this part of the conversation is a good thing to think about. Some people may benefit from easing into the conversation. For example, “I’m afraid this is more impactful than we originally thought.” Others may prefer a more direct form of communication.

Regardless, be cautious in your approach. Erring on the side of bluntness may be best as not being clear and direct can leave patients and their loved ones confused. Allow plenty of figurative space to process the information, ask questions to make sure they understand what you are saying.

Empathy

Tough news is difficult for the one delivering it and the one receiving it. After you’ve communicated the difficult news, listen to your patient.  How each person reacts and processes this information can widely vary.  Be present, be empathetic, and be supportive. Labeling and normalizing feelings may be helpful. For example:

• It is natural to feel frustrated
• All this information can be overwhelming
• It is okay to be upset right now

Never assume you know how each patient or loved one is feeling. Despite our personal experiences, assuming that we know or think we know how someone feels may make them feel invalidated and unheard. Focus on listening, normalizing, and empathizing with them.

Summary and Strategy

This is an easy step to miss!  Make a “game plan” with your patient! For example:

• Provide ways that they can get in touch with you or another provider and be available for additional questions
• Identify what “red flags” they should be on the look for and what to do if they arise
• Schedule times to check in or come back for additional care

Encountering a challenging diagnosis can be very alienating.  It is up to you to make sure they feel connected and supported by the health care team.

Conclusion

As you can see, communication with patients is a large part of what an athletic trainer does, and it is an important skill to develop and master.  Thanks to Dr. Baile and Dr. Buckman and their research into delivering bad news, athletic trainers have a powerful communication tool in the SPIKES mnemonic. If you have any questions, we’d love to hear from you!  Please reach out to ui-at@uidaho.edu.