Effectively conveying serious news is an essential skill in optometry practice, and established protocols1,2 can help optometrists navigate these nuanced, emotional, and complex conversations with patients. Nonetheless, how best to teach these protocols remains a site of debate.3 Clinical educators need discrete strategies for making such pivotal communication skills learnable in an environment where patient care, teaching priorities, and limited resources are regularly juggled.4–6 Despite the importance of this competency, limited study6,7 has focused on teaching optometry learners to deliver serious eye news. In this article, we explore the need for serious illness communication skills in optometry and offer strategies to help optometric educators teach serious news delivery in clinical settings.
THE IMPORTANCE OF OPTOMETRY TALK
Effective health communication extends beyond collecting and conveying information. Patients make sense of new information within the context of their other lived experiences, relationships, and sense of self.8 Nimmon and Regehr8 note that clinicians must move beyond prioritizing clear knowledge conveyance to patients; they must also recognize that they are a “part of patients' resource-rich, temporally extended, iterative process of meaning making.” When done effectively, communication improves the immediate experience and subsequent outcomes for both patients and clinicians.9,10 What and how optometrists communicate matter.
Understanding the multifaceted impacts of vision loss underscores the importance of talking about it. Vision impairment limits education, employability, and independence,11 and its burden increases among older adults12 and those marginalized by their racial and gender identities.13,14 The financial cost of vision loss includes significant direct health system expenditures and nonhealth costs such as lost productivity, welfare, forgone taxes, and supportive equipment and services.15,16 These negative outcomes align with public sentiment that vision loss is the worst ailment to encounter or the second worst after cancer or Alzheimer disease.17
The growing complexity of eye care also bears on communication work. Although early health intervention improves outcomes for many eye disorders18,19 and eye diseases,20,21 the public's knowledge of common eye conditions is limited,22–24 and their confusion about eye practitioner roles23,25 is notable. These knowledge gaps heighten the importance of effective communication in optometry and ophthalmology. Ophthalmology residents have reported that limited patient eye knowledge, the significance of vision loss on quality of life, and multiple ophthalmology subspecialties create profession-specific communication challenges.26 Because optometrists increasingly manage more complex eye disease, often in patients with comorbidities, their work requires them to communicate well and function as part of interprofessional health teams that include ophthalmology, family medicine, nursing, pharmacy, and social work.27 In low-vision work, these teams may extend to occupational therapists, orientation and mobility specialists, and teachers for the visually impaired. Such interprofessional teamwork is complex; it is distributed in time and space, the locus of authority is unstable, and the shared motive of providing “the best patient care” can compete with other relevant objectives such as managing limited resources and educating learners.5 The stakes are high when optometrists talk.
ESTABLISHED PROTOCOLS FOR CONVEYING SERIOUS NEWS
Amid this complex landscape, health care providers must convey serious news while adapting to the individual needs of patients, checking for understanding and meaning making, responding to emotion, and helping patients access relevant information and make informed decisions.28 Well-established mnemonic protocols can guide health care practitioners in delivering serious news. Table 1 summarizes key features of two of the most recognized protocols, SPIKES1 and ABCDE.2 Both highlight the importance of clinicians preparing well for the conversation, eliciting the patient's understanding of the illness, clearly sharing new information, and responding to emotions.
