Breaking Bad News

When a doctor reveals a terminal diagnosis to a patient — that process is as delicate a procedure as any surgery, with potentially serious consequences if things go wrong. If the patient doesn’t understand their prognosis, for example, they could end up making uninformed decisions about their treatment.

That’s why many medical schools now offer training for students on how to break bad news, bringing in actors to help them learn how to navigate this critically important and very high-stakes moment. And that’s not the only connection between acting and this particular facet of medicine.

It turns out that one of the first doctors to recognize the challenges of this particular kind of doctor-patient communication wasn’t just a physician — he was also a comedian. And he drew on that experience to transform the way that doctors break bad news.

His name was Dr. Rob Buckman, and his very unusual life experiences prepared him to tackle what might be the hardest part of a very hard job. Radio reporter and part-time medical school videographer John Fecile went back to trace the strange journey of this comedic doctor, and discovered unexpected connections along the way.

In the late-1960s, Rob Buckman arrived at Cambridge University with the intention of becoming a doctor. By day, he studied medicine and took classes in biochemistry. By night, he wrote and performed sketches with the Footlights, a theatrical club. He only slept 3 or 4 hours a night.

The Footlights put on revues each year that featured comedy and music. And Rob was known for doing a ridiculously clumsy strip routine.

It was big deal to be in the Footlights then, and it still is today. The group has churned out many famous comedians, including members of the comedy troupe Monty Python and, more recently, people like John Oliver.

Rob balanced his performing and sketch-writing schedule with his demanding academic life and, after graduating from Cambridge, went on to a teaching hospital to continue his medical training.

And it turns out that he’d entered medicine just as a big shift in medical culture was happening — one that changed the way doctors thought about their patients.

On Death and Dying

Around the same time Rob was onstage in London’s West End doing his strip routine, a psychiatrist named Dr. Elisabeth Kubler-Ross was working on a radical project. She was spending time with dying patients at hospital in Chicago, listening to their stories.

“If you only can sit and listen and hear what they say, they teach you not only about dying, but about living.”

In 1969, Kubler-Ross published a book based on her research called On Death and Dying — the famous five stages of grief were first described in the volume, which became an international bestseller and brought conversations about dying into the home. Kubler-Ross also encouraged doctors to speak more frankly with their patients about death.

Historically, doctors hadn’t addressed mortality directly. The original code of ethics established by the American Medical Association in 1847 said it wasn’t the role of doctors to make, “gloomy prognostications.” Instead, they should be ministers of hope and comfort.

Doctors feared that disclosing a bad diagnosis might actually be damaging, and could even drive patients to suicide.

In 1951, the Journal of the American Medical Association actually published methods for deceiving cancer patients and their families. They recommended giving evasive answers or using confusing euphemisms, like calling cancer an “ulcer” or an “infection.”

The same article recommended that cancer patients who learned the truth of their diagnosis — and reacted badly to it — be given lobotomies.

This kind of attitude was pervasive. In 1961, a survey showed that ninety percent of doctors preferred not to disclose cancer diagnoses to patients, despite another study showing that the vast majority of patients wanted to know the truth.

But slowly, medical culture started to change. Radiation and chemotherapy led to more hope for patients who might otherwise have been given a terminal diagnosis. Meanwhile, palliative care emerged as a concept in medicine, as well as the hospice movement. Death became less fearful to people.

Doctor & Comedian

These developments — along with the work of Elisabeth Kubler-Ross — all started to change the way our culture talked about death and dying. And it was in this context that Rob Buckman became more than just a doctor, but someone who would also help transform the profession.

Rob’s work in the Cambridge Footlights got him noticed by the BBC. While still training as a doctor, he wrote and performed on radio and TV. In 1978, he and his writing partner were given their own comedy program called The Pink Medicine Show. It was like Saturday Night Live but with exclusively medical sketches.

There was a lot of comedy about medicine at this time, especially in Britain. Doctors were seen as stodgy and distant authority figures, so they made a good target for satire.

Rob’s success eventually also caught the attention of another Footlights alumnus: John Cleese. “Mostly we laughed a lot,” recalls Cleese, a famous member of Monty Python.

He was one of the half dozen people I spent most of my time laughing with.

In 1979, Cleese was producing The Secret Policeman’s Ball, a comedy show that benefitted Amnesty International. And he asked Rob if he’d appear in a routine with him and Michael Palin — the old Monty Python bit known as “The Cheese Shop Sketch.”

Rob’s appearance with Monty Python marked one of the high points of his comedy career. But if you look closely, you might notice his face looks pale and a little puffy. That’s because — after finishing his medical training and establishing himself in the comedy world — Rob got very sick.

Soon, he would learn firsthand what it was like to be a dying patient. And this role reversal, from doctor to sick person, would transform how he thought about his work as a physician and the process of breaking bad news.

In a TV documentary he made about his illness titled Your Own Worst Enemy, Rob can be seen growing ever sicker. He had dermatomyositis, an inherited autoimmune disease that causes the body to reject muscle tissue. Slowly, Rob began to waste away. Married with two daughters, the documentary reveals him in his weakened state, unable to lift his own girls. “What happens,” he recalled, is that “the color drains out of everything.”

It’s the same scene, it’s the same family, it’s the same house, but all the color, the things you enjoy have simply the tone of the illness about them.

