How can we manage this critical situation where patient receives this bad news and will probably blame the surgeon for this unexpected outcome?
Elective cosmetic surgery is an increasingly high-risk area of medical professional liability, and, although some claims of negligence associated with elective plastic surgery are generated because the patient’s expectations were not met, others arise from a genuine adverse outcome where results need revisions, and perhaps surgical planning was not the best.
Unfortunately, sometimes this narrow line between an adverse event and a medical error is viewed as malpractice by patients and their family, friends and lawyers.
Avoiding bad news delivery
How competent are plastic surgeons in giving bad news? Most plastic surgeons struggle with giving bad news and offer many reasons for avoiding it:
• Lack of training in giving bad news
• Fear of being blamed
• Fear of emotional reaction
• Fear of legal consequences
Breaking bad news is one of physicians’ most difficult duties; yet medical education typically offers little formal preparation for this heavy task.
Without proper training, the discomfort and uncertainty associated with breaking bad news may lead physicians to wrongly take distance from patients, but the way this unexpected bad outcome is communicated to the patient and family can strongly help in avoiding legal consequences. Giving bad news is stressful for physicians and hearing bad news is difficult for patients. Yet it is possible to give bad news in a way that creates trust and strengthens the surgeon-patient relationship.
There are some important events to note in this stressful situation:
• Do not delegate communication of bad news. Delivering bad news is role of the surgeon, and patients often accept bad news only from him.
• Patients receiving bad news may not remember much. People who receive bad news may not remember much about the conversation three months later. In a study carried by Ellen (1), 50 percent admitted that they took in “little or none” of the information from the initial conversation; 20 percent didn’t remember that a longer information session had occurred a few days after the initial bad news session; 25 percent remembered the information session, but didn’t understand the content. The results of this study indicate that perhaps we need to have more than one conversation with patients or family members before the bad news “sinks in.” One way to check on the patient’s understanding of the news is to ask them to reflect back on what they have heard, or what their interpretation of the news is.
• Medical language can make bad news worse. A common complicating factor occurs when doctors use medical terminology and technical language that patients don’t understand. This confuses patients and increases their distress.
• Patient and physician stress curve do not match in time. At the encounter time, between patient and surgeon, the physician is stressed himself at the maximum point, for delivering bad news, and this stress decreases for him finalizing the encounter. For the patient, stress begins at that point, and peaks after the encounter, so, be prepared to explain everything again, when the patient takes conscious that cosmetic result was not as planned and will need extra explanation. This is the moment where other players of the conflict appear, i.e., friends, patient’s spouse, lawyers.
c Patient perception is his reality, and that is what counts. Patients describe, interpret and judge medical events based on their own perception. With all the elements and data presented, the patient will decide after the encounter whether he or she will remain with you, run to a lawyer’s office or ask for a second opinion with a “colleague.” Thus, the positive or negative impact of the information received will influence patients’ actions according to their reality. How a patient responds to bad news can be influenced by the way the news is communicated, not only verbally, but also through body language, voice tone and attitude.
• Pitfalls in giving bad news: A recent study about the causes of adverse outcomes in cosmetic surgery conducted by United Medical Protection, the largest medical professional liability insurer in Australia, observed the following trends associated with adverse outcomes and accompanying litigation against the surgeon:
- Poor physician-patient communication, rather than lack of technical skill or competence.
- Poor patient selection.
- Financial considerations. The fact that the patient bears all of the costs of an elective cosmetic procedure emphasizes the patient’s expectations and demands as a “customer” purchasing a service from the physician.
- The patient’s level of dissatisfaction increases when additional surgeries are required to achieve a more desirable outcome.
- Failure to assess understanding or to acknowledge patient emotions.
Bad news strategy
When you notice that an adverse outcome is knocking at the door, anticipate that’s the moment to share information with your patient. Don’t let this moment pass. Confirm medical facts, review relevant clinical data, arrange adequate time and privacy, and be emotionally prepared for the encounter to make this situation more comfortable for both patient and physician.
1. Create an appropriate physical setting: Meet in a quiet, comfortable room. Have all participants, including you, sit down. You can begin with a comment such as, “Unfortunately, I’m afraid the news is not good.”
2. Avoid being interrupted. Do not receive phone calls, turn off your pager, check your personal appearance and posture. Maintain eye contact. Check distance between yourself and the patient; sitting too close may feel intrusive, but too far away may seem disconnected.
3. Determine who should be present. Ask the patient whom they want to participate, clarify who they are. Decide if you want others to be present.
4. Think through your goals for the meeting, as well as possible goals of the patient. Be honest and straightforward about the information being given; do not doubt that this information will be checked.
5. Present bad news in a succinct, direct and professional manner. Be prepared to repeat information and present additional information in response to patient and family needs.
6. Share all the information you have. “Although medical errors do not necessarily constitute improper, negligent or unethical behavior, failure to disclose them are all three.” (4)
7. Allow the necessary time to understand the situation. Wait for the patient to respond. Give an opportunity for questions or comments.
8. Be prepared to receive strong reactive emotions like crying, anger, etc. Let the emotions be expressed and adopt a problem-solving style.
9. Advise your staff that everybody in your office must give the patient special attention. 10. Set a probable date for resolution or for achieving the desired final result. Failure to manage time may cause more anxiety.
11. Keep records. Document every picture, discussion, expectations, names of present people, dates, etc.
12. Contact your legal office to inform about this event. Be proactive and follow legal advice; do not wait to contact them until being named in a lawsuit. Hope for the best, but plan for the worst.
Closing the encounter
• Summarize the main points. Assess understanding.
• Ask whether there is anything further the patient would like to discuss.
• Offer assistance to tell others the difficult news.
• Indicate your availability to be contacted for questions or concerns.
• Offer to get second opinion when appropriate; be conscious of your own limitations. This requires critical self-awareness.
• Establish a follow-up program.
Focused training in communication skills and techniques to facilitate delivering bad news has been demonstrated to improve patient satisfaction and physician comfort.
The guidelines suggested are not rules, and they do not ensure a successful conclusion. Instead, they attempt to define principles of practice for providing appropriate care. The ultimate decision regarding the appropriateness of any strategy must be made by each surgeon in light of all circumstances. Giving patients bad news is difficult, and the first time you do it should not be the first time you try. Practicing this strategy — and being prepared on how to act before an unexpected outcome arrives — can help surgeons manage the conflict.
It’s important to remember, when delivering bad news, that we can’t change the news itself, but the way we give it can shape the experience for the patient and make a great difference. We can make the news worse by adding to patient confusion or anxiety. If well done, we can strengthen the doctor-patient relationship and avoid legal consequences.
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