We describe a protocol for disclosing unfavorable information-"breaking bad news"-to cancer patients about their illness. Straightforward and practical, the protocol meets the requirements defined by published research on this topic. The protocol (SPIKES) consists of six steps. The goal is to enable the clinician to fulfill the four most important objectives of the interview disclosing bad news: gathering information from the patient, transmitting the medical information, providing support to the patient, and eliciting the patient's collaboration in developing a strategy or treatment plan for the future. Oncologists, oncology trainees, and medical students who have been taught the protocol have reported increased confidence in their ability to disclose unfavorable medical information to patients. Directions for continuing assessment of the protocol are suggested.

The purpose of this study was to determine the impact of physician sitting versus standing on the patient's preference of physician communication style, and perception of compassion and consult duration. Sixty-nine patients were randomized to watch one of two videos in which the physician was standing and then sitting (video A) or sitting and then standing (video B) during an inpatient consultation. Both video sequences lasted 9.5 minutes. Thirty-five patients (51%) blindly preferred the sitting physician, 16 (23%) preferred the standing, and 18 (26%) had no preference. Patients perceived that their preferred physician was more compassionate and spent more time with the patient when compared with the other physician. There was a strong period effect favoring the second sequence within the video. The patients blinded choice of preference (P = 0.003), perception of compassion (P = 0.0016), and other attributes favored the second sequence seen in the video. The significant period effect suggests that patients prefer the second option presented, notwithstanding a stated preference for a sitting posture (55/68, 81%). Physicians should ask patients for their preference regarding physician sitting or standing as a way to enhance communication.

Timely intervention by a child psychiatrist or other mental health professional with proven competence in working with children can help children to better cope with the death and dying of their parent and ameliorate the process of bereavement following the parent's death. Because of our small sample, we cannot generalize about all of the findings. Further research is required to characterize the level of distress in the children and the long-term impact in their overall adjustment to life.

CASE HISTORY: PART 1Oscar, a 9-year-old boy, was first diagnosed and treated for medulloblastoma at the age of 1 year. Eight years later, all anticancer treatment options for him had been exhausted. Although Oscar knew that he was dying, his parents could not accept the inevitable. Oscar's parents would not allow anyone else to discuss the end of his life with him either. He reacted by becoming despondent and withdrawn and sometimes very obstinate. He stopped eating, was hyperalert much of the time, and for the most part, would not talk.

BACKGROUND Cancer clinicians do not receive routine training in the psychosocial aspects of patient care such as how to communicate bad news or respond to patients who have unrealistic expectations of cure. Postgraduate workshops may be an effective way to increase interpersonal skills in managing these stressful patient encounters. METHODS The authors conducted 2 half‐day workshops for oncology faculty, one on breaking bad news and one on dealing with “problem situations.” Participants met in a large group for didactic presentations and then small groups in which they used role‐play and discussion to problem‐solve difficult cases from their practices. The small groups were assisted in their work by trained physician facilitators. The workshops were evaluated by means of a follow‐up satisfaction questionnaire as well as a self‐efficacy measure, which was administered before and after the workshops. RESULTS Twenty‐seven faculty and 2 oncology fellows participated in the training programs. Satisfaction questionnaires showed that the programs met the educational objectives and were considered to be useful and relevant by the participants. Self‐efficacy questionnaires revealed an increase in confidence in communicating bad news and managing problem situation cases from before to after the workshop. The majority of attendees welcomed the opportunity to discuss their difficult cases with colleagues. A number resolved to implement newly learned approaches to common patient problems they encountered frequently. CONCLUSIONS Communication skills workshops may be a useful modality to provide training to oncologists in stressful aspects of the physician‐patient relationship. Further research is needed to assess whether long term benefits accrue to the participants. [See editorial on pages 738‐40, this issue.] Cancer 1999;86:887–97. © 1999 American Cancer Society.