Difficult Conversations

Strong interpersonal skills enable surgeons to provide high-quality care and function as leaders in health care teams. In plastic surgery, these skills are frequently put to the test when managing patients’ expectations of aesthetic outcomes, by ensuring safety in a high-stakes or novel procedure, by disclosing surgical complications to the patient, and by resolving disputes among team members. As the practice of medicine shifts toward interdisciplinary teams and a patient-centered model of care, it is essential for plastic surgeons to cultivate strong communication skills in preparation for a variety of difficult conversations that are inevitable in one’s career. To have excellent bedside manner is to be “humane and compassionate, empathetic and supportive.”1 However, upholding these values while navigating a difficult conversation with patients or members of the surgical team can challenge even the most experienced surgeon. Empathetic communication is a cornerstone of patient-centered medical care, yet evidence shows that physicians often overestimate their ability to effectively communicate with patients.2 On average, physicians listen for only 18 to 23 seconds before interrupting or redirecting a patient during conversation.3 Poor communication between provider and patient jeopardizes continuity of care, compromises patient safety, and increases the likelihood of medical malpractice claims.4,5 In this article, we describe frameworks for conducting difficult conversations and present examples of common scenarios to guide plastic surgeons through effective communication. Surgeons who are adept at navigating difficult conversations are poised to strengthen patient rapport, manage complex interpersonal disputes among team members, and build a culture of trust in the workplace. THE BASICS Communication can be conceptualized as the interaction of eight distinct components: source, receiver, message, encoding and decoding of the message, channel through which the message is sent, interference, and feedback (Fig. 1).6 Any conversation can be contextualized within this framework. Take, for example, sending a message to a patient through the electronic health record. The physician would be the source, the patient the receiver, and electronic health record the channel of choice. How the physician chooses to word the message constitutes the encoding of the message, whereas the patient’s interpretation of the message represents the decoding. Interference is any outside distraction that threatens to disrupt the other communication components. Finally, the patient’s response and level of understanding represents feedback. Certain components, such as the message, encoding, interference, and channel, are easier for a source to control than the others. Because the source in this example is the physician, greater effort should be invested in honing these components when developing strategies for guiding difficult conversations.Fig. 1.: SPIKES in the communication process.Physicians may have come across the SPIKES methodology, a six-step strategy for breaking bad news (Fig. 1) that aims to emphasize four key components of effective communication: gathering information from the patient, transmitting medical information, providing patient support, and eliciting patient collaboration for treatment plans and future management.7 The six steps of SPIKES are setting up the interview, assessing patient perception, obtaining the patient’s invitation, giving the patient knowledge and information, acknowledging patient emotions with empathy, and strategy for resolution.7 SPIKES is a highly effective strategy in improving both physician and learner confidence in holding difficult conversations.8 This strategy emphasizes helpful techniques in responding to and supporting patients through emotional reactions by incorporating both patient and physician feedback.9 Although SPIKES was originally developed for breaking bad news, each of its steps facilitate components of communication. For example, setting up the interview is an important step in minimizing interference during a conversation; assessing the patient’s perception is akin to understanding the decoding of the message and eliciting feedback. By integrating both framework and strategy, physicians can become effective communicators during difficult conversations. The following scenarios are relevant to plastic surgeons and walk through each conversation using these frameworks. THE DIFFERENT ROLES OF A PHYSICIAN Mirror, Mirror: Creating Realistic Expectations Ms. Smith presents to your clinic with complaints of neck, back, and shoulder pain. She reports that her large breasts have always caused problems, but “it’s just gotten to be too much.” She has heard bilateral breast reduction “works miracles” and would like to undergo the surgery to alleviate her chronic muscle pain. The surgery is performed successfully with no immediate complications. However, at her 1-week follow-up, Ms. Smith seems distraught. “My breasts don’t look round anymore, doc. I am so grateful that the pain is gone, but my breasts look like boxes now.” Disappointing or unanticipated outcomes often are a result of misaligned patient and physician expectations.10 Although you would love to promise perfection, the reality is that this is often not possible. Therefore, it is important to establish realistic expectations during the initial consultation, not only for the patient but also for yourself. For example, a patient may seek a plastic surgeon for a scar revision, anticipating flawless skin postoperatively. However, a scar revision is meant to improve—not erase—and being honest with the patient about its limitations will help alleviate disappointment down the road.11 Likewise, reconstructive operations may not return all function to the revised structures. When delivering the initial message, the source should create a message that is honest and direct. For example, you could offer a patient a “60 percent improvement in appearance” following laser resurfacing of a scar. The figure serves as an arbitrary but concrete benchmark, and though it may not be what the patient wants to hear, controlling the message upfront can align realistic goals for care between both parties moving forward. In delivering this message, it is also important to gauge the recipient’s feedback and incorporate it into subsequent messages. For example, if a patient continues to express desires to “achieve perfection,” the surgeon should reinforce more realistic expectations. Disclosing an Error or Preventable Complication In the middle of a busy clinic day, you begin a visit with Ms. Smith, the pleasant middle-aged woman who had undergone a bilateral breast reduction surgery with drain placement. Since yesterday, she has noticed a mildly tender 1-cm nodule in her left breast. You are fairly certain the nodule is a hematoma. As you examine the breast, you notice that the drain stitch had been too loose, and her drain has pulled out