**2. Communicating with the surgical patient**

Communicating with a surgical patient is unique in many ways since it will not only involve discussing the diagnosis and surgical management but also communicating with the team to care for the patient perioperatively. The central person and the team leader in these communications remains the surgeon. Communication can be defined as a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior [7, 8]. This implies that at times, communications may not be effective not because the originator did not have the message but because something went wrong within the process of communication.

In this section, we will look at


#### **2.1. The communication processes**

In many books of communication, about 10 components in the communication process are emphasized. The steps include source, encoding, message, noise, media, receiver, decoding, receiver response, and feedback within a context.

The communication process involves the source, in this case, the surgeon or the trainee or the health care worker who wants to communicate with the receiver—the patient. Humans do not often share thoughts directly like computer gadgets. Therefore, the intended message ought to be encoded in ways that should be understandable by the receiver who would also need to decode it. Encoding is an active process of putting the thought into symbols which could be spoken words or unspoken symbols [9]. The receiver would assign meaning to symbols in another active process of decoding. The thoughts are encoded to a product called message, which is the intended thought you want the receiver to get [10]. The interface by which the source passes the encoded thoughts (message) to the receiver is media. This interface can get interference called noise that could be either external, internal, or semantic noise. External noise includes those issues that are outside of self that will distract from concentration. For example, reading while the television set is on. Internal noise includes thoughts, feeling, and conditions within an individual that could interfere with his or her concentration—for example, fatigue, hunger, and anger. Semantic noise includes the alternative ways in which the message could be decoded. Response could be action or inaction intended or not intended by the source's message; feedback then is what makes the source to acknowledge that communication was successful. Without feedback it would be difficult to know whether one has communicated successfully [8]. The context of communication and sitting arrangement matters a lot; the amount of light in a consultation room will help put the patient at ease. Culture as a component of context will be explored in the next section.

Awareness of the process and the pitfalls that could occur during communication is important. The physician-patient relationship has always been personal, so the media for better understanding would be face to face. The physician must set the environment that would enable successful communication including when family members are required—meaning many receivers. A key challenge is that surgery is a team work, and in any team work, communication is a core competency. Without clear, concise, brief, and timely "closed' communication, there would be confusion on goals, expectations, timing, and roles of each team player [11].

#### **2.2. Communication models**

[2, 3]. It has been noted that this high-handed or authoritarian style of communication leads to increased medical errors just as was observed in the aviation industry [4]. The Joint Commission sentinel data reports indicate that lack of communication is responsible for 60% of the adverse events [5]. A number of studies have highlighted the critical part communication plays both in the operating room and in the overall management of surgical patients [1, 3, 6]. A number of researches have highlighted the ways to communicate and the gaps in communication and why failure is more likely in surgical context [3]. This chapter aims to review the literature in communication from around the globe and to contextualize them into the developing world. This is because contexts differ, and similarly, infrastruc-

Communicating with a surgical patient is unique in many ways since it will not only involve discussing the diagnosis and surgical management but also communicating with the team to care for the patient perioperatively. The central person and the team leader in these communications remains the surgeon. Communication can be defined as a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior [7, 8]. This implies that at times, communications may not be effective not because the originator did not have the message but because something went wrong within the pro-

In many books of communication, about 10 components in the communication process are emphasized. The steps include source, encoding, message, noise, media, receiver, decoding,

The communication process involves the source, in this case, the surgeon or the trainee or the health care worker who wants to communicate with the receiver—the patient. Humans do not often share thoughts directly like computer gadgets. Therefore, the intended message ought to be encoded in ways that should be understandable by the receiver who would also need to decode it. Encoding is an active process of putting the thought into symbols which could be spoken words or unspoken symbols [9]. The receiver would assign meaning to symbols in another active process of decoding. The thoughts are encoded to a product called message,

ture and culture may also differ.

32 Vignettes in Patient Safety - Volume 4

cess of communication.

In this section, we will look at

• Communication models

• The communication processes

• Communicating with the patient

**2.1. The communication processes**

• Communicating with the team of care

receiver response, and feedback within a context.

**2. Communicating with the surgical patient**

Models of communication may help one understand what communication is and how it is performed:


There are cultural modifications of these models. While the transmission model may appear to indicate superiority of the source, with a passive listener, some cultures tend to indicate the role of listener as critical in communication.

In Confucius culture, just as in cultures with high-power distance and are collectivistic, harmony and balance through proper behavior are highly regarded in such a way that:-.

**a.** A particular age determines how you communicate. In African culture, like Swahili, greetings differ with age—the young will use 'shikamo'. In Korean culture, terms of friendship differ with age—peers use 'chingu', younger on older people use 'adjussi/adjumoni' for male and female, respectively [8, 12].

**b.** A third party may be used to avoid confrontation with those respected. In African culture, this is seen in dowry negotiations [8].

**c.** Communication approach—respect for and tolerance of other cultures through four skill areas [16]:

and being friendly through

themselves

**iv.** Cultural awareness.

interview which comprises

**iii.** shared-decision making

**iv.** delivering bad news

**ii.** patient education

**2.3. Communicating with the patient**

and expression

• self-concept—how one views themselves

attentiveness, and responsiveness.

**i.** information gathering and diagnostic formulation

**i.** Personality strength—which involves knowing oneself, initiating a positive attitude,

Communication in Surgery for Patient Safety http://dx.doi.org/10.5772/intechopen.79740 35

• self-disclosure—willingness to openly and appropriately reveal information about

• self-monitoring—using social information to control and modify self-presentation

**ii.** Communication skills which involve being able to encode messages for people in diverse environments, interacting with them respectfully with flexibility [16].

