Teaching Serious Illness Conversations using the Elephant and Rider Model

Author

Dr. Kelvin Lou (biography and disclosures)

What I did before:

With growing integration into the medical curriculum, learners are increasingly familiar with communication tools such as the Serious Illness Conversation Guide and the SPIKES tool[1,2]. These tools provide a structured way to approach serious illness conversation. However, I noticed that learners often have a limited understanding of why these tools work and how to adapt them to new situations not covered in the guide. Without an understanding of the underlying principles, it is difficult to adapt these tools to new situations. Another common challenge is that there is no standard framework to troubleshoot the breakdown of communication and provide actionable feedback to learners.

What changed my teaching practice:

Behavioral research shows that emotions can influence how information is processed[3]. Addressing and acknowledging emotion can be a powerful way to enhance communication and improve information retention[4,5]. In my reading, I encountered a helpful model to explain the connection between emotion and communication: the Elephant and the Rider analogy, coined by the social psychologist Jonathan Haidt[6]. The Elephant and the Rider represent the emotional and analytical sides of our brain, respectively. Discussing difficult topics can make it challenging to integrate our emotional understanding with our analytical reasoning. Acknowledging strong emotions allows us to better communicate more holistically with our patients (the Elephant feels heard, which promotes harmony with the Rider). Understanding this key communication principle allows us to better help our patients incorporate both their emotional and analytical understanding into their medical decision making.

Applying this analogy to serious illness conversation, the communication tools can be understood as a structured way to acknowledge emotions and gently provide information that is calibrated to the patients’ understanding of their illness (whispering to the Elephant). This is a helpful way to explain the underlying principle of how communication tools work, and can give learners a framework for how to adapt serious illness conversations to new situations. The components of the SPIKES tool and their function are explained using this approach as an example (Table 1). This analogy can also be used to highlight that the lack of acknowledgement of emotion is a common root cause for the breakdown of communication. By framing the breakdown of communication in this fashion, the analogy can be used as a way to troubleshoot and provide actionable feedback (Table 2). Using this analogy together with established communication tools can be a simple way to enhance the teaching of serious illness conversation. 

Figure 1: The Elephant and the Rider represent the emotional and analytical sides of our brain, respectively

What I do now:

• Explain to learners how decision making is influenced by emotion and highlight the importance of acknowledging emotions to enhance communication (whispering to the Elephant) 

• Explain to learners the underlying principle of how communication tools such as the SPIKES tool work (Table 1) 

• Troubleshoot and give feedback on learners’ challenging conversations (Table 2) 

How this experience is relevant to teachers in the Faculty of Medicine

Teaching serious illness conversation to learners can be challenging. The Elephant and Rider analogy is a simple way to explain the underlying principle behind communication tools, and it provides a way to troubleshoot and give feedback on learners’ serious illness conversations. 

Table 1: Breaking down the SPIKES tool

Table 2: Troubleshooting and providing feedback using the Elephant and Rider model* 

 *These examples are adapted from real-life cases  

References

1. Buckman RA. Breaking bad news: the S-P-I-K-E-S strategy. Community Oncol. 2005;2(2):138-142. doi:10.1016/S1548-5315(11)70867-1
2. Daubman BR, Bernacki R, Stoltenberg M, Wilson E, Jacobsen J. Best Practices for Teaching Clinicians to Use a Serious Illness Conversation Guide. Palliat Med Rep. 2020;1(1):135-142. doi:10.1089/pmr.2020.0066
3. Dolan RJ. Emotion, Cognition, and Behavior. Science. 2002;298(5596):1191-1194. doi:10.1126/science.1076358
4. Jansen J, van Weert JCM, de Groot J, van Dulmen S, Heeren TJ, Bensing JM. Emotional and informational patient cues: the impact of nurses’ responses on recall. Patient Educ Couns. 2010;79(2):218-224. doi:10.1016/j.pec.2009.10.010
5. Ferrer RA, Mendes WB. Emotion, health decision making, and health behaviour. Psychol Health. 2018;33(1):1-16. doi:10.1080/08870446.2017.1385787
6. Haidt, Jonathan. The Righteous Mind: Why Good People Are Divided by Politics and Religion EBook : Haidt, Jonathan: Amazon.ca: Kindle Store. 1st ed. Vintage
7. Elephant Ride Downhill by Clker-Free-Vector-Images from Pixabay, Pixabay License

Resources

https://thischangedmypractice.com/serious-illness-conversation/  

https://thischangedmypractice.com/serious-illness-conversations-in-the-time-of-covid-19/  

https://www.vitaltalk.org/resources/  

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Teaching Serious Illness Conversations using the Elephant and Rider Model

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