Delivering Bad News and Discussing Surgical Complications:
Real World Advice for Physicians Everywhere
December 9, 2016
Unfortunately, the practice of medicine requires the occasional communication of bad news. Within ophthalmology, the bad news may be life-threatening (choroidal melanoma, retinoblastoma), vision threatening (retinal detachment, glaucoma), or lifestyle-threatening (cataract, refractive error). Each type of news clearly differs in severity, but to the concerned, nervous, anxious patient, each represents bad news that may negatively impact their future. In other cases, the bad news that physicians must communicate is a result of an iatrogenic error or surgical complication, where the unforeseen event was due to human error. Such surgical complications are very challenging for physicians to discuss, as they may feel embarrassed and culpable for such errors, and may even fear future litigation.
In this tutorial we will first describe the study of bad news delivery within medical education and review recommended techniques for discussing bad news. We will then discuss delivering bad news in the setting of surgical complications, and will provide recommendations for these challenging discussions.
Delivering Bad News
The Accreditation Council for Graduate Medical Education (ACGME), the governing body responsible for accrediting the majority of graduate medical training programs, considers "Interpersonal skills and communication" to be among the six core competencies for completion of residency. Interestingly, the delivery of bad news is not explicitly included as a key communication skill to be taught during graduate medical training. It is reasonable, therefore, to assume that many resident physicians complete training without formal education in the communication of bad news. In a survey of pediatricians and trainees (residents and fellows) at one large academic medical center, 73% of trainees and 66% of attending physicians felt that formal teaching of bad news delivery was inadequate. The teaching of bad news delivery, therefore, occurs largely through observing a more senior physician deliver bad news, or through trial-and-error, wherein physicians gradually develop their own style for these difficult conversations.
The trial-and-error approach, however, lacks any formal or informal training and takes an implicit toll on patients, families, and the physicians themselves in gaining the skills that could have been imparted in a supervised manner during training. The training of bad news delivery using the classic 'see-one, do one, teach one,' methodology, wherein students learn through observation, seems to be the most common approach, evidenced by a survey of medical students participating in an oncology clerkship where 96% of students reported they had previously witnessed at least one occasion of sharing bad news during medical school, but only half of students (51%) had personal experience with delivering bad news to a patient or family themselves. Multiple barriers to the teaching of bad news delivery have been proposed, including time constraints, poor attending modeling, trainee disinterest in the subject, lack of available resources, and personal fears.[1,3] The physical and emotional discomfort of sharing bad news should not be minimized, as several studies examining trainees delivering bad news have found an increase in cortisol and sympathetic autonomic function, including increased heart rate, systolic blood pressure, and self-reported stress levels during the bad news delivery.
Medical educators have long recognized the need for improvement in teaching physicians to more effectively deliver bad news, and have implemented various techniques for improvement, including large-group lectures, small-group discussions, small group discussions with peer role playing, clinical teaching via observation, and videotaped clinical examinations with standardized patients and subsequent trainee feedback.[2, 5, 6] Several authors recommend a combination approach to teaching bad news delivery by incorporating seminars/lectures to outline various techniques followed by practice-based learning to refine these skills.
Proven Techniques to Deliver Bad News
The specific technique that is ultimately chosen to deliver bad news is at each physician's discretion, and should perhaps be tailored to each patient. In a study examining the bad news delivery style of 30 physicians (both trainees and attending physicians), the following three style of communication were observed:
- Blunt: abrupt news delivery within 30 seconds, characterized by doctors delivering news without providing any context to the news recipients.
- Forecasting (recommended for most situations): staged delivery of the news between 30 and 120 seconds, typified by doctors pre-emptively indicating the news to be bad (that is providing 'warning shots') and followed by the provision of information in a step-wise approach leading up to the event outcome.
- Stalling: delayed news delivery (>120 seconds), after providing very detailed, technically-based information describing the events leading up to the bad news, but delaying the actual news delivery or avoiding explicitly stating the nature of the bad news.
