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Passing the Virtual Tissue: Tips and Tricks for Breaking Bad News Using Virtual Communication

Renee Cholyway, MD; Susan Haynes, MSW, MEd; and Emily Rivet, MD, MBA

December 1, 2020

The COVID-19 pandemic caused an abrupt change in communication practices for physicians and health care providers. Prior to the pandemic, the consensus surrounding the delivery of bad news could be summarized in the statement, “The first rule of breaking bad news is: do not do it over the phone." 2

Beginning in March 2020, social distancing forced the adoption of virtual communication strategies with a rapid revision of HIPAA privacy policies and a $200 million fund for telemedicine approved by Congress, allowing wider access for family and care providers to discuss medical management.5, 6, 4, 7, 8

After the pandemic, pilot training programs were initiated at our institution with the objective of creating an educational model to fill an urgent gap in training, to emphasize the relevance of telehealth skills, and to provide strategies for quality and compassionate communication via virtual modalities. The programs included 38 medical students and 33 surgery residents and faculty. An overwhelmingly positive response from participants supported coaching telehealth communication skills as a highly relevant strategy for improving clinical care delivery at this time and into the future. The program built upon the SPIKES protocol for breaking bad news, a well-established paradigm developed in oncology.

S—Set Up

  • Avoid having bright light directly behind you; instead, position the light in front of you to allow a clear view of your face, eyes, and identification badge during the conversation. Reduce background distractions and interruptions such as staff passing through or ambient noise that impedes conversation. Angle the camera to frame yourself from the waist upward and with eye-level situated one-third down from the top of your video screen.6 If using notes, place them in front of you near the camera to prevent frequently diverting your gaze. Consider having an outline of the SPIKES protocol during the encounter. If possible, conduct a “dry run” to test your audio and video qualities. Professional attire appropriate for your medical setting is recommended. Ensure you are emotionally calm and mentally prepared.
  • Anticipate and plan for technical issues that may interrupt the virtual encounter. Ask for a phone number to contact the person in case a technical issue interrupts the connection. Silence pagers or ask a colleague to cover. Use password encryption for encounters if available for privacy. It is often helpful to have a support person; determine ahead of time whether the person desires to have anyone with them in person or virtually during the discussion.
  • Introduce yourself, confirm the name and relationship of all participants, and include them in the discussion.


  • Ask what the person knows about the situation to understand their point-of-view and preconceptions.

I—Invitation or Immediate Concerns

  • Investigate the person’s readiness to have the conversation and address any immediate needs expressed.


  • Deliver the news directly and honestly. Delaying or prolonging the information can cause additional anxiety. If using hand gestures, ensure your motions are slower and more exaggerated than in face-to-face conversation.
  • Use terms that are easily understood since medical terminology can be confusing and intimidating. Tailor the delivery of news to the person’s level of understanding of the current medical condition.8
  • Provide a pause in the conversation once the bad news is delivered to allow time to process thoughts and feelings. Being present in the moment can be more comforting than providing information. Allow for brief pauses in between short sections of information to allow the person to navigate emotions.


  • Acknowledge and validate emotions. It can be helpful to ask about what the person is feeling to learn more and show concern about their emotional state.
  • Offer to wait patiently if the person needs a tissue or a glass or water before continuing.
  • Silence can be misinterpreted as a frozen screen or disconnection; a subtle shift in posture or facial expression confirms your presence and support.

S—Summaryor Second touch

  • Consider offering resources such as websites and online support groups that patients and families may access at a later point when they can process information clearly.
  • Explore the support system the person has available as the encounter concludes. If visitation is restricted, offer contact between the person and his or her support via virtual communications (tablets, laptops, phones). Discuss how and when updates will be relayed after the encounter and offer availability to address additional questions.

We see that preparation is critical for breaking bad news remotely: minimizing interruptions, being conscious of lighting and camera angles, and preparing for technology failures and disconnections. Empathy is expressed during virtual discussions through key variations of customary practices used in face-to-face encounters. The conclusion of the discussion should include follow-up communication, describing resources, and insuring a support system for patients during a challenging time.


The authors would like to thank Sally Santen, MD, PhD, Senior Associate Dean of Evaluation, Assessment, and Scholarship, Virginia Commonwealth University School of Medicine, and Moshe Feldman, PhD, Associate Professor and Assistant Director for Research and Evaluation, Center for Human Simulation and Patient Safety, Virginia Commonwealth University School of Medicine.


  1. Nickson C. Breaking Bad News to Patients and Relatives. Life in the Fast Lane; Critical Care Compedium. https://litfl.com/breaking-bad-news-to-patients-and-relatives/. Published January 7, 2019. Accessed May 24, 2020.
  2. Seehusen DAA. The Effectiveness of Outpatient Telehealth Consultations. Am Fam Physician. 2019;100(9):575-577.
  3. Rights (OCR) O for C. Notification of Enforcement Discretion for Telehealth. HHS.gov. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html. Published March 17, 2020. Accessed May 24, 2020.
  4. Stern V. Is Surgery Ready for Telemedicine? COVID-19 Spurs Virtual Care. General Surgery News. 2020;47(6):1,18.
  5. NEJM Knowledge+ Team. Exploring the ACGME Core Competencies: Interpersonal and Communication Skills. N Engl J Med. https://knowledgeplus.nejm.org/blog/acgme-core-competencies-interpersonal-and-communication-skills/. Published 2016. Accessed May 25, 2020.
  6. Jewell N, Lewnard J, Jewell B. Predictive Mathematical Models of the COVID-19 Pandemic: Underlying Principles and Value of Projections. JAMA. 2020; 323(19): 1893-1894. doi:10.1001/jama.2020.6585.
  7. Finkelstein JB, Nelson CP, Estrada CR. Ramping up telemedicine in pediatric urology- Tips for using a new modality. J Pediatr Urol. 2020;16(3):288-289. doi:10.1016/j.jpurol.2020.04.010.
  8. Wolf I, Waissengrin B, Pelles S. Breaking Bad News via Telemedicine: A New Challenge at Times of an Epidemic. Oncologist. 2020;25(6):e879-e880. doi: 10.1634/theoncologist.2020-0284.
  9. 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.

About the Authors

Renee Cholyway, MD, is a general surgery resident in the department of surgery at Virginia Commonwealth University.

Susan Haynes, MSW, Med, is a surgical simulation administrator at the VCU Center for Human Simulation and Patient Safety, Virginia Commonwealth University.

Emily Rivet, MD, MBA, is an assistant professor of surgery and internal medicine in the division of colon and rectal surgery and the division of hospice and palliative medicine, Virginia Commonwealth University.