TABLE 1 -
SPIKES, ABCDE, and GUIDE: steps and key points for delivering serious news
| SPIKES
1
|
ABCDE
2
|
GUIDE
29,30
|
Setting
Find a private setting
Sit down and avoid interruptions
Involve loved ones if patient consents |
Advanced preparation
Mentally rehearse delivering news
Arrange for support
Ask what the patient understands |
Get ready
Have right information at hand
Have right people in the room
Ensure privacy |
Perception
Use open-ended questions
Ask what the patient understands |
Build a therapeutic environment
Arrange for time/privacy
Ensure all can be seated |
Understand what's known
Ask what the patient knows |
Invitation
Define information needs
Ask permission to share news
Discuss how much patient wants to know |
Communicate well
Be clear and direct
Avoid medical jargon
Allow for silence |
Inform with a headline
Be clear and to the point
Use a headline (most important information)
Avoid medical jargon |
Knowledge
Be succinct and clear and avoid medical jargon
Check for understanding |
Deal with patient/family reactions
Assess patient reaction
Actively listen
Express empathy |
Demonstrate empathy
Expect emotion
Explicitly acknowledge emotion
Respond with empathy |
Emotions
Monitor for an emotional response
Respond with empathy and validate responses |
Encourage and validate emotions
Correct misinformation
Explore what news means
Arrange follow-up
Process own feelings |
Equip patient for the next step
Ask permission to explain next step
Describe next steps in care
Avoid dismissing concerns |
Summarize and strategize
Summarize the news
Discuss next steps in care |
|
|
Problematically, few scholarly articles examine the delivery of serious news in eye care settings. In a PubMed search of the phrase “breaking bad news,” we identified 836 articles published between 1984 and 2021. Six (0.7%) fell outside health care discourse. Of the remaining 830 health-focused publications, only 11 (1.3%)6,7,26,31–38 were specific to optometry or ophthalmology, with two being editorials.37,38 These eye profession–specific articles underscore the importance of and challenges to attaining competency in delivering serious news in eye care. For example, almost 70% of U.S. ophthalmology program directors in 2017 indicated that resident training was insufficient regarding difficult conversations, including conveying serious news.26 The limited eye care literature signals the need for further inquiry into effective profession-relevant adaptations of communications protocols and teaching strategies.
CURRENT LANDSCAPE FOR TEACHING SERIOUS NEWS DELIVERY IN EYE CARE
Ideally, health professions educators can refer to profession-specific communication competencies when designing their curricula. In Canada and the United States, medical education is guided by established physician competencies that include ones relevant to disclosing serious news.28,39 For example, American medical schools can map their communication curriculum to competencies that include the following:
Demonstrate sensitivity, honesty, and compassion in difficult conversations, including those about death, end of life, adverse events, bad news, disclosure of errors, and other sensitive topics. (4.6)
For ophthalmology residencies accredited by the Accreditation Council for Graduate Medical Education, effectively “breaking bad news” is a milestone to assess resident development.40
Within optometry, educators can look for guidance from the optometric degree program standards of the Accreditation Council on Optometric Education or the attributes of graduating students of the Association of Schools and Colleges of Optometry. However, these communication competencies and attributes are broad, limited in number (one or two), and devoid of mentioning difficult conversations.41,42 The Association of Schools and Colleges of Optometry's Low Vision Educators Special Interest Group has articulated more specific communication competencies, yet none explicitly acknowledge the work of disclosing serious news.43Table 2 summarizes these communication competencies and attributes, highlighting a potential training shortfall.
TABLE 2 -
Optometry communication competencies and attributes
| Accreditation Council on Optometric Education: competencies
41
|
Association of Schools and Colleges of Optometry: attributes
42
|
ASCO Low Vision Educators Special Interest Group: competency objectives
43
|
| 2.9.4 The graduate must be able to provide preventive care, patient education and counseling. |
…before graduation each student will have demonstrated…
effective communication skills, both oral and written, as appropriate for maximizing successful patient care outcomes |
1C: Adapt explanations of [blindness and visual impairment classification] terminology for communicating with patients, the public, and other health care providers. |
| 2.9.8 The graduate must be able to demonstrate effective and culturally competent communications, both oral and written, with other professionals and patients. (effective July 1, 2022) |
|
2B: Customize case history questions to address task performance and safety issues. |
|
|
2C: Elicit specific rehabilitation goals of a patient with impaired vision. |
|
|
3D: Use plain, clear, and individualized language when advising patients, families, and care providers about the implication of common causes of visual impairment. |
ASCO = Association of Schools and Colleges of Optometry.