slightly. As you counsel Ms. Smith about the likely hematoma, she becomes anxious and angry. “I thought that was why this tube is there. To drain anything inside. Why didn’t the tube help?” Medical errors are the eighth leading cause of death in the United States.12 Errors are ubiquitous for all surgeons, and physicians typically react to them with anger, shame, and fear of a malpractice suit.10 Professional organizations, such as the Joint Commission, have adopted patient safety standards requiring disclosure of unanticipated outcomes of care.13 Although making patients aware of medical errors may open the door to lawsuits, in doing so, the practice may actually reduce malpractice costs and recover a patient’s trust in the surgeon. Nevertheless, the conversation is a difficult one to have. Patients are normally frightened, angry, and distrustful following a medical error. Therefore, one of the first steps in holding a difficult conversation with a patient is to control the environment, which will help minimize interference in the communication process. For instance, ensure that the door to the room is closed, and carefully angle your seat toward Ms. Smith. It is invaluable to express empathy and regret for what occurred.10 Finally, it may be wise to let the patient know that your goal is to ensure optimal care and that you desire to continue providing care. Be honest and be sincere. Tell Ms. Smith that the drain stitch was loose and should have been put in tighter. Although the hematoma may have developed independently of the drain’s position, express regret for this oversight. Regardless, you will schedule another clinic visit earlier to keep an eye on Ms. Smith, and make it clear that she can call you if any other concerns arise. Confronting a Colleague You and your partner have worked together for years and built your practice from the ground up. He has always been well known for wonderful patient care, but you notice he has recently been cancelling follow-up clinic appointments and taking on more new patients. Some of his existing patients have become dissatisfied with him and are now being scheduled into your clinic availabilities, leaving you with much less time for your own patients. You begin to wonder whether the two of you should have a conversation. In this case, your partner may not be making overt medical errors, and many of his patients may have similar outcomes regardless of his follow-up. However, this conversation has the potential to significantly impact the quality of care and the efficiency of your practice. This conversation can be dicey; you do not want to question his judgment, ability, or commitment—but you do need to communicate critical feedback constructively. The first question to ask yourself is, what is my goal in having this conversation? Your ultimate goal may be to ascertain the reason behind his recent decline in performance. The next task is, through a constructive dialogue, to determine his perspective and to what he attributes recent developments. You call him: “Hi, Dr. G. Do you remember Mrs. R, your rhinoplasty patient from 2 weeks ago?” “Sure, what about it?” he asks. “I was wondering if you’ve followed up with her recently. I saw her in clinic 2 days ago, and she had some questions for you. She may want the right side revised.” There is a pause, and Dr. G. replies in an annoyed tone, “I’m pretty busy right now and have a lot of patients to see. She can’t have another procedure for a couple months anyway. I’ll see her later.” Unfortunately, Dr. G. was not receptive to your approach. How could this conversation have gone better? He may have become defensive because you caught him unaware, questioning his schedule and commitment to his patients. Effective feedback is delivered in a timely—but not a surprising—manner. Returning to your initial phone call, perhaps a better approach would be to greet Dr. G and simply ask whether there is a time that works for him to discuss the rhinoplasty with you. “Any time you’re available this week?” This opens a window for mutual discussion and input, which helps the receiver to mentally prepare for the conversation. It is also helpful to frame the conversation as a problem-solving activity between both parties. Most importantly, the message should be encoded using objective rather than accusatory language. For instance, instead of asking why his performance is declining, you could instead mention the pattern of clinic appointments you’ve observed over the past couple months. “I’ve noticed that your schedule has been busy lately. Several of your patient follow-ups have been scheduled with me. Is something going on recently that we should talk about?” By offering your observations in a nonjudgmental manner, the receiver may decode a less threatening message and be more willing to offer constructive feedback. DISCUSSION Conversations between patients and physicians have evolved over time. For thousands of years, the patient-physician relationship followed a paternalistic model, where the patient was treated as uninformed.14 The central assumption of this practice was that physicians, because of their extensive education and medical expertise, understood what interventions promoted patient health and acted unilaterally when making medical decisions.15 This is no longer the case. Following the release of the Principles of Biomedical Ethics in 1977, which recognized patient autonomy as a pillar of ethics, the patient-physician relationship shifted toward a patient-centered approach.16 Patient autonomy is a driving force particularly in plastic surgery, where conversations often revolve around a nuanced and highly personalized idea of beauty, which may not always align with the physician’s personal values or best medical judgment.17–19 Physicians are now responsible for holding honest, open communication that integrates the viewpoints of patients and their families into the care team.20 There are other factors at play that can also contribute to a difficult conversation, including low health literacy, information overload, and increasing diversity of the patient population. More than 90 million American adults “may lack the needed literacy skills to effectively use the U.S. health care system”; in fact, only 12 percent of the adult population has proficient health literacy.21,22 Furthermore, the internet has increased public access to vast amounts of knowledge, leading to a phenomenon known as “information overload.” Patients are increasingly researching on their own, often arriving in the clinic with preformed opinions and expectations for management. Physicians today must learn to communicate effectively despite an ever-increasing and evolving set of barriers. In this article, we have provided two frameworks with which a plastic surgeon can better understand and conduct a difficult conversation. We hope that, through better understanding of contributing factors and by implementing these frameworks, future difficult conversations may prove to be more manageable.