AAOS Bulletin - June, 2005

Plan ahead for breaking bad news

By Kathleen Misovic

No orthopaedic surgeon expects to have something go wrong during surgery. But sometimes it happens.

That’s why the time to plan how you’ll break bad news to patients is before any problem occurs. Once you’ve experienced a less-than-satisfactory result in the operating room, it’s already too late.

“We need to prepare for an adverse event in advance of it ever happening,” said John R. Tongue, MD, a member of the AAOS Council on Education and chair of the AAOS Communication Skills Mentoring Program. “So if the situation does come up, we will have already thought through how we would handle it.”

The importance of communication

Just as we can all learn better ways to interview new patients, we can also improve our technique for breaking bad new to patients, Dr. Tongue said. Unfortunately, many orthopaedic surgeons overestimate their communication skills. They may not fully explain complications to their patients, and they may assume the patients already have enough information.

“Sometimes the greatest obstacle to communication is the assumption that it has already occurred,” Dr. Tongue said.

Part of the reason for this lack of communication is that medical training in the past 60 years, during the rise of technology, has given higher priority to teaching technological skills than to learning communication skills. “In my 10 years of formal medical education, I had wonderful teachers, but no feedback on my patient interviews,” Dr. Tongue recalled.

However, current research points out that patients prefer doctors with good communication skills. “During the last 20 years, some very strong research has defined the importance of teaching and evaluating communication skills,” Dr. Tongue said. “Patients are generally very concerned about matters of trust.”

Fortunately, medical schools are addressing the importance of communication better today than they have in the past. Beginning with the class of 2005, the U.S. Medical Licensing Examination will require medical students to pass a clinical skills-assessment examination by interviewing standardized patients at designated national testing centers.

“As a result of this new emphasis on communications, many orthopaeedic residents not only consider communication skills to be an important part of their education, they want to learn orthopaedic-specific communication skills,” Dr. Tongue said.

An obligation for disclosure

Whatever their communication skills, physicians are required to inform patients when something goes wrong during treatment. The ethics committees of the AAOS, the American College of Surgeons and the American Medical Association agree that the physician has a duty to inform the patient about any adverse event or error. In addition, the Joint Commission on Accreditation of Healthcare Organizations requires physicians in accredited hospitals to inform a patient when results of treatment differ substantially from the anticipated outcomes.

Informing patients allows them to make appropriate plans for subsequent treatment. An uninformed patient may not cooperate with necessary corrective measures.

But instead of being open, many physicians find themselves being defensive and closed-mouthed when a patient experiences an adverse outcome during surgery.

“We feel a great sense of responsibility toward our patients. So when things go badly, it’s natural for us to feel bad and sometimes get defensive,” Dr. Tongue said.

Many physicians are afraid to empathize with their patients because they believe it might make them appear unprofessional, he added. But appearing unemotional and cold is a prescription for appearing to be arrogant in the eyes of patients and their families.

Set a supportive scene

A good first step to take before you ever experience a problem with patient treatment is to identify staff at your medical facility who can support you if you ever need to communicate bad news to a patient. “Choose people you have a good relationship with, perhaps the director of the surgery department, a key administrator or someone in charge of quality assurance,” Dr. Tongue suggested.

These people can help ease your burden by assisting you in preparing an appropriate response to the situation. They can also help the family by clearly answering their questions and offering additional factual information, Dr. Tongue said.

If an adverse event arises and you must deliver bad news, schedule a time when the patient’s family members will be present for you to break the bad news. This ensures more people will receive information directly from you, rather than receive second-hand information that may not be correct. It also helps the patient to be surrounded by familiar people at a difficult time.

“Family members not only provide extra support for the patient, but they often think of questions the patient might not think of,” Dr. Tongue said.

Follow these tips

When you meet with patients and their families, use a quiet room with privacy. Avoid barriers such as desks and tables between you and the patient, and eliminate interruptions such as pagers and cell phones.

Make eye contact and speak with an even tone of voice. Try to remain calm and do not rush through the meeting. The meeting should not occur between surgical cases or in the five minutes before your office hours begin.

You may want to start by saying, “I am afraid I have some bad news.” Then give an accurate, clear-cut statement with nondefensive explanations about what has happened. Speak in short statements and avoid slipping into the comfort zone of technical descriptions and medical jargon.

Prepare to receive the patient’s emotional outpouring of fear, anger, disappointment and mistrust. Acknowledge any emotional reactions.

“True to human nature, when our patients get upset, we feel uncomfortable,” Dr. Tongue said. “We have to prepare ourselves for the range of emotional responses the patients will go through, from denial to anger and acceptance.”

Check periodically throughout the meeting that the patient and family members understand the information you’re giving them. “If they’re not responding initially, it may be because they’re thinking of how to manage or how they’ll break the news to someone else,” Dr. Tongue said. “Get them responding verbally to your comments and following along with you.”

Do not assign blame, and avoid offering initial beliefs or subjective opinions of possible causes of the event. The cause of the error may not be revealed until a thorough investigation has been completed. However, you may want to offer an apology without assigning blame, saying something like, “We are sorry that this happened to you.” Don’t let the fear of a medical liability case prevent you from apologizing. An apology cannot be used as an admission of liability.

At the end of the discussion you should summarize a detailed, proactive plan for the patient’s support and care. Make sure the patient understands and accepts the plan. Writing down a list of instructions for the patient can be helpful.

After the meeting is over, document thoroughly the details of the discussion. Be sure to take some time to regroup before moving on to your next task. However, just because the meeting is over doesn’t mean you can set the issue aside.

“It’s important that you document the plan and follow through in a timely manner. Don’t get distracted by other activities,” Dr. Tongue advised. “Not following through may be the tipping point that causes the family to lose trust in you. Once they feel that way, it may be very hard for you to regain their trust.”

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