• Behavioral flexibility-ability to select appropriate behavior in diverse situations

• Interaction management—a person's other-oriented ability to initiate interactions,

• Social skills—involve empathy and identity maintenance where one is able to put themselves in the others person's stead—similar feelings and being able to give feed-

**iii.** Psychological adjustment—acclimatize to a new environment and cope with frustra-

Communication between the physician and the patient can take the usual form of patient

The outcome of the therapeutic encounter is dependent on effective communication; the communication begins with engaging the patient and involves being empathetic to the patient and family [18]. These two components are therefore the milieu that makes the four aspects mentioned above possible. The Institute for Healthcare Communication developed a communication for healthcare curriculum that mainly teaches 4-Es of communication, namely

• social relation—ability to reveal little anxiety about communication

• Message skills—ability to understand and use language and feedback.

back that commensurate with the counterpart's identity.

tion such as stress and alienation (in ambiguous situations).

**c.** Reciprocity is the basis of most relationships, which creates in a group deeper relationship where at times personal and business issues cross over, and is common in Confucius cultures [8].

In communication to the patient in a global village, and even within a country, one must be culturally sensitive. Cultural competency has been defined as the ability of providers and organizations to effectively deliver services that meet social, cultural, and linguistic needs of the patient.

The surgeons therefore must understand the culture and the language in which they practice and the meaning of both spoken and unspoken words in the culture to effectively develop a healing relationship with their patients. In order to heal, one must get into the world of the patient. This will enable them to empathize with them and help them understand their disease better in their own sociocultural context so as to help them overcome not only the disease but the illness as well [13].

In the intercultural communication, one must be sure to understand the different cultures and their emphasis; in medicine, one must understand the ethics practiced in different cultural contexts. Ethics then guides how one communicates. May and Sharratt identified four values in Western ethics namely autonomy, justice, responsibility, and care [14]. Menkiti identified African ethics to stress the well-being of the community and economic over political rights [15]. Other cultural values are more bent on the religion of the individual. Kales theory is that peace is the fundamental value interculturally; hence, ethical communicators ought to maintain that peace through respectful communication, not deliberately misleading, exercising the right to express one's self and identification with other cultures [16].

Several approaches for effective intercultural communication have been identified that include:

	- Self-respect—self-confidence
	- Self-awareness—understanding how others would the other
	- Empathy—viewing things through another person's eye
	- Adaptability—ability to adjust to different environment
	- Interaction—ability to effectively communicate with others
	- Certainty—ability to accept contradictory situations
	- Initiative—being open to new situations
	- tolerance
	- **i.** Personality strength—which involves knowing oneself, initiating a positive attitude, and being friendly through
		- self-concept—how one views themselves
		- self-disclosure—willingness to openly and appropriately reveal information about themselves
		- self-monitoring—using social information to control and modify self-presentation and expression
		- social relation—ability to reveal little anxiety about communication
	- **ii.** Communication skills which involve being able to encode messages for people in diverse environments, interacting with them respectfully with flexibility [16].
		- Message skills—ability to understand and use language and feedback.
		- Behavioral flexibility-ability to select appropriate behavior in diverse situations
		- Interaction management—a person's other-oriented ability to initiate interactions, attentiveness, and responsiveness.
		- Social skills—involve empathy and identity maintenance where one is able to put themselves in the others person's stead—similar feelings and being able to give feedback that commensurate with the counterpart's identity.
	- **iii.** Psychological adjustment—acclimatize to a new environment and cope with frustration such as stress and alienation (in ambiguous situations).
	- **iv.** Cultural awareness.

**b.** A third party may be used to avoid confrontation with those respected. In African culture,

**c.** Reciprocity is the basis of most relationships, which creates in a group deeper relationship where at times personal and business issues cross over, and is common in Confucius

In communication to the patient in a global village, and even within a country, one must be culturally sensitive. Cultural competency has been defined as the ability of providers and organizations to effectively deliver services that meet social, cultural, and linguistic needs of the patient. The surgeons therefore must understand the culture and the language in which they practice and the meaning of both spoken and unspoken words in the culture to effectively develop a healing relationship with their patients. In order to heal, one must get into the world of the patient. This will enable them to empathize with them and help them understand their disease better in their own sociocultural context so as to help them overcome not only the

In the intercultural communication, one must be sure to understand the different cultures and their emphasis; in medicine, one must understand the ethics practiced in different cultural contexts. Ethics then guides how one communicates. May and Sharratt identified four values in Western ethics namely autonomy, justice, responsibility, and care [14]. Menkiti identified African ethics to stress the well-being of the community and economic over political rights [15]. Other cultural values are more bent on the religion of the individual. Kales theory is that peace is the fundamental value interculturally; hence, ethical communicators ought to maintain that peace through respectful communication, not deliberately misleading, exercising the

Several approaches for effective intercultural communication have been identified that

**a.** Business approach—maintenance of self, fostering relationship with the host, and promo-

right to express one's self and identification with other cultures [16].

• Self-awareness—understanding how others would the other

• Empathy—viewing things through another person's eye • Adaptability—ability to adjust to different environment

• Interaction—ability to effectively communicate with others

• Certainty—ability to accept contradictory situations

• Initiative—being open to new situations

tion of correct perception of the environment [17]

this is seen in dowry negotiations [8].

disease but the illness as well [13].

cultures [8].

