Framing family conversation after early diagnosis of iatrogenic injury and incidental findings

Abstract

Background: Surgeons are rarely formally trained in giving bad news to patients. The aim of our study was to examine and compare techniques of disclosure of iatrogenic and incidental operative findings among surgical residents.

Methods: General surgery residents performed a laparoscopic cholecystectomy on the SurgicalSIM device in a mock operating room. Half (n = 8) were presented with a common bile duct injury, and half (n = 7) encountered metastatic gallbladder cancer during the operation. Both groups disclosed this information to a patient's scripted family member and completed a questionnaire. All encounters were videotaped and independently rated using a modified SPIKES protocol, a validated tool for delivering bad news. We compared disclosure of iatrogenic versus unexpected findings by year of training. Analysis was performed using the Mann-Whitney test.

Results: Regardless of the year of training, more residents were comfortable with disclosure of an incidental finding than disclosure of an iatrogenic injury (47 vs. 33%). Senior residents (PGY4-PGY5) had better ratings by SPIKES (p < 0.05), most notably for tailoring disclosure to what patient and family understand, exploring patient and family expectations, and offering to answer any questions (p < 0.05). Even though all residents felt more comfortable with disclosure of an incidental finding, the quality of the disclosure by SPIKES score was the same for iatrogenic and incidental operative findings (p = NS).

Conclusion: In general, trainees are ill prepared for delivering bad news. Disclosure of iatrogenic injuries was more challenging compared to that of incidental findings. Senior residents do better than junior residents at delivering bad news.