Discussing Surgery With Patients
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From the JAMA Network, this is JAMA Clinical Reviews, interviews and ideas about innovations in medicine, science, and clinical practice. Here's your host. Hello, and welcome to this JAMA Clinical Reviews podcast. I'm Anne Coppola, Senior Editor at JAMA, Professor of Medicine at the Perelman School of Medicine at the University of Pennsylvania, and Director of the Penn Medical Communication Research Institute.

Joining me today is Dr. Lauren Taylor, who is a surgeon at the Central Virginia VA Healthcare System. We will be discussing her piece from JAMA's Communicating Medicine series titled, Communicating with Patients About Surgery. Welcome, Lauren. Thank you, Dr. Coppola.

I am so delighted to be able to discuss your manuscript today. When I look back on my experiences with communicating with patients about surgery, which was a long time ago because I'm an endocrinologist, they were all about obtaining informed consent. Can you tell us what is special about surgeon-patient communication? Dr. Anneke Vandenbroek

So I will say it's a lot more than obtaining informed consent. Surgeons face a unique set of challenges when talking with patients and families about surgery. And part of that is due to the nature of many surgical diseases, which means they have an acute presentation. These conversations can happen in the middle of the night, on the weekends.

in a noisy emergency room or in the middle of the intensive care unit. And oftentimes, surgeons don't have the luxury of having a preexisting relationship with a patient or their families, which means that they have to navigate both the clinical information and also work on establishing trust and understanding what the patient values in a really short period of time.

And the final thing that I will say is that emotions can run really high in these conversations. And this is certainly true in the context of high-risk surgery, but also can be true even in the setting of what we would consider to be a minor operation. Well, that is a perfect lead-in to my next question,

which was about the meat of the piece. And in your piece, you provide evidence-based recommendations about three advanced communication skills. The first is attend to emotion. Please tell us about this skill. Yes. So as I just alluded to, emotions can run really high. And if you ignore them, it can create a whole sequelae of downstream complications that we can avoid.

Really, there's two parts to this component. And the first is disclosing difficult news. And this could be in the context of discussing a potential major operation or disclosing a post-operative complication. And really, before you actually provide the news, it's important to prepare patients and families that this serious news is coming. And we recommend starting with a heads-up statement, which is really so that they can process that this information is coming and understand the gravity of the news that you're about to share.

Once you've provided this heads-up statement, then you can provide a concise headline. And this is really a brief summary of what has happened and really to make sure that they understand your main message. The second part of this is really understanding that these strong emotions can drive what patients say and their actions. And really, this emotional response can happen much more quickly than rational thinking. And surgeons can fall into something called a cognitive trap.

when they fail to acknowledge these underlying emotions in terms of the responses that patients or families are giving them. And when they ignore these emotional responses, they provide an answer that includes more information. And this is not necessarily what patients and families need. Instead, surgeons can first provide an emotional or an empathic response.

And this does not mean an in-depth conversation about their emotions, but really can be a brief statement to acknowledge where patients and families are coming from. And this can do a lot to de-escalate the emotional tenor of the conversation, promote trust between patients and families, and really create a space for the conversation to proceed in terms of more rational conversation about what happens next.

All right, can you give us an example of news that you need to deliver, starting with the heads up and the headline and tell us what you would do? Let's consider an older frail patient. Say his daughter noticed that he had a sore on his toe that wasn't healing, so she brings him into the hospital.

After you evaluate the patient, he has some workup, you realize things are a lot more serious than you initially thought. So if I was talking to this patient's daughter, I might start with a heads up statement like, things have changed, or I have some news to discuss that's hard to hear. And for this particular patient, I'm worried that he's going to need an amputation. So I would follow this with a headline of something like,

Your father's condition is a lot worse than we initially expected. I'm worried he's going to lose his foot. And the important thing to notice here is that in that headline, I didn't provide information about his laboratory values or interpretation of the angiogram or anything like that. I really just focused on the core message so that's understandable. You can imagine delivering this type of news, his family might be shocked, upset, frustrated, all sorts of things. And a response I might hear is something like,

Well, but the other doctor said it was just a little sore on his toe. Don't you guys even talk to each other? This seems like something minor. And I can fall into the cognitive trap explaining how I talked to my colleague or my interpretation of the angiogram. But really, a better approach is to acknowledge this family member's frustration and fear and worry by saying something like, it must be really hard to see your dad this sick.

And then the next thing that you recommend is to use scenario planning to manage uncertainty. So you've gotten to the point where they're realizing or accepting that

perhaps in this case, the amputation or any one of a number of possibilities. Can you explain to us how do you do scenario planning? When surgeons are talking to patients and families about surgery, oftentimes we provide a long list of all the things that can go poorly or go wrong during surgery or after the operation.

