Stimulus and Response: How to Use the Space Between in Patient Communication

“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” — Viktor Frankl

I knew better. I reminded myself of that after the fact. There are times when I inexplicably forget what I’ve learned as a clinician.  And there are times when a skill I’ve used in practice is replaced by my eagerness to solve the problem I see. Communication challenges can come from within.

Case

Mary is a friend of a friend. I’d told our mutual friend I was happy for her to call so we could talk. Mary was close to the end of a long treatment regimen for lung cancer. I thought I could offer strategies for managing her symptoms.  The first thing she said to me was, “I never smoked, never even tried a cigarette.  Not even when I was a teenager and everyone else was trying it.” As a nonsmoker, she felt she’d been dealt a particularly unfair diagnosis.

However, her call to me was not about managing her symptoms, nor was it about reviewing what her doctor had told her. Instead, she quickly blurted out, “I want to know about the End-of-Life Option Act. (EOLOA),” which is legal in California where she and I both live. I’ve been asked this question in the hospital on multiple occasions, and I am comfortable providing information about the details of EOLOA.

On the few times I’ve been asked my personal view on taking medicine to end life I always say the same thing: What I think does not matter and should not be part of their decision making. When asked about EOLOA, the first question I pose is, “Why do you ask?” This is not an avoidance technique. I follow an edict of palliative care that actually applies to all areas of patient care: Inquiry before advocacy. In other words, before you jump in and answer a question, find out what the question really is.

This same guideline is also useful in nonclinical settings. Outside of our professional interactions there are times when we take a question at face value and answer without investigating what the true question is.  One example I use when I am teaching about clinical communication is from when my oldest son was 6. He surprised me one day by asking where babies come from. I made the mistake of answering his question with more biology than he understood. I was trying to be open and approachable.  When I finished my mini “birds and bees” talk, he looked at me with a puzzled expression and asked, “But do they come from the doctor’s office or the hospital?”

Turns out he and a friend had gotten into a disagreement about where babies came from, with one of them insisting they came from the doctor’s office and the other saying they came from the hospital. It would have been so much simpler if I’d first said to him, “Why do you ask?”

On the day I spoke to Mary, I had the same temporary lapse in judgement and didn’t follow my own communication guidelines, just as I had with my son. Maybe it was because I really wanted to be helpful and also because I wanted to be sure Mary understood that I was a professional who knew a lot about the EOLOA and was willing to talk about it. I explained, and overexplained. I was clinical, too clinical, using medical language and explaining the step-by-step process as well as the nuances of the option part of the law. 

Not only did I talk too much and listen too little, I jumped into my answer without creating an atmosphere conducive to her hearing the information. I jumped over the space between stimulus (Mary’s question) and response (my explanation).

It wasn’t until we were winding up the phone call that I realized my error. What tipped me off was that when we started the call Mary was engaged in the conversation, but by the end it sounded like all she wanted was to get off the phone with me — and fast. I admit that I was trying too hard; her relationship with our mutual friend had me overly eager to be helpful.

Discussion

In the SPIKES [Setting, Perception, Invitation, Knowledge, Emotion, Summary] protocol,¹ setting refers to the actual physical setting — a quiet room with no interruptions, being seated while speaking to the patient, but also connecting with the patient through eye contact and other cues to your attentiveness. In my effort to share my knowledge, I failed to use the space between.

I took the liberty of adding one more component to setting: soothing. All of the aspects of creating a good setting are essentially directed at soothing. Soothing is a way to reduce discomfort, and we know that when a patient is uncomfortable, whether physically or emotionally, processing complicated medical information is more difficult for them.

My mistake with Mary was that I did not successfully create a soothing presence for her. Since we were on the telephone, I had to rely on my voice to do that. With only one sense at work — auditory — creating a setting conducive to taking in information is essential. The space between in communication challenges is when we hold ourselves back and allow that space to expand. I wish I had spoken less when I talked to Mary. I wish I’d stopped and reassessed. I wish I’d been humble enough to realize that my knowledge and expertise were meaningless if Mary had stopped listening to me. That space between can be a quiet place, a watchful place. A place where I am a learner, not an educator.

Reference

1. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES — a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist.2000;5(4):302-311. doi:10.1634/theoncologist.5-4-302