Interestingly, 45% of the physicians examined used the forecasting approach, followed by 37% who used the blunt approach, and finally just 18% who used the stalling approach to deliver bad news.
The SPIKES protocol. The most widely recommended approach to deliver bad news is the six-step SPIKES protocol seen below, developed in 1990 to help guide oncologists in the delivery of bad news. Here are the key components of the SPIKES protocol.
- S: Setting up the interview, including preparing and planning of the space, the presence of others, the seating arrangements, and managing time constraints and interruptions
- P: Assessing the patient's Perception—finding out how the patient perceives the medical situation
- I: Obtaining the patient's Invitation to the type and depth of information they want to receive
- K: Providing Knowledge and information to the patients—sharing the information with the patient in a tailored level of communication and vocabulary
- E: Addressing the patient's Emotions and Empathic responses—responding to the patient's emotions with empathy
- S: Strategy and Summary—planning the next steps, setting goals and treatment plans, and establishing follow-up.
The ABCDE protocol. An alternative approach, which piggybacks on the popular ABC mnemonic is the ABCDE protocol.
- A: Advance preparation—arrange adequate time and privacy, confirm medical facts, review relevant clinical data, and emotionally prepare for the encounter
- B: Building a therapeutic relationship—identify patient preferences regarding the disclosure of bad news
- C: Communicating well—determine the patient's knowledge and understanding of the situation, proceed at the patient's pace, avoid medical jargon or euphemisms, allow for silence and tears, and answer questions
- D: Dealing with patient and family reactions—assess and respond to emotional reactions and empathize with the patient
- E: Encouraging/validating emotions—offer realistic hope based on the patient's goals and deal with your own needs.
Discussing Surgical Complications
Despite the obvious similarity between delivering bad news and discussing surgical complications, there is a paucity of peer-reviewed literature describing how physicians should best discuss surgical complications with patients and their families. In a large review, authors were unable to find any article describing the delivery of difficult news of unexpected death or unexpected change in prognosis in the intraoperative setting. For many physicians, these discussions are perhaps more anxiety-provoking and difficult than any other bad news that can be shared, as physicians may feel they are to blame for surgical complications, and may speak cautiously for fear of potential malpractice litigation. Healthcare workers involved in serious adverse events have been termed "second victims," and several studies have found that physicians involved in serious adverse events suffer profound emotional effects, including fear, guilt, anger, embarrassment, humiliation, anxiety, depression, and post-traumatic stress disorder.
Teaching physicians to effectively and empathetically discuss surgical complications is an integral skill for surgeons in training, and is a direct extension of teaching physicians to deliver bad news.
Tips for discussing surgical complications
Discussing surgical complications after a case is much easier when the patient understood the nature of possible complications prior to the surgery during the initial preoperative consent process. The consent is critical to help prepare the patient and their family for the possibility of a suboptimal outcome or surgical complication. More important than the written document is to look the patient in the eye and have a discussion that is tailored to their background and to their ocular and systemic conditions.
Always document and discuss the special situations in their case that are different, such as, for example, an epiretinal membrane which could lead to less than 20/20 vision postoperatively and an increased risk for cystoid macular edema. If you only mention the epiretinal membrane after the surgery it is hard for even the most reasonable of people to believe that this membrane was not caused by the cataract surgery.
Patients may not remember the details of this preoperative discussion, so you must be very concrete about it, such as by saying 'you have a cornea problem that might lead to issues,' 'you have a retinal problem that might lead to issues,' and 'you have the general issues that face all patients undergoing cataract surgery, wherein 1% of cataract patients do worse after surgery than before.' After your consent, watch your patient, ask yourself, 'Are they following me? Do they want more/less detail?'
For more information on the preoperative consent, click here (http://www.medrounds.org/cataract-surgery-greenhorns/2005/09/chapter-2-preoperative-preparation.html).