And the problem with this approach is that this doesn't give patients any information about what it's actually like to live with a complication. And it allows the patients to listen to all everything that I've said and say, well, that sounds fine, but it'll never happen to me. Scenario planning is a fundamentally different approach, and it's a core component of a communication framework called best case, worst case. And this is designed for high-stakes surgical decision-making.

So in creating a scenario, it's important to understand that the goal is not to make one scenario to predict the future. Rather, you are generating multiple plausible scenarios under different sets of assumptions. So what are those sets of assumptions? So when uncertainty in a clinical situation is high, I can't predict what's going to happen. But oftentimes, I do have a reasonable assumption of how things will play out if surgery goes as well as I could hope for or if things go really poorly.

So for creating scenarios, we ask surgeons to tell a story, assuming first, in the best case scenario, that everything goes well. And this story starts with the experience of surgery and recovery in the hospital, but also includes longer-term outcomes, such as functional status or the ability of the patient to live at home independently after surgery. In the same way, surgeons can describe a different scenario, assuming that things go poorly.

So instead of providing that long list of all the complications, assume that these complications occur and tell a story about what it's like to be in the intensive care unit on a ventilator, unable to speak to family, and potentially dying in the hospital depending on the clinical situation.

And what this does is really pushes patients to think critically about what is important to them and also helps them understand the interconnectedness of things like underlying comorbidities and frailty and how these things might play out over time after an operation.

All right. That leads us to your third recommendation, which is describe the goals and downsides of surgery to support deliberation. That flows from the upside, downside, or best case, worst case scenario, now moving to the goals of surgery. So can you elaborate on that? I will say the scenario planning is really most helpful in the setting of these high stakes decisions when there is a lot of uncertainty.

Describing the goals and downsides is something that we recommend that surgeons do every time they talk to a patient about surgery, even a small surgery, a small outpatient procedure.

And really, this recommendation is based on a novel framework called Better Conversations. And this was developed by Dr. Gretchen Schwarzzi in her lab based on analysis of hundreds of surgeon-patient conversations. And what we found is that surgeons commonly provide their reasoning for surgery in terms of an anatomic abnormality and how surgery can fix that problem. Say, remove a tumor or repair a hernia, for example.

And the problem with this is it not only takes a lot of time for surgeons to provide this sort of technical information, but it also oversimplifies the story of what surgery can do while neglecting what meaningful health outcomes surgery can achieve for the patient.

So an example of this might be for a patient considering a lower extremity bypass, surgery could be described as a way to unblock an artery, which yes, it can do, but that's not a meaningful health outcome for that patient. Instead, really the goal of that operation is to help the patient's pain if they have breast pain or to preserve that patient's foot.

And describing the goals of surgery in this way really makes sure everybody is on the same page and the patient has a realistic expectation of what surgery can plausibly achieve for them. Now, the other side of this is discussing the downsides. And we've already, you know, in speaking about scenario planning, talked about the problems with providing all these risks. But another problem is that the risks of surgery don't tell the whole story.

There are downsides to having an operation for every time a patient has an operation, such as the pain of surgical scars or the effort that they need to put into surgical recovery. There's also changes in functional or cognitive status that might happen with surgery and the possibility that surgery falls short and just doesn't reach the goals that we hope it will.

So by providing the goals and the downsides in this way, it does a couple of things. Number one, it makes sure everybody is on the same page about what surgery can achieve and the downsides of that. And more importantly, it helps patients first determine if the goal of surgery is something that's valuable to them. And in turn, if the burdens are tolerable, the burdens and the downsides of surgery, and deliberate between those two things to determine if an operation is worth it to them.

That's great. If anyone is interested in learning more, you and your co-authors are part of a multi-institutional group of surgeons who've developed a curriculum for surgery residents. So where can they find out more if anybody wants to read more about your curriculum? So we have a five-year skills-based curriculum that we feel really fills a void in communication education for surgical residents, and it's called the Fundamentals of Communication in Surgery, or FCS.

And anybody who's interested in learning more, we would love if you go to our website at www.fcsprogram.org.

Thank you so much, Dr. Lauren Taylor, for joining us today to discuss your piece titled Communicating with Patients About Surgery. You can find a link to the articles in this episode's description. To follow this and other JAMA Network podcasts, please visit us online at jamanetworkaudio.com or search for JAMA Network wherever you get your podcasts. This episode was produced by Daniel Morrow at the JAMA Network. Thanks for listening.

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