34 Vignettes in Patient Safety - Volume 4

include:

**b.** Military approach [16]

• tolerance

• Self-respect—self-confidence

#### **2.3. Communicating with the patient**

Communication between the physician and the patient can take the usual form of patient interview which comprises


The outcome of the therapeutic encounter is dependent on effective communication; the communication begins with engaging the patient and involves being empathetic to the patient and family [18]. These two components are therefore the milieu that makes the four aspects mentioned above possible. The Institute for Healthcare Communication developed a communication for healthcare curriculum that mainly teaches 4-Es of communication, namely engage, empathize, educate, and enlist. In this section, we will consider more beginning with setting the environment right [19–21]. The Kalamazoo consensus added more that included building the doctor-patient relationship, opening the discussion, gathering information, understanding the patient's perspective, sharing information, reaching agreement on problems and plans, and providing closure [22].

for the doctor to lay his agenda too, it should not be dominating the history taking. Listening and getting patient perspective is at the heart of good history taking. A true account of a patient's concern and how it has evolved over time requires practice, patience, understanding, and concentration. History is a sharing of experience between patient and doctor [25]. A

Communication in Surgery for Patient Safety http://dx.doi.org/10.5772/intechopen.79740 37

The ability to connect with the patient in a deep sense, pay attention keenly, and listen are central in clinical practice leading to patient trust in the physician and satisfaction of both the patient and the doctor. Empathy is the ability to understand the patient feelings, situation, and perspective and to communicate to the patient that one truly does understand. Done well, it helps promote diagnostic accuracy, therapeutic adherence, and patient satisfaction, while remaining time-efficient. Certain words facilitate empathy when used at

Empathy has cognitive, affective, and action components. The cognitive component requires the surgeon to "enter into" the perspective and experience of the patient by using verbal and nonverbal cues but does not lose own perspective or collapse clinical distance. Emotional component requires resonant feelings and the action required is the feedback. The surgeon could use statements such as "Let me see if I have this right" or "I want to be sure I understand what you mean." It helps give the patient a chance to correct but also connect and reinforces

Sympathy requires that the congruent feelings between the patient and the physician, while empathy does not. Even when patients are disagreeable, culpable, or unlikable, the surgeon

Barriers to empathy include time constraints, medical jargon, missing clues, and blocking behavior by the physician. Active listening means listening to and understanding the patient. The patients will give clues to their distress and the impact of their experience of illness; if we fail to acknowledge these clues, patients will repeat them that means prolonged patient visit and they will perceive us as "not listening, not caring, or in a rush." It is a good practice to have several empathic stems to use to allow one to fill in the blanks with the emotion or feelings witnessed [27]. The stems could be queries, responses, or

• "Would you (or could you) tell me a little more about that?"

consultation can allow a patient to unburden himself or herself.

the bond between the surgeon and the patient [23].

• "What has this been like for you?"

• "Is there anything else?"

• "Are you OK with that?"

*2.3.3. Empathize*

the right time [26].

can still empathize with them.

clarifications. Such as:

• "Hmmmm"

**i.** Queries

#### *2.3.1. Setting the stage*

While the Institute for Healthcare Communication curriculum combines "engage" with "information gathering" for diagnostic purposes, "setting the stage for communication" should be treated differently [21]. The setting the stage for communication requires that the surgeon removes every distraction to help them focus on the patient, and it could have several components. It includes setting aside the phone, good posture that is upright and open, and a sitting position that is below the patient's eye level so as not to be threatening. There should be lighting in the consultation room. First impressions communicate many things, majorly the attitude of the individual. How we present ourselves to patients is critical in making the favorable first impression that can lead to a trusting partnership between the surgeon and the patient [23]. A smiling face, warm greeting that is coupled with introducing self and any other person in the room, and firm greeting or social touches will give an impression of openness and trustworthiness.

#### *2.3.2. Information gathering*

Having set the environment, the patient is engaged by eliciting the reason for the visit; this is usually done by open-ended questions. The patients should be allowed to tell their own story without interruption as one uses verbal and nonverbal cues to indicate active listening and keen interest in their words. Patient's story often should help in diagnostic formulation as well as their concerns, fears, and the impact of the disease in their life. They must be allowed to speak freely. The biomedical is the norm, but the patient should be looked at as the whole person.

The patient often has more than one concern; to avoid "doorknob syndrome", the provider needs to engage the patient to put all their agenda on the table [1]. This will help in prioritizing the agenda of the patient during this visit. Having stated the agenda, the surgeon can then clarify the agenda and summarize them as well. The physician, after listening to patient agenda, should agree with the patient on the agenda and also state what he intends to do [24]. Once the agenda is set, the patient is then allowed to tell the full story, and helped along using facilitative comments such as


A good consultation skill is not just about history taking as learned in textbooks. A good history will include patient's ideas, concerns, expectations, and diagnosis. While it is important for the doctor to lay his agenda too, it should not be dominating the history taking. Listening and getting patient perspective is at the heart of good history taking. A true account of a patient's concern and how it has evolved over time requires practice, patience, understanding, and concentration. History is a sharing of experience between patient and doctor [25]. A consultation can allow a patient to unburden himself or herself.

