• 
  

  Communication failure occurs across all phases of the surgical pathway.

  
  
• 
  

  Suboptimal communication between surgeons and their patients can lead to misdiagnosis/delayed diagnosis.

  
  
• 
  

  Problematic team communication is a root cause in more than 60% of serious adverse events (“never events”).

  
  
• 
  

  The majority of serious adverse events in hospitals occur in surgical patients.

Effective communication between surgeons and patients is critical to patient safety in all phases of the surgical journey.^1,2 Communication problems contribute to patient harms in multiple ways, and, according to The Joint Commission, they are root causes of more than 60% of serious adverse events leading to patient harm.³ Moreover, the majority of serious adverse events in hospitalized patients occur in patients undergoing surgical treatment.^4,5 Skillful physician-patient communication was often characterized (and minimized) in the past as bedside manner and considered to be secondary in importance to the fine motor skills of surgery.⁶ However, it is increasingly apparent that communication and other nontechnical skills are critical to safe surgical performance and outcomes, in the same way these skills were found to be critical to aviation safety. Crew Resource Management training (the model for medical team training) has been mandatory for commercial aviation since 1991.⁷ Although most surgeons consider themselves to be good communicators, our patients and the nurses and other professionals with whom we work do not rate us as highly.^8,9 A systematic literature review of surgeon-patient communication studies showed that the greatest “opportunities for improvement” (ie, deficits) lie in surgeons’ discussing patients’ concerns and using empathy.¹⁰

Surgeons face many barriers to safe, effective communication. Among these are time/production pressures, interruptions, distractions, the physical layout of the exam room, multiple patient complaints/concerns, patients’ limited health literacy, and language barriers.¹¹

Our communication style (“warm” vs “authoritarian”)¹² and our training (focused on constructing a differential diagnosis)¹³ also represent barriers to communication, patient-centered care, and shared decision making. Communication difficulties can lead to incorrect or delayed diagnosis, and, in the case of patients with limited health literacy and/or limited English proficiency, they are associated with a higher rate of adverse events.¹⁴ Patient dissatisfaction⁹ and surgeon dissatisfaction (with increased risk of burnout) and lawsuits are associated with communication problems (over 70% of patients who sued their physicians cited communication problems such as feeling disrespected, devalued, or even abandoned by the physician). A closed claim study of orthopedic surgical claims, although focused on technical errors, acknowledged that more thorough discussion of uncertainties about surgical risks and outcomes was warranted in almost all of the cases reviewed.¹⁵ Between the decision to proceed with an operation and the patient’s arrival in surgery, there are also potential communication pitfalls. Scheduling error due to communication lapse is a common root cause of “wrong site/side/procedure/patient surgery”, though awkward, is most accurate.¹⁶ In a study of shared decision making in surgery, not only were critical elements absent in nearly one-fourth of the patients, the surgical informed consent did not meet minimum legal standards in 13%.¹⁴ Communication failures in the perioperative period can also compromise outcomes, with failure to coordinate care, and optimize patient comorbidities. Transitions of care represent the highest risk due to loss of critical information in the handoff process.¹⁷

Surgical Team Communication

Team performance is critical for safe surgery. Communication is the key competency in teamwork; without it, there can be confusion about expectations, goals, roles, and behaviors. Most importantly, the crucial “shared mental model” (all team members “being on the same page”) that is the hallmark of effective teamwork cannot be reliably maintained.

Effective communication is complete, clear, brief, and timely. Information needs to be directed to the team member(s) who need it and can most effectively use it to advance the progress of the team’s work.

The “safe surgical checklist” has generated a great deal of controversy, with conflicting reports in the literature about whether it affects morbidity and mortality. In essence, the checklist is intended to be used as a teamwork and communication tool, incorporating briefings and debriefings in addition to (and distinct from) the time-out. Deficient time-outs frequently are implicated in wrong site/side/procedure/patient events (see Case Study 1.1).^16,18 Briefings allow proactive sharing of important information with the team and make the surgical schedule run more smoothly (for the current patient). Debriefings are an opportunity to capture errors and system issues to improve quality and efficiency (for future patients). Much of the recent literature questioning the efficacy of checklist usage suggests that there were implementation problems or “watering down” of the checklist. Adherence to use of different elements of the checklist also seems to vary by surgical specialty.¹⁹ Relevant sections of a typical surgical checklist are shown in following boxes.