Drawing from the limited literature on disclosing serious news in optometry settings may help unlock contextually specific findings and applications. In an optometry teaching clinic, limits to applying aspects of the oncologist-derived SPIKES protocol have been noted, specifically, rehearsing (Setting) and disclosure preferences (Invitation), with these misalignments being attributed to differences in professional scope and identity.7 Furthermore, learning to convey serious news in optometry has been hindered when students must juggle their dual and sometimes competing roles as care providers and learners and when they have more formal communications training than their clinical supervisors.6 Finally, clinical novices in optometry, medicine, and social work have demonstrated unique professional signatures to their rhetorical treatment of clinical uncertainty.4 In a study of case presentations by students, acknowledging clinical uncertainty was considered a touchstone of competent social work and graded accordingly.4 In contrast, optometry and medical students distrusted and avoided talking about clinical uncertainty because they believed acknowledging it would garner poorer clinical assessments by their supervisors.4 Thus, how we need optometry students to talk and how we assess this talk may be informed, in part, by our particular professional, clinical, and educational environments.
As the primary eye care providers in North America, optometrists disclose serious news thousands of times throughout their careers. Nonetheless, eye care clinicians self-report insufficient communication training in this area.6,26,32,35 They need training to manage this complex and nuanced communication task.
REFRAMING THE TEACHING OF SERIOUS NEWS DELIVERY
Protocols for delivering serious news, like SPIKES and ABCDE, lack guidance on how to teach component skills or manage struggling learners. A useful paradigm is to view effective communication like any clinical procedure; it requires specialized skills and preparation, involves discreet steps, and carries the risk of known complications.44 Back et al.45 provides justification for implementing formal communication skills training. For example, attending to patient emotion is problematically not widely recognized by clinicians as essential to effective communication. In addition, untrained clinicians have variable skills, inaccurately self-assess their communication abilities, and do not reliably improve their skills merely with clinical experience and time. Formal communication training can help clinicians avoid common harmful communication practices such as blocking (not addressing or redirecting patient concerns), lecturing (giving too much information), colluding (assuming patients ask when they want to know [and patients assuming clinicians will tell if it is important]), and premature reassuring (comforting patients before fully understanding their concern).29,45
Optometric educators may benefit from health care communication teaching tools developed and taught by the nonprofit, educational organization VitalTalk.30 These tools aim to enhance clinicians' serious illness communication skills. Developed by American internist and oncology educators, VitalTalk illuminates skills for clinicians approaching difficult conversations and skills for educators who teach communication in workshop and clinical settings. The organization's educational approach minimizes passive learning; instead, it promotes active learner engagement and skills practice as a more effective way to learn communication skills.46,47 The approach emphasizes clear articulation of learning goals, reliable frameworks (called “talking maps”) for navigating difficult conversations, active skills practice through role play, and constructive performance feedback. Studies48–50 using VitalTalk methods to teach serious illness communication have demonstrated improvements in clinician confidence, preparedness for difficult conversations, use of key communication skills, and professional satisfaction.
Skills for Clinicians
VitalTalk's educational approach emphasizes key skills germane to conveying serious news. Teaching is structured around specific communication strategies. One strategy is Ask-Tell-Ask, in which the clinician first asks the patient about their understanding of the illness; then tells the patient new information using succinct, jargon-free language; and then asks the patient about their understanding of this information, to ensure effective news delivery.29 This iterative approach allows the clinician to build on the patient's existing knowledge, understand the patient's perspective, and support a conversation that can clarify the news and invite questions. Of note, patients immediately forget 40 to 80% of the medical information they obtain from health professionals51; thus, “guarding against cognitive overload” is important for any health news and essential when the news is serious.29 Excessive clinician talk confuses and overwhelms patients, truncating their willingness or ability to share their thoughts, feelings, and priorities.
Once clinicians deliver serious news, they should expect an emotional reaction from the patient and be prepared to engage another strategy—responding with empathy.29 Rather than problematizing patient emotions, clinicians should view them as valuable data that signal that the patient has heard the difficult news and is beginning to process it. Pausing to respond to the patient's emotion with empathy can allow the patient to share their feelings and concerns, feel heard by the clinician, and shift to an emotional state that allows the difficult conversation to move forward. This pause also avoids prematurely reassuring the patient or planning next steps.29,45 The mnemonic NURSE offers five ways of responding to patient emotion with empathy.29Naming statements identify an emotion the patient might be experiencing and affirm it (e.g., “This must be overwhelming.”). Understanding statements acknowledge the patient's emotional experience without claiming to know what the patient is feeling (e.g., “I can only imagine how difficult this must be.”). Respecting statements provide an opportunity to acknowledge and praise the patient's role in the illness experience (e.g., “I can see how hard you've been working to manage all this.”). Supporting statements express partnership and a willingness to help (e.g., “I'm here for you and we'll figure out next steps together.”). Exploring statements, including “tell me more,” invite the patient to share more about their emotional experience, allowing the clinician to better understand the patient's perspective. In responding to emotions with empathy, clinicians maintain an accepting response, where the patient's emotions are acknowledged without judgment, validated, and deemed essential to the therapeutic relationship. As Back et al.29 note, an accepting response does not mean clinician endorsement of the patient's response; a clinician can accept a patient's wish to remain sighted while disagreeing it is possible.