#### *2.3.3. Empathize*

engage, empathize, educate, and enlist. In this section, we will consider more beginning with setting the environment right [19–21]. The Kalamazoo consensus added more that included building the doctor-patient relationship, opening the discussion, gathering information, understanding the patient's perspective, sharing information, reaching agreement on prob-

While the Institute for Healthcare Communication curriculum combines "engage" with "information gathering" for diagnostic purposes, "setting the stage for communication" should be treated differently [21]. The setting the stage for communication requires that the surgeon removes every distraction to help them focus on the patient, and it could have several components. It includes setting aside the phone, good posture that is upright and open, and a sitting position that is below the patient's eye level so as not to be threatening. There should be lighting in the consultation room. First impressions communicate many things, majorly the attitude of the individual. How we present ourselves to patients is critical in making the favorable first impression that can lead to a trusting partnership between the surgeon and the patient [23]. A smiling face, warm greeting that is coupled with introducing self and any other person in the room, and firm greeting or social touches will give an impression of openness

Having set the environment, the patient is engaged by eliciting the reason for the visit; this is usually done by open-ended questions. The patients should be allowed to tell their own story without interruption as one uses verbal and nonverbal cues to indicate active listening and keen interest in their words. Patient's story often should help in diagnostic formulation as well as their concerns, fears, and the impact of the disease in their life. They must be allowed to speak freely. The biomedical is the norm, but the patient should be looked at as the whole

The patient often has more than one concern; to avoid "doorknob syndrome", the provider needs to engage the patient to put all their agenda on the table [1]. This will help in prioritizing the agenda of the patient during this visit. Having stated the agenda, the surgeon can then clarify the agenda and summarize them as well. The physician, after listening to patient agenda, should agree with the patient on the agenda and also state what he intends to do [24]. Once the agenda is set, the patient is then allowed to tell the full story, and helped along using

A good consultation skill is not just about history taking as learned in textbooks. A good history will include patient's ideas, concerns, expectations, and diagnosis. While it is important

lems and plans, and providing closure [22].

*2.3.1. Setting the stage*

36 Vignettes in Patient Safety - Volume 4

and trustworthiness.

person.

*2.3.2. Information gathering*

facilitative comments such as

• "tell me more"

• "Go on"

The ability to connect with the patient in a deep sense, pay attention keenly, and listen are central in clinical practice leading to patient trust in the physician and satisfaction of both the patient and the doctor. Empathy is the ability to understand the patient feelings, situation, and perspective and to communicate to the patient that one truly does understand. Done well, it helps promote diagnostic accuracy, therapeutic adherence, and patient satisfaction, while remaining time-efficient. Certain words facilitate empathy when used at the right time [26].

Empathy has cognitive, affective, and action components. The cognitive component requires the surgeon to "enter into" the perspective and experience of the patient by using verbal and nonverbal cues but does not lose own perspective or collapse clinical distance. Emotional component requires resonant feelings and the action required is the feedback. The surgeon could use statements such as "Let me see if I have this right" or "I want to be sure I understand what you mean." It helps give the patient a chance to correct but also connect and reinforces the bond between the surgeon and the patient [23].

Sympathy requires that the congruent feelings between the patient and the physician, while empathy does not. Even when patients are disagreeable, culpable, or unlikable, the surgeon can still empathize with them.

Barriers to empathy include time constraints, medical jargon, missing clues, and blocking behavior by the physician. Active listening means listening to and understanding the patient. The patients will give clues to their distress and the impact of their experience of illness; if we fail to acknowledge these clues, patients will repeat them that means prolonged patient visit and they will perceive us as "not listening, not caring, or in a rush." It is a good practice to have several empathic stems to use to allow one to fill in the blanks with the emotion or feelings witnessed [27]. The stems could be queries, responses, or clarifications. Such as:

#### **i.** Queries

	- "Let me see if I have this right."
	- "I want to make sure I really understand what you're telling me. I am hearing that."

Other barriers to patient education are time pressure, language barrier, and limited health

Communication in Surgery for Patient Safety http://dx.doi.org/10.5772/intechopen.79740 39

Patient education is core to the two things for the surgeon namely, informed consent and shared decision-making, which are discussed in the next sub-section. The aim is to improve health literacy including knowledge and skills that are conducive for individual survival. It is performed in clinical setting and its goals are related to patient assessment, diagnosis, prognosis, evaluation, individual needs, and requirements related to interventions. The patient should receive education and training that is specific and appropriate to care, treatment, and service provided. It should be personalized to each patient depending on cultural differences,

At times, we try to force-feed the patients without assessing their understanding. Some of the strategies that have been suggested include "Ask me 3" from the National Patient Safety

What is important is to break down the information in portions that the patient can understand, avoiding medical jargon, and using teach-back method to assess their comprehension.

**i.** Patient assumes better responsibility for their own health care and ability to manage their

**iv.** Provides patient-centered care and as a result, patient's active involvement in their plan

**v.** Increases adherence to treatment regimen, more efficient and cost-effective health

This involves asking the patient to be involved in making the decision about his or her treatment. It involves discussing candidly all the options of treatment, including not treating at all, their merits, limitations, and complications. This, however, should be done respectfully and in

**iii.** Increases patient satisfaction with their care, decreases providers risk of liability.

**vi.** Ensures continuity of care, reduces complications related to illness.

**vii.** Maximizes individual independence with possible home care and plans.

literacy [23, 27, 29].

Foundation [31];

• What is my problem? • What do I need to do?

own illness

of care.

systems.

*2.3.5. Shared decision-making*

specific needs, and level of education [30].

• Why is it important for me to do this?

For example, instead of using 60%, use "6 out of 10".

**ii.** Provides opportunities to choose healthier lifestyle

The benefits of patient education include [30]


#### **iii.** Responses


One serious issue why surgeons hardly empathize is the blocking behavior that could be done by offering advice or reassurance before the main problems have been identified, explaining away distress as normal, attending to physical aspects only, switching the topic, and "jollying" patients along [23, 26, 27].

