A key skill that all surgeons should possess is the ability to communicate difficult news to patients and their families. When attendings are unable to engage in these conversations because they are dealing with another urgent situation, they will sometimes delegate this responsibility to a resident, who often has limited training in how to handle these challenging conversations. Attendings have more experience with navigating these difficult discussions, but like residents they often are not formally trained in how to approach these discussions using advanced communication skills.
This article provides an experiential scenario in which a resident is asked to speak with the family of a trauma patient. The resident describes the moral distress experienced due to a lack of training necessary to engage in this challenging discussion. The article also provides a call to action to help residents and attendings become proficient in communicating with patients and their families.
The case
A 14-year-old boy is injured in a hit-and-run automobile incident. An ambulance takes him to the closest trauma center. He is unresponsive and unstable. The on-call attending surgeon and junior surgical resident conduct a trauma evaluation while simultaneously initiating mechanical ventilation and hemodynamic resuscitation. An abdominal ultrasound reveals free fluid consistent with hemorrhage. Massive transfusion protocol is initiated, and the patient is taken to the operating room (OR).
Exploratory laparotomy reveals a shattered spleen and hepatic lacerations with active hemorrhage. The team packs his abdomen and systematically controls the bleeding, performing a splenectomy and hepatorrhaphies. No other life-threatening intra-abdominal injuries are identified and the team achieves control of the hemorrhage.
At the end of the operation, the boy goes into cardiac arrest. After 10 minutes of advanced cardiac life support, spontaneous circulation is restored, but he requires continuous vasopressor support while being mechanically ventilated. A temporary negative pressure dressing is applied, and he is transferred to the surgical intensive care unit (SICU) with an open abdomen. He remains in critical condition with hypothermia, hypotension, and hypoxia but without significant blood loss from his abdominal dressing. The team is concerned the patient may have a concomitant traumatic brain injury and plans a head computed tomography if his condition stabilizes and requests a neurosurgery consult. The attending and resident who operated on the boy give verbal sign-out to the junior resident covering the SICU, and request that all resuscitative efforts continue.
After escorting the boy to the SICU, the trauma team responds to another emergent consult. An obese, middle-aged man with uncontrolled hypertension, type II diabetes mellitus, and chronic renal insufficiency presents with peritonitis due to perforated sigmoid diverticulitis. The team plans to take him to the OR for an urgent Hartmann procedure. The attending surgeon anticipates the case will take several hours.
Shortly after the start of the operation on the man, the boy’s SICU nurse calls to report that his parents have arrived, and they want to speak with the physician in charge. The parents have already spoken with the junior resident working in the SICU. The boy’s nurse informs the parents that the physician in charge is in the OR with another emergency. However, the parents are insistent. No other senior staff member is available to talk with the boy’s parents. The attending and resident discuss how to proceed.
The critical portions of the man’s operation have not been completed. The attending does not want to prolong the operation by leaving the junior resident, who is unable to operate independently, while she speaks with the family. The attending suggests the resident update the family and discuss goals of care. The resident states it would be inappropriate to speak with the boy’s parents without the attending given the gravity of the situation and the resident’s inexperience with breaking bad news. The attending and the resident agree that the boy’s parents should not be kept waiting until the case is over. What should they do?
The resident’s perspective
The Accreditation Council for Graduate Medical Education mandates that trainees record completion of 850 major surgery cases before graduation.1 However, no similar mandate is in place to document the evolution of communication skills. The American Board of Surgery (ABS) does not require, for example, that specific communication tasks be performed a mandated number of times. The pressure to complete the required number of cases before graduation necessitates that residents preferentially focus on operative care. As a result, residents may not develop their communication skills with the same rigor they use to develop operative skills, even though it is clear that obtaining informed consent, providing daily clinical updates, establishing goals of care, and breaking bad news are essential components of surgical practice.
Perhaps it is a reflection of the ABS’ operative focus that many surgical residencies do not incorporate communication skills into their formal training.2,3 Not surprisingly, some studies indicate that trainees want to develop the ability to communicate effectively with patients and families.3,4
Given their lack of training, residents faced with communication-related tasks may feel they lack the skills necessary for engagement. Residents who are attuned to their lack of training recognize that leading high-stakes discussions without appropriate communication skills compromises patient care.3 In the case described previously, the boy’s parents unquestionably deserve a transparent and compassionate explanation of their son’s critical condition from a surgeon who is equally adept at operating and communicating.