Building on the key communication skills of Ask-Tell-Ask and NURSE statements, VitalTalk offers their own five-step talking map for delivering serious news, called GUIDE: Get ready; Understand what is known; Inform with a headline; Demonstrate empathy; Equip with next steps.30 GUIDE resembles the SPIKES and ABCDE frameworks in its emphasis on preparing for the conversation, asking the patient's understanding, delivering news succinctly and clearly, and responding to emotion with empathy (Table 1).
The skills associated with disclosing serious news must transcend appreciation of the component steps. VitalTalk teaching strategies offer a path to unlocking that learning. The journey begins with preparing the teacher for this work.
Skills for Teachers
Teaching communication well requires educators to possess not only the key communication skills themselves but also a pedagogical approach to help learners grow and experience success in this work. Optometric educators who teach learners to develop the skills of delivering serious news will ideally use scaffolded, active learning approaches that bridge the “classroom” and “clinic” learning spaces.46,52 Strategies that can serve this work include: (1) creating a safe learning space, (2) providing focused didactics, (3) pairing skill drills with simulation-based learning settings, and (4) using a facilitation map in clinical settings.46,52,53 This article focuses on the first and last of these strategies.
Attention to making learning spaces safe is important for all educational activities.54 This is particularly true when setting the stage for learning communication skills. This can be supported by explicit discussion with learners at the outset about respective roles, the scope of the topics, the intended skill-building path, and the planned assessments of learning. In clinical settings with patients, time should be devoted away from the patient to determine how the instructor and student will keep communication skill development on the agenda while patient care unfolds.
Serious news delivery is high-stakes and emotional work not only for patients but also for learners. Thus, teachers need to remain aware of this tension when they teach these skills and consider what behaviors may mitigate vulnerable learner emotions. For example, many health care students and residents report experiencing shame55 and the imposter phenomenon.56,57 There is evidence that such learner vulnerability can be triggered in the face of high-stakes clinical work, such as delivering serious news.55 In clinical settings, the learner's communication skills become closely interwoven with their professional identity and sense of self. As noted by Bynum et al.,55 learner shame “may masquerade as unprofessional behavior, including anger, defensiveness and disengagement.”Although such behavior requires remediation, it should not be assumed to be willful and may be a harbinger of underlying deep-seated, damaging pain that clinical supervisors can “amplify or mitigate.”55 Helpfully, mitigating strategies have been developed to address these forms of learner vulnerability.55–57
VitalTalk has developed a novel facilitation map to help clinical educators more effectively teach communication skills during real-time patient care, where much of clinical education occurs.53 Optometry educators may find this framework particularly useful for teaching serious news delivery while teaching learners one-on-one in the clinic. Its three broad steps are detailed hereinafter and summarized in Table 3: pre-encounter preparation, patient encounter, and post-encounter debrief.
TABLE 3 -
Key steps for teaching communication in real-time clinical settings
| Key step |
Suggested teacher statements/actions
30,53,58
|
Pre-encounter preparation:
Establish a learning goal and expectations for the
encounter |
What might be challenging for you in this conversation?
What skill could you use to address this challenge?
Remember, if you want my help, you can say, “Dr. […], do you have anything to add?”
Also, I may step-in by saying, “May I add something?” if I think I can help.
I will take some notes so we can debrief later. |
Patient encounter:
Observe conversation, take notes, and, if needed, step-in |
Could I add something? |
Post-encounter debrief:
Discuss learner's successes, challenges, and a take-away learning point |
How did that go?
What went well?