#### *2.3.3.1. Case scenario*

The story: A 22-year-old girl was taken by her parents to see a general surgeon for breast lump. Her history did not indicate any risk but given the surgeon had just dealt with a 24-year-old lady with breast cancer, the surgeon preceded to perform mastectomy based on FNAC (core biopsy was then not readily available and was not the norm). The histological result of the mastectomy indicated fibroadenoma.

The patient's outcome: re-evaluation revealed that the history and examination did not align with FNAC and the surgeon should have asked for core biopsy. It is also possible that the pathologist mixed up results. The patient's parents filed suit against the original surgeon.

What went wrong? Cognitive bias and ignoring patient history and distraction from the previous patient made the surgeon to diagnose what was not there.

#### *2.3.4. Patient education*

One study comparing primary care physicians with surgeons showed that surgeons spend more time emphasizing patient education and counseling [28]. Given the complex intervention and the chances of complication, surgeons get involved in patient education so as to get informed consent. Unfortunately, much of the explanation is done through medical jargon, monolog without an attempt to seek the comprehension of the patient. Other barriers to patient education are time pressure, language barrier, and limited health literacy [23, 27, 29].

Patient education is core to the two things for the surgeon namely, informed consent and shared decision-making, which are discussed in the next sub-section. The aim is to improve health literacy including knowledge and skills that are conducive for individual survival. It is performed in clinical setting and its goals are related to patient assessment, diagnosis, prognosis, evaluation, individual needs, and requirements related to interventions. The patient should receive education and training that is specific and appropriate to care, treatment, and service provided. It should be personalized to each patient depending on cultural differences, specific needs, and level of education [30].

At times, we try to force-feed the patients without assessing their understanding. Some of the strategies that have been suggested include "Ask me 3" from the National Patient Safety Foundation [31];

• What is my problem?

**ii.** Clarifications

38 Vignettes in Patient Safety - Volume 4

**iii.** Responses

• "Let me see if I have this right."

• "That sounds very difficult."

• "I can see that you are …"

ing" patients along [23, 26, 27].

mastectomy indicated fibroadenoma.

*2.3.3.1. Case scenario*

*2.3.4. Patient education*

• "I can imagine that this might feel …"

• "Sounds like …"

• "I want to make sure I really understand what you're telling me. I am hearing that."

• "When I'm done, if I've gone astray, I'd appreciate it if you would correct me. OK?"

One serious issue why surgeons hardly empathize is the blocking behavior that could be done by offering advice or reassurance before the main problems have been identified, explaining away distress as normal, attending to physical aspects only, switching the topic, and "jolly-

The story: A 22-year-old girl was taken by her parents to see a general surgeon for breast lump. Her history did not indicate any risk but given the surgeon had just dealt with a 24-year-old lady with breast cancer, the surgeon preceded to perform mastectomy based on FNAC (core biopsy was then not readily available and was not the norm). The histological result of the

The patient's outcome: re-evaluation revealed that the history and examination did not align with FNAC and the surgeon should have asked for core biopsy. It is also possible that the pathologist mixed up results. The patient's parents filed suit against the original surgeon.

What went wrong? Cognitive bias and ignoring patient history and distraction from the pre-

One study comparing primary care physicians with surgeons showed that surgeons spend more time emphasizing patient education and counseling [28]. Given the complex intervention and the chances of complication, surgeons get involved in patient education so as to get informed consent. Unfortunately, much of the explanation is done through medical jargon, monolog without an attempt to seek the comprehension of the patient.

• "I don't want us to go further until I'm sure I've gotten it right."

• "That's great! I bet you're feeling pretty good about that."

• "Anyone in your situation would feel that way …"

vious patient made the surgeon to diagnose what was not there.


What is important is to break down the information in portions that the patient can understand, avoiding medical jargon, and using teach-back method to assess their comprehension. For example, instead of using 60%, use "6 out of 10".

The benefits of patient education include [30]


#### *2.3.5. Shared decision-making*

This involves asking the patient to be involved in making the decision about his or her treatment. It involves discussing candidly all the options of treatment, including not treating at all, their merits, limitations, and complications. This, however, should be done respectfully and in an appropriate language and manner. It will also involve discussing patient values, preferences, and the best medical evidence that supports the treatment options in a language and respectful, empathic manner. The barrier would be patients' desire to be involved, physician knowledge of patient preference, and physician willing to explore patient concern and preferences [32].

*2.3.5.1. Case scenario*

Ms. Rono presented to a health clinic for assessment for a job. When the physicians perform examination, he finds a 1 cm x 1 cm lump on the right upper outer quadrant. A mammogram indicates it is BIRAD 4c. He refers the patient to Dr. Otieno, the breast surgeon. Dr. Otieno confirms the finding and begins talking to Ms. Rono, taking history and performing physical examination. Dr. Otieno gets to know Ms. Rono's preference, interest, and life plans. Dr. Otieno incorporates this knowledge into subsequent discussions about choices for medical

Communication in Surgery for Patient Safety http://dx.doi.org/10.5772/intechopen.79740 41

Although it may seem a straightforward decision of biopsy on a palpable lump, Dr. Otieno needs to consider age, physical condition, and whether she would be able to undergo the treatment based on the results of the biopsy. Equally important would be whether Ms. Rono

Discuss the risks associated with biopsy. Dr. Otieno should discuss the risk of biopsy itself that includes infection, bleeding, and cosmetic consequences of the scar. He should ask the patient questions about her concern and preferences that may arise from her own research or

