top of page

Feedback "Spikes"

Updated: Apr 28, 2019

I think a lot about how to best structure the feedback sessions. Not just what to say, but how to say it.

Do you just dive right in, or do make a little small talk to ease them in? When it's time to talk results, do you start with the details and lead up to the big picture? Or do you begin with an overview and then add in supporting points? (See also this post on deductive vs. inductive order when organizing a summary.) Do you need to give a mini lecture on the brain first, as some psychologists suggest in Feedback that Sticks? If the parent wants to know about strengths and weaknesses, do you start with the "good news" first, or lead with the "bad news"? Once you're into the heart of the matter, how much do you talk and how much do you listen? Is it collaborative, or more like a doctor talking to a patient?

Amazingly, there is no literature I'm aware of that discusses or even mentions best practices in delivering feedback. There's that one book, Feedback that Sticks, but most of the book is a collection of analogies and pat phrases experienced psychologists have found "work" for them, rather than a systematic exploration of how to give feedback.

However, maybe we can learn from our colleagues. The field of medicine has been looking into how to give patients information they need for decades.

One physician in England came up with a specific protocol for delivering bad news that is still taught and used by doctors today. His name is Rob Buckman, an there's a great podcast about him over at 99% Invisible. He became interested in this topic based on his own experience being a patient (he had an autoimmune condition that caused muscle wasting) and his experience as a comedian (he worked with the guys in Monty Python), which he found deepened his empathy.

Buckman came up with a protocol called the SPIKES protocol. The letters stand for:

  • Setting - Make sure the environment and the patient (and his or her family) are as comfortable as possible

  • Perception - Get a sense of what the patient and his or her family think is going on

  • Inquiry - Ask for permission to share what you have learned

  • Knowledge - Share what you have learned using understandable language

  • Emotion - Check in with and empathize with how the patient is responding emotionally to the news.

  • Summary and Strategy - Summarize what you have told them and explain the strategy going forward.

Modified SPIKES is now the basic framework I use for my feedbacks:

Setting & Perception:

In the calm comfort of my office, on plushy furniture with tissues nearby and a cup of tea for comfort, I start by reviewing with the family their perception of the problem and the questions they have about their child.

Inquiry and Knowledge:

I then ask if it would be okay if I share what I have learned about their child. When they agree, I explain what I now know. The structure of this part is what I'm still working on - I usually use one of the frameworks in the post on organizing a summary.


Then I spend a lot of time checking in with how the parents are responding emotionally to the information we've discussed. Sometimes parents want to jump ahead to the strategy part, and I used to respond to their anxiety by moving quickly there myself. Over time, I've found it more helpful to slow down and really spend some time and space on their emotional reaction to the feedback info.


Now we talk strategy. In this part, I try to condense all my recommendations into a 3 point plan. [I don't have any good research supporting this number; it comes from my ABPP board oral defense, where Joel Morgan told me the average number of recommendations families follow is three - for some reason that really stuck with me!] So I'll say something like, "Our plan is (1) to support his physical health as best we can, (2) to make sure he gets what he accommodations at school so that he's challenged but not overwhelmed, and (3) to build his skills directly through specific therapy."

  • Once parents have the general idea of the 3 parts, we'll get more specific. For example, supporting his physical health might include improving his sleep, talking with a psychiatrist about a medication, making sure he is getting plenty of regular exercise, and trying yoga or relaxation training. As another example, there might be multiple specific therapies or services he needs to build his vulnerable skills.

Summary & Repeat Strategy:

Last, I summarize. I give most* parents a 2 page Feedback Summary at the end of the feedback. This is the point where I hand that summary to them. I say, "This is a summary of what we just talked about. I put it on paper the same way we talked about it just now. Here [point to first paragraph] is a little bit about why you were here. Here are his strengths [listed in bullet points], which you'll remember are A, B, and C. Here [next set of bullet points] are his weaknesses, which as we talked about are are D and E. Here [next section] is the diagnosis we came up with. And here [numbered list at the end] is our 3 point plan for how to support him." (*Lately, I've been giving families the full report at the feedback, so I'll orient those families to the summary section of the report instead of a separate summary.)


For more on learning from comedians, scientists, and medical doctors about how to communicate, I also recommend Alan Alda's work (yes, that Alan Alda). Check out the Alan Alda Center for Communicating Science, his book on communication (If I Understood You Would I Have This Look On My Face), and this Hidden Brain Podcast interview with him.

1,627 views1 comment

Recent Posts

See All

1 Comment

Wait. At which step do you share the diagnosis?

bottom of page