PEOPLE SKILLS
Educational Objectives
| The goal of this program is to improve delivery of bad news to patients and families and to improve the management
of physicians’ performance at work. After hearing and assimilating this program, the participant will
be better able to:
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 | 1. Recognize elements of the conversation most important to recipients when a clinician relates bad news.
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| 2. Describe behaviors that help family members understand and accept bad news.
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| 3. Appreciate the value of good communication with patients and family members and its impact on the
success of the physician.
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| 4. Create cultural expectations of high performance among physicians’ clinical departments.
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| 5. Effectively manage behavioral problems and implement work improvement plans for poor performers.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of
the planning committee to disclose relevant financial relationships within the past 12 months that might create
any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity
promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty
and the planning committee reported nothing to disclose.
Acknowledgements
Dr. Jurkovich’s lecture was recorded at the 36th Annual Phoenix Surgical Symposium, held February 13-16, 2008, in
Phoenix, AZ, and sponsored by Banner Health and the Phoenix Surgical Society. Dr. Lints’ lecture was recorded at
the 4th Annual National Surgical Symposium, held April 2-4, 2008, in Ojai, CA, and sponsored by Kaiser Permanente.
The Audio-Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.
| FAMILY PRESENCE AND GIVING BAD NEWS —Gregory J. Jurkovich, MD, Professor of Surgery, University
of Washington School of Medicine, and Chief of Trauma Services, Harborview Medical Center, Seattle,
WA
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| Background: surgeons frequently deliver bad news without benefit of evidence-based guidelines for best
practices; unlike oncologists, trauma surgeons have little opportunity to become acquainted with patient
and family
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| Literature review: several publications have dealt with giving bad news in settings of pediatrics and oncology
from perspective of clinician; little empiric validation available
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| Importance of method of delivery: comparison of 2 cases—2 families with young adult children who died
from injuries sustained in automobile accidents; one family present for attempts at resuscitation and death; in
second case, patient (initially unidentified) transferred from another hospital but died during resuscitation;
family members went to wrong hospital first and arrived at Harborview after patient had died and been transferred
to morgue; family learned of death when asked by nurse whether they were parents of patient who
died; 2 families knew each other and discussed their experiences; later had conference with staff at Harborview
to discuss pros and cons of methods of receiving news of their family members’ deaths
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| Study evaluating delivery of bad news from perspective of receiver: survey tool administered to surviving
family members of patients who had been in emergency department (ED) and intensive care unit (ICU);
first part of survey tested importance of certain elements in communication of bad news; second part rated
performance of clinical staff in handling these elements; areas covered—amount of clinical detail family
wanted; whether family wanted newsgiver to physically express empathy (eg, hug, touch on hand); whether
family wanted information about role of medical examiner; whether clergy made available; whether directions
given to family; whether time allotted for family to ask questions; whether follow-up contact made with
family; whether family knew identity of newsgiver; survey—conducted over 18 mo; 120 families of patients
contacted within 2 to 6 mo of relative’s death; 25% rate of response to initial mail survey; when converted to
telephone survey, response rate 90%; final number of respondents totaled 54 family members of 48 patients;
patients mostly older men; 75% to 79% suffered from trauma and died in ICU, but some died in ED; general
surgery involved in 60%, neurosurgery in 30%, ED and others involved in remainder of cases; 50% of patients
died within 24 hr, 66% within 2 days; length of stay did not influence results
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| General results: one-half of families expected deaths and took part in process; some families told afterwards; 3
families not told at all; only 7% knew that person delivering news was attending surgeon; others told by another
physician or by nurse; news communicated in conference room, waiting room, hallway, or by telephone
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| Most important elements of communication: attitude of person giving news, clarity of message, privacy of setting,
extent of physician’s knowledge of case; attitude—families care about how person giving news approaches
them (eg, whether person giving news appears busy, leaves pager on, appears cavalier or eager to
