By Dr. Kathryn McElhinney
One of the most challenging aspects of our careers as surgeons is delivering bad news to patients, but it is also one of our most important jobs. No matter the subspecialty, every surgeon has to have frank conversations about unexpected outcomes or diagnoses with their patients. There are a number of different formal and informal curriculums that have been proposed on how to teach residents how to navigate difficult conversations with patients and their families but no singular method prevails. As a resident, it is the ultimate opportunity to learn how to master these communication, empathy, and leadership skills.
1. Embrace the opportunity to learn and be uncomfortable
No one enjoys telling a family that the diagnosis is likely terminal or that the next best step in care may not be the surgery that they have been told would solve all their problems. It is okay to feel like this is not the kind of conversation you want to have. However, surgeons are afforded a unique relationship with their patients. Surgeons take ownership over the care of patients that they have operated on. This often leads to the surgeon being the de facto communicator in situations where there has been an unexpected outcome. Additionally, the resident is often the face that the patient and their family associate with the surgery team. They are the person they see rounding everyday despite revolving attendings. Embrace the opportunity to have these challenging conversations when they come up. Set up a specific time with the family and your team to sit down and fully explain the situation. If feasible, set up to have the conversation in a quiet and comfortable space away from distractions. If this discussion is going to be in the outpatient setting, make sure the patient will not be alone. Utilize known constructs for having these challenging conversations, and be prepared to revisit the topic more than once. We know that many times during these meetings, the shock of a new diagnosis or a change in treatment plan limits how much information is actually absorbed by our patients. Leave the door open to revisit this conversation again, once they have processed the new information.
2. Ask for help
As trainees, we have access to attendings who have been where we are. We have mentors around us who have had profound experiences in having difficult conversations with patients. Ask for their support. Ask for an attending to be present for the conversation if you need help. Before you walk into the patient’s room, ask for their advice on how to best approach the subject, especially if it’s a topic you haven’t discussed before. There are many resources available to help support conducting difficult conversations. Many like to use previously described protocols such as SPIKE to organize their conversation.¹ The American College of Surgeons also provides a resident’s guide for surgical palliative care that has sections on delivering bad news and discussing resuscitation status.²
3. Recognize when the conversation is above your pay grade
There are going to be some conversations that are not appropriate for a trainee to lead. In those instances, I would still advocate for being present if it’s a patient you have rapport with and if your presence would not be distressing. Don’t be surprised if you are asked to leave the room or to not join the meeting. In these scenarios, it is okay to take “No” for an answer.
4. Process your experience and ask for feedback
After the conversation, expect that you may have an emotional response to the difficult conversation and recognize that is normal. Take a minute to step away and collect yourself if needed. Take the time when it is appropriate to process what happened and what was said in the way that is most appropriate for you. Decompressing with co-trainees, writing it down, or discussing the encounter with a professional counselor are all options to explore.
Ask for feedback from your attending if they were present. Discuss what you think went well and what you think could have been communicated better. Ask if your attending saw areas that could have been worded better or explained more fully. Debrief with your team members if they were present or not: update the team on how the conversation went and what next steps are. Get feedback from other residents or fellows about anything they have experienced themselves.
Delivering bad news is an inevitable part of our careers as surgeons. Residency is the
perfect time to learn and master the skills needed to manage these complex interactions. We all have the opportunity to take advantage and practice these skills and hone them under the guidance of mentors and colleagues.
1. 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. The Oncologist. 2000;5(4):302-311. doi:10.1634/theoncologist.5-4-302
2. Dunn GP, Martensen R, Weissman D. Surgical Palliative Care: A Resident’s Guide. American College of Surgeons; 2009.
Kathryn McElhinney, MD is a general surgery resident from the University of Texas at Austin currently in her research years at Ann & Robert Lurie Children’s Hospital of Chicago. She is originally from Austin, TX and completed medical school at the McGovern Medical School at the University of Texas at Houston. When not in the lab, she is out running on the lakeshore with her dog, Snickers.