In the postoperative phase, the largest communication risk for patients is in transitions of care or handoffs, such as transfers to other facilities or to an on-call physician covering the patient. Information loss is greatest in these transitions.²

Finally, when things are not going right for the patient, resolution of problems can be delayed by our dependence on heuristics (“fast and frugal” decisions are only correct about 80% of the time) and by cognitive biases, such as continuation and framing effects. These subconscious processes can make us hesitant to reconsider our diagnosis and treatment plan (see Case Study 1.2).

As with any procedure, skills can be learned and improved (or lost if not practiced regularly). This section is based on the Institute for Healthcare Communication’s (IHC) “Clinician-Patient Communication” workshop and the “4-E” model of communication. The American Academy of Orthopedic Surgeons, in cooperation with IHC, has presented more than 400 of these workshops to over 6000 orthopedic surgeons.

The First E—Engage

Malcolm Gladwell in Blink made the case that people “size up” situations and other people in milliseconds. How we present ourselves to patients is critical in making the favorable first impression that can lead to a trusting partnership between the surgeon and the patient.

Removing distractions and focusing on the patient is critical; a greeting ritual, practiced routinely, helps with this task.

Now you can elicit the reason for the visit with an open-ended question (don’t assume the schedule information is complete or correct!).

Patients often have more than one concern, so getting multiple concerns “on the table” early helps to prioritize the visit and avoids the dreaded “doorknob syndrome” (ie, “but doctor, what about my…?”).

Summarize the patient’s agenda (and allow the patient to correct you if you misunderstood).

If this is a follow-up visit, you will also have an agenda.

Once you have negotiated the agenda, invite the patient to tell the “story” and then listen, without interruption, for 1 to 2 minutes. Normal humans speak at a rate of about 200 words/min. Multiple studies show that physicians interrupt the patient’s story in 12 to 22 seconds! Use facilitative comments to bring out the story.

The patient’s story includes important information not only about diagnosis but also impacts of injury or illness, fears, and concerns. Keep eye contact with the patient and be on the lookout for nonverbal clues (eg, facial expressions—smile, frown, grimace, eye rolling; tearing up; posture—shrug, slump; hand wringing).

The Second E—Empathy

Surgeons’ willingness to discuss patients’ concerns and use of empathy have been identified as the greatest “opportunities for improvement” in communication.¹⁰ Empathy is not the same as sympathy.

Empathy is the strongest determinant of patient satisfaction.

There are multiple opportunities to use empathic communication during any patient encounter, but also some barriers.

Listening to and understanding the patient should be the goal. Patients give us clues to their distress and the impact of their experience of illness; if we fail to acknowledge these clues, patients will repeat them (prolonging the visit) and will perceive us as “not listening, not caring, or in a rush.”

It is good practice to have several empathic stems to use. These allow you to fill in the blank with the emotion or feeling you have witnessed.

Empathy is both verbal and nonverbal. Examples of nonverbal empathy include pausing when you see a patient becoming emotional and offering a box of tissues to a patient who is tearing up. Acknowledge the emotion (what you are seeing and hearing) with an appropriate statement.

A serious pitfall (and the antithesis of empathy) is use of blocking behaviors.²⁰ We often use these behaviors when we don’t want to explore the issue.

Effective engagement and use of empathy (and avoiding “blocking”) set the stage for the other two E’s: education and enlistment.

The Third E—Education

Most physicians (surgeons are no exception) overestimate the amount of time they spend in educating their patients. There are significant barriers to educating patients. These include time/production pressure, our medical “voice” (aka jargon), the patient’s level of health literacy,²¹ and limited English proficiency. Most patients will have a self-diagnosis, either culturally based or (increasingly) based on an Internet search.

Surgeons are proficient at discussing and describing treatment (especially surgery).¹⁰ Unfortunately, this “discussion” often takes the form of a surgeon monologue with use of medical jargon and without any attempt to assess the patient’s comprehension. Often we try to treat their confusion by force-feeding patients with information, without assessing what patients already know or their ability to understand it.

Effective educational strategies include “teach backs” (to assess comprehension) and “chunking” information into small discrete pieces that make it easier for the patient to remember them. The National Patient Safety Foundation’s “Ask Me 3” tool encourages patients to ask for three specific chunks of information from their health provider.

Another technique, “Ask-Tell-Ask” uses the patient’s existing knowledge to help craft specific messages in discrete chunks, using the teach-back method to assess comprehension.