Determine whether the patient is competent to make decisions. This is often determined based on the ability of the patient to understand the information and situation awareness, weigh options, and make and communicate their choice. For Ms. Rono, this includes her circumstances of coming for check up for a job but now has a new diagnosis. If Ms. Rono is not competent, then Dr. Otieno should seek out her durable attorney and discuss with her. The

Ms. Rono and Dr. Otieno make shared decisions to proceed with the biopsy. The biopsy turns

Dr. Otieno's subsequent talks with Ms. Rono require being comprehensive and includes patient's preferences and concerns. He should give her options of treatment without surpassing her capacity to understand. The patient potential circumstances should be considered as she is offered breast conserving surgery (BSCS) versus mastectomy. Can the patient access

Most patients take time to make a decision and will take more than one visit. The informed consent and shared decision-making process take time as patient looks for more information and do further consultation of family and friends. Decision aids such as pamphlets will be important because she can review the information when she feels she is not under stress.

The informed consent should be performed by the person doing the procedure or understands the procedure. It should include indications for procedure, steps of the procedure, potential

information from family, friends, and media. Address these concerns at this time.

would want any treatment if the biopsy revealed a malignancy.

capacity to comprehend is assessed by using teach-back method.

The process should proceed in this manner.

The story:

treatment.

The patient's outcome:

out to be positive for breast malignancy.

and afford radiation after the BCS?

The application of communication models is seen in decision-making in surgery where there are three ways namely, paternalistic model, informational model, and shared-decision making model. All these models have their merits and demerits and can actually be used by well-meaning surgeons. In the paternalistic model, the surgeon makes the decision and the patient accedes. This model best works in emergency situations. It leaves the patient uninformed, assumes that the patient preferences are aligned to the physicians, and leads to low adherence, less engagement during recovery and dissatisfaction with likelihood or litigation if untoward outcome occurs [33]. Informational model is where the physician will give only the information and let the patient decide. It assumes the patient is able to process and take into consideration their preferences. However, it has been noted that most patients are not able to process the information, and that given the emotions involved in sickness, some may even shut down because of information overload. Furthermore, often the physicians may give biased information. Shared decision involves giving information, hearing from patient and both parties participating to ensure understanding of patient preferences, and aligning the physician and patient. It also involves assessing patient judgment [34].

The traditional style of paternalistic communication may not welcome patient's input and the patient may also fear being labeled as a 'difficult' patient. But the reward will be that when patients understand their diagnosis, the implication of treatment, and possible outcomes, they would own the process and would adhere to treatment protocols [33]. Many other things could affect adherence and include social support, financial concern, and communication with the doctor. It may therefore call for exploring the social support and enlisting family or other important people in their lives. In some cultures, such as Africa, some of the decisions will have to be family-based.

Several factors may influence patient choice, including information from physician, from family, from internet, and other media sources. The physician can also be influenced by the industry, recommendation made previously that may not be useful for the current illness or articles read with evidence. Certain patient personalities may also be barriers to shared decisionmaking; there are patients who will leave the decision to the physician—they prefer minimal information, others may prefer information only. The physician may also fail to provide a conducive environment when they discount patient preferences and concerns. Other barriers include time constraint and physician attitude—some may feel shared decision-making is not necessary. The physician must ensure the information given is of right quality (understood) and quantity (not overwhelming) [32].

The patient perspective while making decisions may be fourfold. They may feel the decision is obvious and can be done immediately or feel overwhelmed and defer it to someone else or just require time to process and they may require more information to make the decision. The surgeon must allow the patient time and space to go through the motions. Though it may take time, once shared decision is made, the process will be long and compliance will be total [32].

#### *2.3.5.1. Case scenario*

#### The story:

an appropriate language and manner. It will also involve discussing patient values, preferences, and the best medical evidence that supports the treatment options in a language and respectful, empathic manner. The barrier would be patients' desire to be involved, physician knowledge of patient preference, and physician willing to explore patient concern and preferences [32].

The application of communication models is seen in decision-making in surgery where there are three ways namely, paternalistic model, informational model, and shared-decision making model. All these models have their merits and demerits and can actually be used by well-meaning surgeons. In the paternalistic model, the surgeon makes the decision and the patient accedes. This model best works in emergency situations. It leaves the patient uninformed, assumes that the patient preferences are aligned to the physicians, and leads to low adherence, less engagement during recovery and dissatisfaction with likelihood or litigation if untoward outcome occurs [33]. Informational model is where the physician will give only the information and let the patient decide. It assumes the patient is able to process and take into consideration their preferences. However, it has been noted that most patients are not able to process the information, and that given the emotions involved in sickness, some may even shut down because of information overload. Furthermore, often the physicians may give biased information. Shared decision involves giving information, hearing from patient and both parties participating to ensure understanding of patient preferences, and aligning the

The traditional style of paternalistic communication may not welcome patient's input and the patient may also fear being labeled as a 'difficult' patient. But the reward will be that when patients understand their diagnosis, the implication of treatment, and possible outcomes, they would own the process and would adhere to treatment protocols [33]. Many other things could affect adherence and include social support, financial concern, and communication with the doctor. It may therefore call for exploring the social support and enlisting family or other important people in their lives. In some cultures, such as Africa, some of the decisions

Several factors may influence patient choice, including information from physician, from family, from internet, and other media sources. The physician can also be influenced by the industry, recommendation made previously that may not be useful for the current illness or articles read with evidence. Certain patient personalities may also be barriers to shared decisionmaking; there are patients who will leave the decision to the physician—they prefer minimal information, others may prefer information only. The physician may also fail to provide a conducive environment when they discount patient preferences and concerns. Other barriers include time constraint and physician attitude—some may feel shared decision-making is not necessary. The physician must ensure the information given is of right quality (understood)

The patient perspective while making decisions may be fourfold. They may feel the decision is obvious and can be done immediately or feel overwhelmed and defer it to someone else or just require time to process and they may require more information to make the decision. The surgeon must allow the patient time and space to go through the motions. Though it may take time, once shared decision is made, the process will be long and compliance will be total [32].

physician and patient. It also involves assessing patient judgment [34].

will have to be family-based.