The resident in this case thinks it is inappropriate to speak with the boy’s parents without the attending and feels challenged by the difficulty of relaying the prognosis. The resident may never have had an opportunity to discuss end-of-life care decisions in the presence of an attending surgeon or in a simulated setting. The resident may realize that when communication is absent or poorly executed, gaps in patient care and reduced opportunities for shared decision making are possible.
The attending cannot leave the OR to attend to the needs of the boy’s family, and the anxious resident is the most senior member of the team available to speak with the boy’s parents. Not infrequently, the busy nature of surgical practice presses residents into roles for which they may feel ill-prepared. Such scenarios push residents outside of their comfort zones, forcing them to rise to the demands of their positions and assume responsibilities without the requisite training and experience to do so skillfully. It is possible that surgical culture underestimates the effect of this “learning by fire” training culture on patient care and provider well-being.
One potential sequelae of this practice is the development of moral distress. Moral distress occurs when an individual feels that constraints make it impossible to pursue the ethically appropriate course of action according to their professional values.5 Moral distress arises as a result of both internal constraints, such as lack of knowledge or confidence in one’s abilities, and external constraints, such as institutional policies or inadequate staffing. Individuals who experience moral distress feel unable to satisfy their professional obligations, a sentiment often accompanied by a loss of moral integrity. This phenomenon is recognized across health care disciplines.
Internal constraints are particularly relevant for trainees. It is possible that perceived constraints, particularly those that are internal, may not represent true situational constraints, yet, nonetheless, lead to moral distress. In this case, for example, the resident already may have excellent communication skills, despite a lack of confidence. Arguably, such feelings may be unavoidable during the training process, as trainees gain experience and develop expertise.
The resident’s perceived inability to communicate skillfully with the boy’s parents is a source of moral distress. Similarly, a 2008 study of moral distress among 40 pediatric surgery fellows showed that moral distress occurred when fellows were asked to communicate with patients’ families independently or when they felt they lacked “knowledge or expertise to properly counsel families as to the appropriate or best course of action in acute situation[s].”6
Moral distress negatively affects physician well-being and may be associated with the development of anxiety and depression.5 Importantly, moral distress is known to be one of many contributors to burnout.5 Like burnout, moral distress can lead to reduced quality of patient care.5 Repeated experiences of moral distress can also lead to avoidance of certain patients and clinical scenarios or to attrition, which is high among surgical trainees.5,7 In recent years, there has been growing interest in burnout and wellness among surgeons and surgical trainees. Despite the effect of moral distress on well-being and its association with burnout, no studies to date have evaluated the experience of moral distress among general surgery residents.
Preparing surgical residents for advanced communication tasks may improve the quality of patient care they are able to provide and alleviate some of the moral distress that arises in the context of surgical training.
The attending’s perspective
The word “triage” is derived from the French word trier, which means “to sort.”8 In medicine, triage is defined as sorting patients according to urgency and need for care in order to maximize the number of survivors. This definition is applied to trauma and disaster scenarios, but is also relevant to the day-to-day practice of running a busy surgical service. Surgical teams triage time, workforce, and institutional resources to optimize patient outcomes.
During surgical training, residents master triaging patient-oriented tasks. Surgical residents become the ultimate taskmasters, because success in their daily work lives and future careers necessitates coordination and delivery of inpatient perioperative and intraoperative care simultaneously. Anticipating the needs of each patient on service is essential for ensuring patient safety, satisfaction, and optimizing outcomes. Adhering to a hierarchical communication protocol keeps information flowing and creates a patient safety net essential to any successful surgical service. This communication protocol allows senior surgical residents and attending staff to retreat into the OR for hours without unnecessary distraction. Perioperative experience to enhance one’s clinical judgment and surgical technique is the focus of surgical training, and in this context, developing advanced communication skills and perfecting the art of communication is secondary. Residents are frequently unsupervised when communicating with patients and families and, therefore, do not receive the same modeling and mentorship they do in the OR.