leave, shows empathy); clarity—families want to know exactly what happened without being confused;
privacy—families prefer to receive news in private setting; knowledge—families want person giving news to
be able to answer questions knowledgeably
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| Other important aspects: empathy of person giving news, time allowed for questions, adequate information
about autopsy, and information about availability of clergy (40% considered this important, 40% did not care)
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| Unimportant aspects: appearance or rank of person giving news, and written expressions of condolence from hospital
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| Performance ratings: top 4 aspects—attitude (empathy) of person giving news considered acceptable <50% of
time; communication considered clear 50% of time; privacy considered inadequate 83% of time; sufficient
time allowed to answer questions only 50% of time; other elements—no communication about autopsies or
availability of clergy; timing and location of bad news inappropriate; worst results (6 cases)—delivery of news
considered extremely poor; in all 6 of these cases, clinician lacked empathy; in 5, clinician could not answer
questions; in 4, message confusing; 5 of these 6 occurred on single clinical service (neurosurgery)
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| Overall scores: respondents gave poor score on 96 items; neurosurgery received 55% of poor scores, general
surgery received 33%, and ED received 13%; 87% of families gave high scores on some aspect (eg, nurses,
professionalism of physicians, or small acts of kindness performed by staff)
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| Examples of helpful behaviors: physician looked family member in eye and briefly shared pain of bad news;
clinician made sure family member not alone when delivering bad news; physician asked what sort of person
patient had been; details communicated clearly but not graphically
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| Study of interaction of physicians with patients and rates of malpractice lawsuits: audiotaped interactions
of 65 surgeons with patients; interactions rated by psychologists (blinded)—on warmth of exchange; presence
of anxiety or concern; level of interest shown by physician; hostility of environment; extent of
sympathy; professionalism and appearance of competence vs dominance by physician; satisfaction level of
patient, and genuineness of physician
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| Results: most important 4 elements included level of warmth and professionalism, level of concern vs anxiety,
hostility, and dominance; surgeons who had more dominant and less concerned tone of voice had 2.7-times
greater likelihood of having lawsuit filed against them; those who appeared concerned, warm, and professional
had one-half average number of lawsuits
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| Outcome of studies: used data to educate staff and developed team model for delivering bad news; nursing
staff wanted more involvement of families at bedside and more involvement of physicians with families, but
also wanted to protect family from patient’s appearance; therefore, allowed family members in for brief time
during first 10 min; assigned one member of resuscitation team as family liaison to manage family’s presence
in resuscitation room; concluded after 1 yr that process difficult but worthwhile; Harborview policy allows
family members in ED and ICU (not operating rooms) accompanied by liaison; important to balance rights of
family with those of patient and physician’s ability to function
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| DEALING WITH THE BEHAVIORALLY CHALLENGED SURGEON —Rasjad K. Lints, MD, Assistant Medical
Director, Human Resources, Northwest Permanente Medical Group, Portland, OR
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| High-performance culture: creating culture of expectations for high performance critical to managing performance
issues in team; important to regularly and publicly acknowledge and recognize good performance;
perception of interaction—conversation with fewer than 4 positive comments per every 1 negative comment
viewed as negative by perceiver; may take 18 mo to change culture from one in which most of department
head’s time spent coaching leaders on how to handle performance issues to one in which most time spent with
low-performing members of team
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| Low performers: first create uncomfortable gap between low performers and remainder of team, then deal with
problems; otherwise, better team members drop in performance; ≈66% of low performers typically improve
with good management
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| Documentation: clarify expectations in writing—including areas of quality, partnership and collegiality, access
and service, patient-physician communication, and resource stewardship; set minimum standards—begin with
regional standards, then add those specific to department; gain consensus of department; hold members accountable;
do not ignore peer and staff concerns (“what you permit you promote”)
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| Courageous conversations: deal with problems immediately; handle minor issues quickly and informally; if