For a time, Rob’s condition was so bad that his doctors thought he might not survive — and the experience of being that close to death was profound. Years later, Rob would recall an especially important encounter with this one of his physicians who told him “it must be awful for you, I am sorry.” Rob nearly burst into tears and hugged him, because the doctor gave him permission to feel ill.

The doctor was paying attention not just to Rob’s physical state, but also his emotional state. The moment was simple but important, and it would go on to become the cornerstone of Rob’s approach to doctor-patient communication.

Little by little, Rob started getting better. He was having blood plasma replacement therapy and a new drug he was taking started to work. “The last four weeks have been like a gift,” he said, on the path to recovery. “I can drive my car … straighten my elbows … dress myself.”

By May of 1980, Rob’s condition had turned around and he was able to get back to his normal life. Which meant getting back to his packed work schedule. He trained as a specialist in oncology — the branch of medicine that deals with cancer — while also co-hosting a popular TV science show called Where There’s Life. But that intensity wasn’t good for his marriage. He and his wife ended up getting a divorce, and in 1985, Rob moved to Toronto to take a job at a hospital.

In Canada, Rob had to restart his life completely, but it was there that he would end up making his most lasting contributions to the field of medicine. He started studying the way that doctors communicated with the people they were treating. Specifically, he was interested in how doctors interacted with dying patients, because he himself had recently been a dying patient.

“The great thing about being ill from my point of view,” he said in an interview in the late 1990s, “was that I found out that I could tolerate … a fair amount of pain and handicap … I didn’t collapse, and I didn’t turn into a different person.” His big realization was that doctors didn’t need to hide information from their patients and tiptoe around tough subjects. Sick people could withstand a lot and deserved to know about their conditions.

In Toronto, Rob met and married Dr. Patricia Shaw, a cancer researcher at the same hospital. “He was told that I had the best microscope,” she recalls. “I had the newest microscope. And so he came in to see me. And that’s how we really met, our first conversation.”

Around the same time, Rob began writing more. His first book was called I Don’t Know What To Say: How to Help and Support Someone Who is Dying. It’s a very frank but easy-to-read book that covers everything from basic listening skills to survivor’s guilt after someone has passed.

Then, in 1992, Rob published the most important book of his career, titled How To Break Bad News. It was the first medical textbook on the subject.

Rob drew on his vast experience as an oncologist who had to break bad news several times a week. He understood the process could be broken down into a series of steps, which eventually became the basis of the SPIKES protocol — an acronym standing for Setting, Perception, Invitation, Knowledge, Empathy, Strategy and Summary. It’s a mnemonic device that doctors can use as they prepare to give bad news, and then during the actual conversation with the patient.

Soon Rob and his collaborator Walter Baile were giving presentations on SPIKES at hospitals all over the world. They made videos for medical schools, which demonstrated how SPIKES could help doctors navigate these difficult conversations. In some of the videos, Rob performs improvised scenes with actors playing patients or family members.

Rob was masterful at breaking bad news. He was calm, present, compassionate, and clear. And he was good at it not just because he’d been a patient, but because he’d been a comedian.

“It’s the ability to put yourself in your audience’s shoes and understand what makes them tick,” says Walter Baile.

Despite his recovery from dermatomyositis, Rob’s health problems persisted for the rest of his life. At one point, a case of shingles left him paralyzed on one side. He had difficulty dressing himself and walking. But, in his typical Rob way, he kept working on his many projects.

In 2011, he flew to London to film a series of health videos with Terry Jones, another member of Monty Python.

Then Rob got on the plane back to Toronto.

At about midnight, a police officer knocked on his wife Pat’s door. “He talked a bit of nonsense … and then eventually got got around to saying that Rob had passed away.” Rob had died in his sleep on the plane from an undiagnosed heart condition.

Beyond Rob’s death, SPIKES has endured. It’s been absorbed into the mainstream of American medicine. The American Society of Clinical Oncology now recommends that doctors use a protocol when giving bad news. They offer SPIKES as a good example. And SPIKES is taught in many medical schools in the U.S. and Canada, as well as schools in Europe, Asia, and South America.

SPIKES isn’t the only set of guidelines for breaking bad news, and it may not apply to every bad news situation. But throughout the course of their careers, many doctors will have to break bad news over and over again. SPIKES can help make this challenging task easier for doctors and also better for patients, many of whom are facing one of the most difficult experiences a person can go through.

When you really get down to it, SPIKES is a protocol that can help doctors be more like Rob — or at least the person he tried to be: open, honest, and empathetic.

Coda: Laughter is the Best Medicine

When John Fecile began reporting this story, he had no idea there was a connection between Rob Buckman and Monty Python, but he was thrilled to discover one.

In the course of his reporting, he uncovered a lot of rare footage that we couldn’t fit into the main episode. So these extras are for the Monty Python fans.

Around the same time Rob was writing How to Break Bad News in the early 1990s, John Cleese got in touch with him about an idea he had for a series called “Videos for Patients.”

In them, Cleese plays a patient inquiring about his condition. Rob, playing the doctor, proceeds to lay some heavy medical jargon on him.

Increasingly flustered, Cleese takes it all in, then gets up and walks offstage, revealing to the audience that he’s on a set. Then Rob gets a bit more serious, and goes over the condition in detail.

The videos didn’t sell very well, and mostly disappeared. At least until now.