Efficient and effective communication skills are a critical resource for all clinicians including surgeons. A surgeon must be capable of establishing a rapport with the patient and family quickly and reliably. This mutual respect is critical to a therapeutic relationship. The patient and family must be confident of the competence of the surgeon in order to participate in the recommended management and recovery. Judgments about surgeon competence frequently come within the first few moments of interaction based on the surgeon’s ability to communicate. In addition to communicating with patients, clinicians must communicate with referring and collaborating physicians, and also within their own health care teams.
Communicating With Patients
Communication with patients requires attention to several aspects. First, the clinician must demonstrate respect for the patient as a person. Second, the clinician must display effective listening to the patient’s message, followed by demonstrated empathy to their situation or concerns. Finally, the clinician must have clarity in the response. If any of these items are omitted, then the interaction will be less effective than it could be. Many surgeons try to jump straight to a very clear concise statement of the plan; however, unless the first three steps have occurred, the patient may not listen to the plan at all.
It is critically important to show respect for the patient and family as persons. The health care environment is often inconvenient and encountered during a time of stress. The patients are out of their normal venue and zone of comfort. They are often frightened by the prospect of what they may learn. Showing respect for their identity will place the patient at more ease and encourage their trusting communication with the clinician. Failing to show respect will have the contrary effect. Thus meeting an adult for the first time and addressing them by their first name can immediately put many patients on guard with respect to their personal independence and control. Similarly, referring to the mother of a pediatric patient as “Mom” rather than using her name implies lack of attention to her as an individual worthy of learning her identity. On initial meetings, the clinician should use the patient’s last name preceded by an honorific title (Mr. Smith, or Ms. Jones). If you are not certain if a woman prefers Mrs. or Ms, then ask her. In contemporary US society, a woman over 18 years of age is never referred to as Miss.
In addition, engaging in brief small talk regarding some aspect of a patient’s life other than the medical matter at hand can additionally put them at ease (“It must be interesting to be a dog trainer. What is your favorite breed?”). These efforts will be rewarded by a more trusting patient and a more efficient interview, with a better therapeutic relationship over the long term.
Listening to the patient is critical to establishing a correct diagnosis and appropriate therapeutic plan for the individual. Every patient who comes to the medical system with a problem has a story that they have thought through and decided to tell. It is important to let them do so. Not only is the patient likely to reveal critical issues regarding the clinical matter, but they are also often determined to tell the story eventually, whether they are allowed to do so at the outset or not. Allowing, and in fact encouraging them, to tell the story at the beginning of the interview relieves them of this burden of information, and allows the clinician to move on to interpretation.
Listening should be an active, engaged activity. The clinician should appear comfortable, settled, and upon as much of an even eye level with the patient as possible. It is important not to appear rushed, inattentive, or bored by their account. Interjecting questions for clarity or intermittent, brief verbal encouragements will let the patient know that the clinician is engaged with the problem.
It may be helpful at the outset of the listening phase to let the patient know what materials have been reviewed; for example, telling the patient that the clinician has reviewed the referral letter from the primary physician, the results of the last two operations, and their recent laboratory work may help the patient to be more concise in their discussion.
Once the patient has recounted their history and the other aspects of examination and data review have been completed, it is important to review this material with the patient in a way that demonstrates empathy with their situation. A surgeon’s understanding of the problem is important for the patient, but the problem is not confined to the medical issue, the problem must be understood in the context of the patient. For this reason demonstration of empathy is important to the patient’s trust of the physician. Establishing this connection with the patient is crucial to their engagement in the process of care.
Having established respect for the patient, heard and understood their story, and empathized with their situation, the physician must speak clearly and in a vocabulary understood by the individual, about the recommendations for further evaluation or care. This portion of the conversation should include a clear distinction between what is known about the patient’s diagnosis or condition and what is not known but might be anticipated. When appropriate, likelihoods of various outcomes should be estimated in a way that the patient can grasp. The recommended approach to next steps should be listed clearly, along with alternative approaches. Patients always have at least one alternative to the recommended choice, even if this is only to decide not to have further medical care. This portion of the conversation can be augmented with illustrations or models that may improve the patient’s understanding. Often reviewing radiological studies directly with the patient or family at this time can help their understanding.
The risk taken by failing to establish this relationship with the patient is great. This can lead to errors in judgment about diagnosis or management. It also precludes the opportunity to engage the patient as an ally in his or her care. If things go badly, it also can make subsequent communication about problems or complications difficult or impossible. Finally, the surgeon who communicates poorly excludes him- or herself from enjoying a personally and professionally satisfying physician-patient relationship.
Communication With Collaborating Physicians
Surgeons often work with other physicians in collaboration of care for patients. Communication in these settings is important to the overall patient outcome, particularly when the surgeon will be involved in the patient’s care for some defined interval which has been preceded and will be followed by the ongoing care provided by the primary care physician. The communication in these settings can be separated into two basic types: routine and urgent. Routine communication can take place in a variety of ways depending on the health care setting. This communication is typically asynchronous and written. It may take the form of a note in the patient’s electronic medical record, or a letter sent to the physician’s office. This is an appropriate way to communicate reasonably expected information that does not need to be acted on urgently. For example, a patient who is referred to a surgeon for cholecystectomy and who has a plan made for cholecystectomy can have routine communication back to the referring physician.
Urgent communication should occur to the collaborating physicians when there are unexpected or adverse outcomes. Again, there are a variety of communication modes that may be utilized for this, but the communication is more often synchronous via a direct conversation either in person or by telephone. The communication is more than courtesy to the collaborating physician, as knowledge of these events allows them to participate constructively on behalf of the patient. Examples of situations that warrant more urgent communication include new diagnosis of significant cancers, life-altering complications from interventions, and certainly death of the patient.
Clarity in transfer of care responsibility is critical to the continuous optimal care of the patient. For that reason, any communication with the collaborating physicians should indicate either the ongoing role of the surgeon in the patient’s care, or the deliberate transfer of responsibility for ongoing care issues back to other collaborating physicians.
Communications Within Teams
Surgical care is often provided in a team setting. Current surgical teams typically include physicians, nonphysician mid-level providers (often physician assistants or nurse practitioners), and a variety of students. The student trainees may include students in medical school, physician assistant programs, or nursing school. These teams have become increasingly complex, and the information that they manipulate as a team to provide patient care is voluminous. In addition, the transfer of information from one provider to another as shifts or rotations change is recognized as a weak point in the patient care continuum.
With these complex teams and extensive information, the keys to efficient and effective team processes appear to be clarity of roles and designing processes that involve only writing things down once. The advent of electronic medical records has allowed the generation of electronic tools to transfer information from team member to team member. This may be useful to facilitate this process. Careful attention to transfers of care from one provider to another and explicit recognition that this is a potential time for errors is important.