Three phases to discuss a surgical complication
- During surgery. When an unforeseen event or complication occurs during surgery, you should pause and mention that the surgery will take a little longer, that you will be using some special equipment to continue safely, but that you are going to take good care of the patient.
"It is going to take a little longer than your other eye as we had some trouble with the capsule that supports the lens. We will be using some other instruments to help us move safely forward. "
- Immediately following surgery. When the patient is still in the recovery area come in the room and sit down. Take a deep breath. Explain briefly that you had a problem during the surgery. Tell them that you are working on the next steps and that you will soon have a plan to take them safely forward. Apologize that it happened, even if it is not your fault. Reassure them that you are going to be with them all the way.
"We had some trouble with the thin capsule that surrounds the lens. This thin capsule tore and so we had to change our strategy a bit to support the artificial lens. We will have to follow you more closely and I would like you to see a retina specialist to make sure that we don't need to do another surgery. Some of the lens may have fallen back and may need to be removed. I am so sorry that this happened but I think we can move on safely from here. I will call you later today to set up a visit with one of my colleagues who specializes in this work."
- Long-term. It is very important that you stay in touch following the surgery. Your patient will be scared and unsettled. Our healthcare system is very complex and our ophthalmology terms and subspecialties are confusing to the majority of patients. You should always strive to call them, email them, and continue to help them navigate through the medical system.
"I am calling to make sure you are doing OK. I talked to Dr. Mercedes and she told me that you are going to have another procedure to remove some lens material. I am so sorry that you have to have another procedure but I agree with her that this is the safest course for you. She is a great surgeon and if you were my brother I would want you to see her. Please keep me informed and call me if you have any questions. I know this is an inconvenience and difficult for you."
If video fails to load, use this link: https://vimeo.com/195703544
- Orgel E, McCarter R, Jacobs S. A failing medical educational model: a self-assessment by physicians at all levels of training of ability and comfort to deliver bad news. J Palliat Med 2010;13(6):677-683. [PMID 20597701]
- Kiluk JV, Dessureault S, Quinn G. Teaching medical students how to break bad news with standardized patients. J Cancer Educ 2012;27(2):277-280. [PMID 22314793]
- Dosanjh S, Barnes J, Bhandari M. Barriers to breaking bad news among medical and surgical residents. Med Educ 2001;35(3):197-205. [PMID 11260440]
- Brown R, Dunn S, Byrnes K, Morris R, Heinrich P, Shaw J. Doctors' stress responses and poor communication performance in simulated bad-news consultations. Acad Med2009;84(11):1595-1602. [PMID 19858823]
- Rosenbaum ME, Ferguson KJ, Lobas JG. Teaching medical students and residents skills for delivering bad news: a review of strategies. Acad Med 2004;79(2):107-117. [PMID 14744709]
- Lamba S, Tyrie LS, Bryczkowski S, Nagurka R. Teaching Surgery Residents the Skills to Communicate Difficult News to Patient and Family Members: A Literature Review. J Palliat Med 2016;19(1):101-107. [PMID 26575251]
- Shaw J, Dunn S, Heinrich P. Managing the delivery of bad news: an in-depth analysis of doctors' delivery style. Patient Educ Couns 2012;87(2):186-192. [PMID 21917397]
- Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist2000;5(4):302-311. [PMID 10964998]
- VandeKieft GK. Breaking bad news. Am Fam Physician 2001;64(12):1975-1978. [PMID 11775763]
- Pinto A, Faiz O, Bicknell C, Vincent C. Acute traumatic stress among surgeons after major surgical complications. Am J Surg 2014;208(4):642-647. [PMID 25241953]
Christiansen SM, Oetting TA. Delivering Bad News and Discussing Surgical Complications: Real World Advice for Physicians Everywhere. EyeRounds.org. posted December 15, 2016; Available from: http://EyeRounds.org/tutorials/delivering-bad-news.htm