40 Vignettes in Patient Safety - Volume 4

and quantity (not overwhelming) [32].

Ms. Rono presented to a health clinic for assessment for a job. When the physicians perform examination, he finds a 1 cm x 1 cm lump on the right upper outer quadrant. A mammogram indicates it is BIRAD 4c. He refers the patient to Dr. Otieno, the breast surgeon. Dr. Otieno confirms the finding and begins talking to Ms. Rono, taking history and performing physical examination. Dr. Otieno gets to know Ms. Rono's preference, interest, and life plans. Dr. Otieno incorporates this knowledge into subsequent discussions about choices for medical treatment.

Although it may seem a straightforward decision of biopsy on a palpable lump, Dr. Otieno needs to consider age, physical condition, and whether she would be able to undergo the treatment based on the results of the biopsy. Equally important would be whether Ms. Rono would want any treatment if the biopsy revealed a malignancy.

The process should proceed in this manner.

Discuss the risks associated with biopsy. Dr. Otieno should discuss the risk of biopsy itself that includes infection, bleeding, and cosmetic consequences of the scar. He should ask the patient questions about her concern and preferences that may arise from her own research or information from family, friends, and media. Address these concerns at this time.

Determine whether the patient is competent to make decisions. This is often determined based on the ability of the patient to understand the information and situation awareness, weigh options, and make and communicate their choice. For Ms. Rono, this includes her circumstances of coming for check up for a job but now has a new diagnosis. If Ms. Rono is not competent, then Dr. Otieno should seek out her durable attorney and discuss with her. The capacity to comprehend is assessed by using teach-back method.

The patient's outcome:

Ms. Rono and Dr. Otieno make shared decisions to proceed with the biopsy. The biopsy turns out to be positive for breast malignancy.

Dr. Otieno's subsequent talks with Ms. Rono require being comprehensive and includes patient's preferences and concerns. He should give her options of treatment without surpassing her capacity to understand. The patient potential circumstances should be considered as she is offered breast conserving surgery (BSCS) versus mastectomy. Can the patient access and afford radiation after the BCS?

Most patients take time to make a decision and will take more than one visit. The informed consent and shared decision-making process take time as patient looks for more information and do further consultation of family and friends. Decision aids such as pamphlets will be important because she can review the information when she feels she is not under stress.

The informed consent should be performed by the person doing the procedure or understands the procedure. It should include indications for procedure, steps of the procedure, potential complications, benefits of the procedure, options and complications of the alternative procedures, and risk of not doing anything. Finally, the patient competence and understanding should be assessed. The core principles of informed consent are that it is not the paper that matters but the process of involving the patient [33, 34]. It is therefore an opportunity to help the patient come to shared decision rather than obligation for the surgeon. It is very helpful as a first step of disclosure should something go wrong and applies to all medical treatment.

according to patient needs, expectation, and desires; thirdly, to support the patient by reducing emotional impact and isolation experienced by the patient; and finally, to formulate treat-

Communication in Surgery for Patient Safety http://dx.doi.org/10.5772/intechopen.79740 43

**i.** The patient and relatives if present require a setting that would be private and if pos-

**ii.** It is important that the patients have relatives or friends comfortable to accompany

**iii.** Posture and sitting arrangement should be ones that help calm the patient and makes

**iv.** Eye contact, holding the patient's hand, or any social touch may help make connection

Before discussing medical findings, clinical or investigations, the clinician should use open-ended questions to create a reasonably accurate picture of how the patients perceive

This information can then be used to correct any misinformation and contextualize the bad news to the patient's understanding. It may also help to find out if the patient is in denial either through wishful thinking or omission of essential but unfavorable details or

Although most patients desire full information about their diagnosis and prognosis, some may not. Expressing desire for the information may place the surgeon at ease, and shunning information may indicate a coping mechanism and may be a sign of severity of illness. The surgeon may prepare the patient at the time of ordering the test by asking

**ii.** "Would you like me to give you all the information or sketch out the results and spend

In case they do not want details, the surgeon can offer to answer any question they may

**i.** "How would you like me to give the information about the test results?"

more time in planning the treatment?"

ment plan in shared decision model.

sible have tissues in case patient is upset.

**v.** Ensure there are no possible interruptions within the time.

**i.** "What have you been told about your situations so far?"

**ii.** "What is your understanding of the reason we did the mammogram?"

them during these discussions.

This can be done in six steps [36].

**a.** Setting up

them relax.

with the patient.

**b.** Assessing patient perception.

their medical situation.

unrealistic expectations. **c.** Obtaining patient invitation.

have in future.

Surgeons should be transparent and truthful about their experience and the data that are available when a patient asks for risk of complications of procedures without being too detailed in order to help patients in decision-making about their care. The physician should help the patient interpret data that is available in broad terms as was suggested above [32].