In the dynamic state of triaging patient care needs, what is considered urgent and important usually involves procedural tasks, out of necessity and, undeniably, out of preference. This specialty tradition has created a surgical culture that neglects the equally important task of skillful communication. It may be an inconvenient truth that the adage coined by William Stewart Halsted, MD, FACS, of “see one, do one, teach one” does not typically apply to the delicate and omnipresent task of communicating with patients and their families.
Our case highlights two different yet equally urgent and important tasks required of the team simultaneously. The optimal workforce to manage these competing patient care needs is not readily available in this scenario. Surgical culture reinforces that the patient in the OR comes first, especially when life hangs in the balance. However, the parents of this critically ill boy are just as entitled to the team’s presence in this moment of life and death. The surgical attending must triage available team resources, but staffing constraints prevent upholding their professional ethical duty to attend to the boy’s parents immediately. The surgical attending has a professional responsibility to be present for the critical portion of the operation and to get the patient out of the OR safely and efficiently. The attending experiences moral distress because an external constraint—the lack of available experienced staff—prevents communicating with the boy’s parents immediately, which is the right thing to do. Instead, the resident, who is uncomfortable with and inexperienced in navigating difficult discussions, is asked to go to the boy’s bedside. The attending not only feels moral distress because of a failure to respond to the boy’s parents’ request, but also recognizes a missed opportunity to model and mentor the resident through communicating bad news and discussing goals of care.
These difficult cases can haunt us, leaving lasting effects, scars if you will, on our personal and professional integrity.5,9 The accumulation of similarly distressing cases throughout a surgeon’s career can result in moral residue, which is defined as “the lingering feelings after a morally problematic situation has passed.”5 Moral residue has the potential to amplify the effects of future morally distressing events and influence the quality of an individual’s personal and professional life.5
As we continue to evolve as surgeons dedicated to enhancing perioperative care and operative technique to improve patient outcomes, we need to be mindful that our care of patients and their families during serious life-limiting illness is measured not only by our surgical skills, but also by our proficiency with compassionate, transparent, timely, and patient-centered communication. Until we acknowledge that what happens at the bedside is as important and urgent as what happens in the OR, developing advanced communication skills will continue to be marginalized.
Addressing moral distress in surgery
In a published literature survey of physician-patient communication, Jennifer Fong Ha, MB, BS, and Nancy Longnecker, PhD, stated “effective doctor-patient communication is a central clinical function in building a therapeutic physician-patient relationship, which is the heart and art of medicine.”10 Physicians with advanced communication and interpersonal skills are more likely to better support their patients.10 Conversely, poor communication is associated with increased patient complaints and liability claims.11 Despite these findings, surgical training has not consistently supported trainees’ development of advanced communication skills, and continuing medical education for surgeons does not prioritize refinement over the continuum of one’s career. In fact, it has been observed that communication skills tend to decline as medical students progress through their training, and, over time, residents tend to lose their focus on holistic patient care.10,12 The emotional and physical stress of surgical training may suppress empathy and can lead to depersonalization and, thus, negatively affect the physician-patient relationship.13 For surgical trainees to develop and refine their communication skills, training programs must incorporate formal instruction, graduated responsibility, and standardized evaluation of their performance of these tasks.
Surgical training may be changing to include communication skills. As of 2017–2018, the Surgical Council on Resident Education curriculum for general surgery residents includes material designed to help trainees develop their ability to communicate with patients and members of the multidisciplinary treatment team.14 There are now 12 modules related to interpersonal communication skills, which cover topics including advanced communication skills, delivering bad news, communicating medical errors, enhancing social skills, and coping mechanisms for managing the stress related to surgical practice.14 It is unclear, however, how widely these materials are used. Regardless, the inclusion of these nonprocedural skills into this nationally used curriculum represents a step toward advancing communication competency and preparing learners for entering into crucial conversations more confidently.
The acquisition of advanced communication skills benefits not only the surgeon-patient relationship, but the educator-trainee relationship as well. An adjunct to implementing advanced communication training in surgical residency should be a mandate to communicate with one another about the impact of moral distress during training and practice.