Invite learner's reflections, then share what you noticed went well
Looking back, what would you have done differently?
Discuss a challenge in the conversation and strategize around skills to manage the challenge in the future
What did you learn from this encounter that you can try with your next patient? |
Key steps and suggested language are adapted with permission from VitalTalk
30 and Topoll et al.
53
Pre-encounter preparation involves a brief learner-centered discussion away from the patient during which the teacher helps the learner establish a learning goal and sets expectations to foster a safe learning environment. The teacher initially asks the learner what they might find challenging about the encounter and what communication skills they might use to navigate that challenge. These questions aim to enhance learner engagement by inviting reflection on their unique skills and areas for growth while equipping learners with discrete communication tools. The teacher then reminds the learner that they will be present for support during the conversation and willing to step in, if needed. Establishing explicit language for the learner to invite the teacher's input into the conversation fosters a safe learning environment (e.g., “Dr. […], do you have anything to add?”). Finally, the teacher should inform the learner that that they will debrief after the patient encounter, and the teacher may take notes to help provide specific feedback.
During the patient encounter, the teaching clinician observes the learner's communication, taking note of particularly effective skills and areas for improvement. The clinical educator also monitors the conversation for points at which they may need to intervene because the learner invites help or the instructor recognizes the learner needs help. The phrase “Could I add something?” can be a supportive yet clear way for teaching clinicians to insert themselves into the conversation.58
The post-encounter debrief occurs after stepping away from the patient. The teacher asks a general question such as “How did that go?” to invite the learner's overall impression of the conversation, acknowledge any learner emotions, and focus the debrief on learning. The teacher next asks the learner to identify what they did well and adds their impressions of the learner's strengths not noted by the learner. This strategy reinforces effective communication behaviors and builds learner confidence and self-awareness. The debrief then shifts toward skills improvement, with the teacher asking, “Looking back, what would you have done differently?” This question creates a teachable moment by inviting the learner to identify a stuck point in the conversation. The teacher and learner then brainstorm around skills for the learner to use the next time that challenge arises. Notably, the debrief of a stuck point often coincides with the moment when the teacher stepped into the conversation. Finally, the teacher invites the learner to consolidate their learning and commit to practice improvement by identifying a single take-home point with a question such as “What did you learn from this encounter that you can try with your next patient?”
CONCLUSIONS
We have described the importance and features of disclosing serious news and offered strategies to optometric educators who are teaching this vital skill to their students and residents in clinical settings. Based on emerging best practices for teaching communication during real-time patient care, we endorse establishing a learning goal before the encounter, respectfully stepping in during the encounter, as needed, and debriefing afterward to highlight the learner's successes, discuss challenges, and obtain a take-home point.
Adopting this approach needs to consider factors related to the clinician, the curriculum, and the clinical work. First, most clinicians teaching communication skills in the clinic are not teaching communication skills in classrooms and laboratories and do not have much of a voice in curriculum design. Hence, curricular care must be taken to prepare learners for enhancing their communication skills in situ. Second, some clinicians have limited formal training in conveying serious news, and many more clinicians have no formal training in teaching communication skills. Thus, optometry schools and colleges that offer faculty/clinician development programs in conveying serious news and teaching this skill will be better positioned to help students with their skill development. The work of delivering serious news can be messy and uncomfortable, and clinical educators need to know that this learnable skill is worth the time investment. Third, clinicians in a typical teaching clinic day are responsible for advancing the care of multiple patients at one time while assisting several students to develop a range of skills. Accordingly, they are continually making decisions about what skills to address within the time constraints of the clinical work. The approach we have described may enhance teaching efficiency when clinicians and learners identify at least one patient encounter in a clinic day and follow the recommended steps to foster a communication teachable moment. Finally, like all procedures, not all communication steps are equal, and educators looking to invest their time maximally will focus on helping students to respond to patient emotions with empathy. Expressing empathy is the key skill at the heart of delivering serious illness news.
Much of what is known about the teaching of difficult conversations with patients has occurred in health settings outside optometry. This is true of the strategies we have conveyed in this article. Although we believe these skills translate well, we encourage more research situated in optometry settings to unpack nuances specific to the professional and educational environment.
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