Training can help surgeons tell patients best and worse scenarios
Surgeons who get extra training to sharpen their communication skills may have an easier time explaining best and worst case scenarios to frail elderly patients as part of shared decision making, a small study suggests.
For the study, researchers paid 25 surgeons to complete a two-hour training session on how to discuss a range of possible outcomes with patients and families. Before and after training, researchers analyzed transcripts of surgeons' interactions with patients and families, awarding up to 100 points for optimal communication.
Half of the surgeons scored at least 74 points after training, up from 41 points before, researchers report in JAMA Surgery.
"Surgeons commonly disclose treatment risks using the language of informed consent, for example, quoting a 35 percent chance of stroke or a 20 percent chance of death," senior study author Dr. Margaret Schwarze of the University of Wisconsin in Madison said by email.
"This information satisfies legal requirements; however, it does little to help patients imagine what life might look like should they suffer an adverse events or help them to think about treatment options in relation to their values and goals," Schwarze added.
All of the patients were at least 65 years old and frail, at increased risk for death or complications, or had multiple medical problems that surgeons thought would impact their long-term health outcomes.
Patients needed acute care, but not emergency operations. They were candidates for surgery to address problems like hernia, valve or vascular conditions, or bowel issues. Surgeons participating in the study specialized in cardiothoracic, vascular or acute care procedures.
Among other things, surgeons' training included exercises designed to help them focus beyond the risks and benefits of specific operations to consider alternative treatments or no intervention as options that might fit better with patients' quality of life goals.
"When surgeons talk to patients they typically focus on the patient's isolated problem and the surgery required to fix it," Schwarze said.
"This model makes it difficult for patients to consider a non-operative alternative and gives patients a false sense that surgery will fix their problem and return them to normal," Schwarze added. "Yet for the patients in our study, their surgical problem was bad news and many were unlikely to survive even with surgery."
By focusing on what researchers called "scenario planning," surgeons learned to use stories to describe what life might look like after surgery or alternatives like medical management or palliative care.
Surgeons' communication scores improved after training because they got higher marks for presenting treatment options, describing what different intervention choices would involve and then encouraging patients to thoughtfully deliberate and arrive at the best choice for their particular circumstances and goals.
Beyond its small size, other limitations of the study include a lack of data on whether this type of training for surgeons improves clinical outcomes for patients, the authors note.
Still, the findings suggest it might be possible for surgeons to change how they describe treatment options so patients think about surgery in terms of how it would impact their life, not just in terms of what might happen during the operation itself, Dr. Peter Angelos of the University of Chicago writes in an accompanying editorial.
"At the point when a patient needs surgery, he or she is in a particularly vulnerable state and may not be thinking in the most analytic manner possible," Angelos told Reuters Health by email.
"In addition, surgeons have tended to focus on the risks, benefits, and alternatives to a specific operation in the informed consent process," Angelos added. "Although that information is necessary, it is not sufficient for a patient to understand how a particular operation might impact their overall status in terms of independent living or other important aspects for their quality of life."