Mentorship and discussions regarding one’s experiences can offer a powerful solution to moral distress during training and beyond. Members of surgical teams can discuss their experiences with each other, providing a space to support and acknowledge one another despite the surgical hierarchy. Importantly, faculty can provide feedback on clinical skills and clarify clinical details, which may change trainees’ perception of the right course of action in a particular situation. Larger platforms designed to address and share causes of moral distress among trainees and faculty may offer validation that our daily work lives include delegating tasks, crucial conversations, operative complications, and other cases that are difficult to process. Additionally, such platforms may facilitate collective efforts to rectify institutional constraints, such as policies that engender moral distress. Creating a process and safe space to discuss moral distress has the potential to improve how we care for our patients, ourselves, and each other.
A resolution to the case
The attending instructs the resident to leave the OR to update the boy’s family. The attending acknowledges the resident’s discomfort and perceived lack of preparation but reassures the resident that conversations like this are never easy, even for experienced surgeons. The attending coaches the resident on how to approach the discussion with the boy’s parents by modeling language that is empathetic and direct about prognosis in order to set up a goals of care discussion that is compassionate and tailored to the parents’ needs. The attending encourages the resident and is complimentary about the communication skills they demonstrated earlier in the informed consent process for the man with diverticulitis. They agree to return to the boy’s bedside together after the case, as well as debrief about how the resident’s conversation with the boy’s parents went before the end of their shift. Additionally, the attending intends to discuss the role of dedicated communication training within the department.
Acknowledgment
The authors would like to thank Elizabeth B. Dreesen, MD, FACS; Carol Scott-Connor, MD, FACS; Kimberly Joseph, MD, FACS; and Kimberly Kopecky, MD, for their insightful contributions to this article.
References
- Accreditation Council for Graduate Medical Education. Case Log Information. Available at: www.acgme.org/Specialties/Case-Log-Information/pfcatid/24/Surgery. Accessed May 15, 2018.
- Bakke KE, Miranda SP, Castillo-Angeles M, et al. Training surgeons and anesthesiologists to facilitate end-of-life conversations with patients and families: A systematic review of existing educational models. J Surg Educ. 2018;75(3):702-721.
- Falcone JL, Claxton RN, Marshall GT. Communication skills training in surgical residency: A needs assessment and metacognition analysis of a difficult conversation objective structured clinical examination. J Surg Educ. 2014;71(3):309-315.
- Sise MJ, Sise CB, Sack DI, Goerhing M. Surgeons’ attitudes about communicating with patients and their families. Curr Surg. 2006;63(3):213-218.
- Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20(4):330-342.
- Chiu PP, Hilliard RI, Azzie G, Fecteau A. Experience of moral distress among pediatric surgery trainees. J Pediatr Surg. 2008;43(6):986-993.
- Khoushhal Z, Hussain MA, Greco E, et al. Prevalence and causes of attrition among surgical residents: A systematic review and meta-analysis. JAMA Surg. 2017;152(3):265-272.
- Triage. Merriam-Webster. Available at: www.merriam-webster.com/dictionary/triage. Accessed April 23, 2018.
- Ponce Martinez C, Suratt CE, Chen DT. Cases that haunt us: The Rashomon effect and moral distress on the consult service. Psychosomatics. 2017;58(2):191-196.
- Ha JF, Longnecker N. Doctor-patient communication: A review. Ochsner J. 2010;10(1):38-43.
- Harnof S, Hadani M, Ziv A, Berkenstadt H. Simulation-based interpersonal communication skills training for neurosurgical residents. Isr Med Assoc J. 2013;15(9):489-492.
- Han JL, Pappas TN. A review of empathy, its importance, and its teaching in surgical training. J Surg Educ. 2018;75(1):88-94.
- DiMatteo MR. The role of the physician in the emerging health care environment. West J Med. 1998;168(5):328-333.
- The SCORE Portal from the Surgical Council on Resident Education. SCORE general surgery resident curriculum portal. Available at: www.surgicalcore.org/. Password protected. Accessed April 16, 2018.
