SKIPS: A Tool for Difficult Discussions

SKIPS: A Simple Modification of a Prior Simulation Tool for Difficult Patient Discussions


Patient communication during ethical or difficult treatment decisions is a complex interaction. We present our initial experience with a structured framework for discussion, SKIPS (setting, knowledge, invitation, perception and strategy), as a modification to a previously reported tool for breaking bad news, SPIKES. Our new framework emphasizes patient beliefs and wishes in the setting of a discussion requiring ethical considerations or treatment decisions. Initial evaluations of the SKIPS tool were favourable by resident and faculty, with faculty reporting a greater chance of utilizing SKIPS than the residents.


Simulation, communication, residency education, milestones


Patient communication with an emphasis on empathy may lead to improved patient outcomes [1, 2]. And while beneficial, this skill may not be intuitive to all physicians. This importance of communication skills has been acknowledged by the ACGME by inclusion as a core component of the ACGME milestones [3]. In residency, detailed evaluations for resident performance is needed to accurately monitor resident progression in many areas including these interpersonal and communication skills. It is from this need that we developed our SKIPS tool. Objective Structured Clinical Exams (OSCEs) are a tool often utilized to simulate physician-patient interaction to allow consistent evaluation and performance as evaluation of milestones in a clinical setting may lead to evaluations with less consistency [4, 5]. There are preexisting methods for framing difficult discussions while providing information regarding life threatening diagnosis or patient loss in the medical literature. One method is the SPIKES tool which is reported in the oncology literature [6, 7].

However, we did not find the SPIKES method provided the correct framework to engage in a treatment or ethical discussion that requires patient decision making based on independent beliefs, preferences or ethics. We submit a simple modification of the acronym to use in discussions for complex discussions or discussions providing patient treatment options: SKIPS (Figure 1). This tool uses setting, knowledge, invitation, perception, and strategy to provide the framework for the discussion. We present the SKIPS framework as a method to approach difficulty patient discussions, both for education and for clinical application.

SKIPS Tool Creation and Implementation

We developed this tool for our anaesthesiology residency program and feel this may be utilized for many other specialties. Our department had a need for an objective evaluation of interpersonal and communication milestones with OSCEs to allow residents to simulate a difficult patient discussion. We already used a structured discussion for breaking bad news, such as a patient death or chipped tooth. In this setting, we found the SPIKES tool [setting up, patient perception, invitation, knowledge (physician to patient), emotion/ empathy, strategy/ summary] to be a well-suited acronym to assist our resident learners. However, we did not find the SPIKES method provided the correct framework to engage in a treatment or ethical discussion that requires patient decision making based on independent patient beliefs, preferences or ethics. Examples of such events includes acceptance of blood products for a Jehovah’s witness patient or procedures where two options for treatment are both acceptable solutions, such as a general anaesthetic versus spinal anaesthesia. In these situations, patient ‘perception’ occurs later in the discussion and expressing ‘empathy’ is typically not a major component.

Our residents are trained to use SPIKES during their first year of anaesthesiology residency training for a breaking bad news event and therefore, we wanted to present them with a similar format for these other types of patient discussions. We designed SKIPS to maintain a similar familiar structure (Figure 1). The structure for SKIPS includes: setting up, knowledge (provided by the physician), invitation, perception (physician determines patient beliefs or preference) and strategize. In the second year of anaesthesiology residency (PGY3) the residents are given an OSCE with a Jehovah’s witness patient. The residents are provided both the scenario and education on the SKIPS tool the week prior to the OSCE. The specific concerns to address with a Jehovah’s witness patient require independent preparation by the resident.


The residents were presented with a 45-year-old patient with a past medical history of hypertension, hyperlipidemia, and non-insulin dependent diabetes. In the scenario, the patient was involved in a roll-over motor vehicle collision 4 hours ago and was transferred to the hospital for urgent surgery. There is an open femur fracture with visible bone. Admission laboratory studies in the emergency room show a hemoglobin concentration of 8.5 mg/dL and a platelet count of 247. There is expected blood loss during the procedure. The patient reports they are a Jehovah’s witness. For the simulated scenario, a standardized patient is used to create a realistic scenario. The resident uses the SKIPS tool to conduct a discussion about the patient’s potential blood loss and explores the patient beliefs about the use of blood products. Following our simulated scenarios, residents were given surveys to evaluate the SKIPS tool. In addition, faculty evaluators were provided surveys to evaluate the tool.

Figure 1: SPIKES versus SKIPS tools for clinical discussions.


Residents and faculty were provided post-event surveys with rating scales from 1 to 5, with a 3 rating of neutral. As this was a pilot project, was had a limited number of respondents with 4 faculty and five residents surveyed. Faculty report SKIPS was helpful for a structured way to approach the discussion (5), while residents’ rate this near neutral (3.4). Faculty were more likely to use the SKIPS tool in their personal clinical practice (4.5) compared to residents (3.8), (Figure 2). The sample size was not sufficient for a statistical analysis. Overall, subjective responses from faculty and residents were favorable to continue using this communication tool.

Figure 2: Faculty and residents evaluation of SKIPS following a simulated patient discussion.


The SKIPS tool allows our resident physicians to modify a common communication tool (SPIKES) to provide a new framework for difficult physician-patient discussions. This tool may be used for a variety of other clinical discussions beyond the scenario presented here that involve providing the patient with treatment options and involving them in decision making. We had no need for remediation for this session to evaluate a resident milestone. Providing the resident with the SKIPS format prior to the session to prepare may relate to this high level of performance. We were limited in our data collection based on our small residency size. Also due to the nature of anaesthesiology clinical interactions, we have limited opportunity for this tool to be evaluated in the clinical setting. We encourage physicians in larger residency programs or other medical specialties with more opportunity to engage in these patient discussions to consider SKIPS as a tool for clinical use or consider opportunities for further evaluation of the SKIPS format.

Author Contributions

Julie M. Marshall assisted in the creation of the case and preparation of the manuscript. Michael S. Brown assisted in the creation of the case and preparation of the manuscript. Marty Runyan assisted in the creation of the case and preparation of the manuscript. Dena Higbee assisted in the preparation of the manuscript.





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Short Report

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© 2023 Julie Marshall. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hosting by Science Repository.

DOI: 10.31487/j.ACR.2020.01.05

Author Info

Julie Marshall

Michael S. Brown

Marty Runyan

Dena Higbee

Corresponding Author
Julie Marshall
Associate Professor, Department of Anaesthesiology and Perioperative Medicine, University of Missouri, One Hospital Drive, Columbia, Missouri, USA
Figure 1: SPIKES versus SKIPS tools for clinical discussions.
Figure 2: Faculty and residents evaluation of SKIPS following a simulated patient discussion.
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