minor problems recur or major issue present, take action (with help from colleague, if necessary)
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| Mechanics: set time and place for conversation; describe unacceptable behavior and expectations; point out
how behavior affected others; listen to individual’s response; acknowledge (not necessarily agree with) concerns;
reiterate expectations; may need to create formal plan for improvement of behavior that places burden
on individual; document conversation in file, send copy to individual, and obtain signature on any formal
plans for work improvement; leader must understand process and communicate process to individual involved
(team member going through process should never be surprised); follow through with consequences
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| Prevention: hire appropriate people; use critical recruiters; listen to team members who are not physicians;
have policy of one-vote veto on hiring committee
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| Recurrence of behavior problems: speaker recommends implementing formal work improvement process
even if long intervals between episodes of problem; at end of improvement process, make clear to individual
that process does not really stop, ie, if behavior recurs, there will be consequence; consider using outside
counselors to work with individual; speaker suggests using 360° review process (involving colleagues
and support staff) to highlight long-term underlying issues
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| Methods for tracking performance issues: speaker uses software for annual reviews; also use formal written
work improvement process; can involve human resources department, but actually responsibility of department
chief or chair to track performance issues in file
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| Advice for physicians in leadership role dealing with friends and colleagues: remember that problem does not
come from team leader but from team member with performance issue; leader’s emotional response to
situation not important
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| Performance review: for senior physicians—review should be positive experience; do not use annual performance
review as primary opportunity to discuss performance issues; deal with issues immediately, and
use annual review as opportunity to motivate; for junior physicians—performance review should consider
positive and negative areas and how to achieve improvement
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| Overseeing remote locations: critical to have strong local leaders to deal with issues immediately; focus on
hiring physicians with leadership capacity
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| Terminating senior partner involuntarily: especially challenging problem; board of directors must understand
importance of executing process well and that success of organization depends on quality of partners; important
to minimize number of behavior issues presented to board
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Suggested Reading
Agard M: Creating advocates for family presence during resuscitation. Medsurg Nurs 17:155, 2008; Critchel CD, Marik
PE: Should family members be present during cardiopulmonary resuscitation? A review of the literature. Am J Palliat Care
24:377, 2007; Dalio AM: Family presence during cardiopulmonary resuscitation. Am J Crit Care 17:310, 2008; Demir F:
Presence of patients’ families during cardiopulmonary resuscitation: physicians’ and nurses’ opinions. J Adv Nurs 63:408, 2008;
Dingeman RS et al: Parent presence during complex invasive procedures and cardiopulmonary resuscitation: a review of the
literature. Pediatrics 120:842, 2007; Farah MM et al: Evidence-based guidelines for family presence in the resuscitation
room: a step-by-step approach. Pediatr Emerg Care 23:587, 2007; Gettman MT et al: Urology resident training with an unexpected
patient death scenario: experiential learning with high fidelity simulation. J Urol 180:283, 2008; Hill R Jr., Fuhrman
C: Presence of family members during resuscitation. Ann Emerg Med 52:309, 2008; Krichhoff C et al: Trauma
surgeons’ attitude towards family presence during trauma resuscitation: a nationwide survey. Resuscitation 75:267, 2007;
Laskowski-Jones L: Should families be present during resuscitation? Nursing 37:44, 2007; Mercer LM et al: Patient
perspectives on communication with the medical team: Pilot study using the communication assessment tool-team (CAT-T). Patient
Educ Couns Aug 12, 2008 [Epub ahead of print]; Minichiello TA et al: Breaking bad news: a practical approach for the
hospitalist. J Hosp Med 2:415, 2007; Muroff LR: Dealing with the problematic partner or associate. J Am Coll Radiol 4:527,
2007; Sherman DA: Family presence during cardiopulmonary resuscitation: grief therapy or prolonged futility? Dimens Crit
Care Nurs 27:114, 2008; Sise MJ et al: Surgeons’ attitudes about communicating with patients and their families. Curr Surg
63:213, 2006; Taylor D et al: Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care.
Arch Surg 143:87, 2008; Terzi AB, Aggelidou D: Witnessed resuscitation: beneficial or detrimental? J Cardiovasc Nurs
23:74, 2008; Walker WM: Accident and emergency staff opinion on the effects of family presence during adult resuscitation:
critical literature review. J Adv Nurs 61:348, 2008
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