Chicago's O'Hare airport is often the site of impromptu medical conferences. As I was returning from a Spine Summit hosted by the North American Spine Society, I met several orthopaedic surgeons—including AAOS President and Larry Halperin, MD—who had attended a patient safety meeting in Rosemont. Edward Dohring, MD, who had attended the Spine Summit, was also present. While waiting for our flights, we discussed issues surrounding patient safety, particularly those relating to breaking "bad news." I was interested to hear that these experienced colleagues had similar experiences and lessons learned as I had with these conversations we hate to have.
My own communication skills are still far from perfect, and I continue to work on them. Adverse patient outcomes keep me up at night. I often take a deep breath before relaying devastating news of a spinal cord injury to patients or their families.
Transparency and disclosure
The slow, steady trend toward greater transparency is to be applauded. Certainly this is what we would demand for ourselves and our families. However, recent studies suggest we are not there yet. Despite knowing that the physician-patient relationship is built on trust, and that we owe it to our patients to explain unexpected outcomes, we don't always live up to this aspiration, especially from the patient's point of view. When I see patients who have sustained an adverse outcome—whether from physician error or as a known risk of a procedure—they often report that the treating doctor buried the explanation of what happened in 15 minutes of medical jargon.
For example, I was not aware of the accepted elements for "full disclosure" (Table 1), as outlined in a recent article by Elwy et al, "Surgeons' Disclosures of Clinical Adverse Events." In assessing the responses from surgeons in 12 specialties who practiced at three Veterans Affairs medical centers, the authors found that surgeon disclosures varied in terms of the elements covered. More importantly, 26 percent of the surgeons reported "very or somewhat difficult experiences discussing the event." These surgeons were four times more likely to have been "negatively affected" by these events and to experience significant anxiety when anticipating the disclosure discussion.
The authors concluded, "Surgeons who reported they were less likely to discuss preventability of the adverse event, or who reported difficult communication experiences, were more negatively affected by disclosure than others." They noted that adverse outcomes, whether preventable or not, have been shown to have a serious impact on surgeons, including "burnout, shame, guilt, and even depression." They also cited "barriers to seeking support for these events, including a perceived negative effect on their careers, stigma, and lack of confidentiality in the process."
Some readers of Dr. Elwy's study might criticize its limited pool of participants, and say that their attitudes and experiences cannot be generalized to the rest of us. But according to a Kaiser Health News article, the surgeons who participated probably felt very comfortable talking to patients, compared to those who didn't participate. And even among those surgeons, noted Dr. Elwy, "there was a lot of anxiety."
Marjorie Stiegler, MD, an anesthesiologist at the University of North Carolina at Chapel Hill, has found that physicians are twice as likely to commit suicide compared to the general population, and that anesthesiologists involved in surgical deaths experience symptoms of posttraumatic stress disorder. She has argued for more awareness of physicians' well-being when faced with clinical adverse events.
What can be done?
Sometimes, just knowing what to say and planning it out in advance decrease the anxiety associated with a difficult conversation. The resulting discussion offers greater value to the patient and might actually take less time.
In a more immediate sense, open communication in the operating room (OR) may obviate some of these difficult conversations. When I work with new OR staff, I share Homeland Security's mantra—"When you see something, say something." I don't want a hierarchical OR culture with strict communication constraints to let me crash because someone was afraid to speak up.
I make sure everyone I work with is empowered to ask questions. If nothing else, it keeps them engaged in the case at hand. Often an ongoing dialogue enhances staff preparedness for the next steps and thereby speeds the procedure along. None of us is perfect, and I am more than happy to acknowledge the positive impact that staff reminders have had on the care my team provides.
Despite my best efforts, I seem to fall into some familiar traps, including the following:
Reeling off the usual speech—I notice myself drifting into this mode in the office, on rounds, and in postoperative discussions with the patient's family. But giving more information doesn't necessarily equate with giving better care. When their eyes glaze over, I have to stop, ask questions, and make sure they are engaged.
Using different words than my team members—I try to avoid jargon, to define key terms, and to repeat those definitions. But everyone on the care team needs to use the same terms. My attempts at transparency will not add up to much if the patient thinks that the nurse's use of "dural tear"— when I called it a "durotomy" or "spinal fluid leak"—means I am hiding something. I ask my care team to avoid using emotionally charged words when appropriate.
Addressing only the patient—For preoperative and difficult postoperative discussions, family members should be present. Family can not only offer needed emotional support, but because they will hear things differently, they may ask more questions and help to clarify issues.
Doing it all at once—In an emotionally charged situation, retention may be limited. I try to sketch out the conversation I want to have, including the number of installments it might take. This is especially true if a complication occurs that requires further investigation. Coming back around is very reassuring to the patient and the family. Having a series of shorter conversations enables me to direct the discussion back to the critical issues that have to be covered. Ultimately, the total discussion time is shorter and the conversations are more satisfying and direct. Save marginal concerns for a later date.
When I use this approach, my interviews are clearer and less taxing (to both parties). More often, I get "the real reason" for the patient visit or the unspoken concern that the patient or family really had. Less often do I get lost in the weeds of biomedical explanation, though I remember long talks about L4 versus L5 nerve root symptoms, after which the patient or family ask, "So, are you saying it's not cancer?"
Each of us comes to these issues of patient communication from a different background, both culturally and in terms of training. Many medical schools are adding communication skills to their residency programs, and the AAOS offers workshops and other tools to assist orthopaedic surgeons in this area of practice. Although some physicians may be reluctant to seek out these courses, a communication techniques course may be of more benefit than other CME offerings.
Good communication is as critical a skill as a steady hand in the OR. We can share some portions of the surgery with residents and other team members, but critical aspects of informed consent and any "bad news" has to come from us as attending surgeons. They may be conversations we hate to have, but we're the ones who are responsible for holding them.
Eeric Truumees, MD, is the editor-in-chief of AAOS Now.
- Error Disclosure
- Surgery error leads doc to public mea culpa
- Elwy AR, Itani KM, Bokhour BG, et al. Surgeons' Disclosures of Clinical Adverse Events. JAMA Surg. doi:10.1001/jamasurg.2016.1787.
- For Surgeons, Talking About Adverse Events Can Be Difficult: Study
- Could Malcolm Gladwell's Theory of Cockpit Culture Apply to Asiana Crash?
- Physician‐Patient Communication: A Lost Art?
- Information Statement
- Communication Skills Mentoring Program