Ms. Rono is choosing whether to undergo mastectomy, or BCS, then radiation. Dr. Otieno should understand Ms. Rono's preferences. It is possible that Ms. Rono is most interested in pursuing the treatment that is likely to leave her with a breast rather than understanding slight differences in 5-year recurrence rates. Dr. Otieno needs to elicit these priorities during the conversation about surgical options. At the same time, if Dr. Otieno is excited about a new surgical modality, like BCS, he needs to be truthful about what the data say and his own experience with the procedure.

#### *2.3.6. Delivering bad news*

The "news" to the patient after clinical assessment or investigation is potentially bad news. Buckman defines bad news as "any information which adversely and seriously affects an individual's view of his or her future" [35]. However, it is the patient who knows what they consider as bad news. The impact of bad news can only be determined after the recipient's expectations and understanding are known. Ms. Rono's biopsy results could cause her shock given she did not go with the knowledge of the lump to the doctor.

Sharing of bad news can be difficult for the doctor based on certain factors such as fear of being blamed for the bad news, fear of arousing strong emotions or causing pain, uneasiness with their inability to make the disease go away or to answer all the patient's questions, difficulty in facing death, and discomfort arising from the fact that they simply do not know how to carry out the task well [35].

Sharing bad news is frequent and stressful but it is what needs to be done because patients require knowing the truth about their diagnosis and prognosis. This needs to be handled sensitively and sincerely. The practice of deception cannot instantly be remedied by a new routine of insensitive truth telling [36]. The way bad news is discussed can affect the patient's understanding of information, satisfaction with medical care, level of hopefulness, and subsequent psychological adjustment [35]. As much as many patients desire accurate information to help them make important quality-of-life decisions, some may find it threatening and may get into denial or minimizing the significance of the information while continuing with care.

The goal of breaking bad news is fourfold, firstly, to gather information on what the patients know, their readiness, and their expectations; secondly, to provide appropriate information according to patient needs, expectation, and desires; thirdly, to support the patient by reducing emotional impact and isolation experienced by the patient; and finally, to formulate treatment plan in shared decision model.

This can be done in six steps [36].

**a.** Setting up

complications, benefits of the procedure, options and complications of the alternative procedures, and risk of not doing anything. Finally, the patient competence and understanding should be assessed. The core principles of informed consent are that it is not the paper that matters but the process of involving the patient [33, 34]. It is therefore an opportunity to help the patient come to shared decision rather than obligation for the surgeon. It is very helpful as a first step of disclosure should something go wrong and applies to all medical treatment. Surgeons should be transparent and truthful about their experience and the data that are available when a patient asks for risk of complications of procedures without being too detailed in order to help patients in decision-making about their care. The physician should help the patient interpret data that is available in broad terms as was suggested above [32].

Ms. Rono is choosing whether to undergo mastectomy, or BCS, then radiation. Dr. Otieno should understand Ms. Rono's preferences. It is possible that Ms. Rono is most interested in pursuing the treatment that is likely to leave her with a breast rather than understanding slight differences in 5-year recurrence rates. Dr. Otieno needs to elicit these priorities during the conversation about surgical options. At the same time, if Dr. Otieno is excited about a new surgical modality, like BCS, he needs to be truthful about what the data say and his own

The "news" to the patient after clinical assessment or investigation is potentially bad news. Buckman defines bad news as "any information which adversely and seriously affects an individual's view of his or her future" [35]. However, it is the patient who knows what they consider as bad news. The impact of bad news can only be determined after the recipient's expectations and understanding are known. Ms. Rono's biopsy results could cause her shock

Sharing of bad news can be difficult for the doctor based on certain factors such as fear of being blamed for the bad news, fear of arousing strong emotions or causing pain, uneasiness with their inability to make the disease go away or to answer all the patient's questions, difficulty in facing death, and discomfort arising from the fact that they simply do not know how

Sharing bad news is frequent and stressful but it is what needs to be done because patients require knowing the truth about their diagnosis and prognosis. This needs to be handled sensitively and sincerely. The practice of deception cannot instantly be remedied by a new routine of insensitive truth telling [36]. The way bad news is discussed can affect the patient's understanding of information, satisfaction with medical care, level of hopefulness, and subsequent psychological adjustment [35]. As much as many patients desire accurate information to help them make important quality-of-life decisions, some may find it threatening and may get into denial or minimizing the significance of the information while continuing with care. The goal of breaking bad news is fourfold, firstly, to gather information on what the patients know, their readiness, and their expectations; secondly, to provide appropriate information

given she did not go with the knowledge of the lump to the doctor.

experience with the procedure.

to carry out the task well [35].

*2.3.6. Delivering bad news*

42 Vignettes in Patient Safety - Volume 4


Before discussing medical findings, clinical or investigations, the clinician should use open-ended questions to create a reasonably accurate picture of how the patients perceive their medical situation.


This information can then be used to correct any misinformation and contextualize the bad news to the patient's understanding. It may also help to find out if the patient is in denial either through wishful thinking or omission of essential but unfavorable details or unrealistic expectations.

**c.** Obtaining patient invitation.

Although most patients desire full information about their diagnosis and prognosis, some may not. Expressing desire for the information may place the surgeon at ease, and shunning information may indicate a coping mechanism and may be a sign of severity of illness. The surgeon may prepare the patient at the time of ordering the test by asking


In case they do not want details, the surgeon can offer to answer any question they may have in future.

**d.** Giving patient information

Words that express some form of warning before the bad news is given may prepare the patient, lessen the shock, and help in processing the information. This may be expression such as

to medical error as a result of miscommunication. The Agency for Healthcare Research and Quality (AHRQ) developed tools for communication among the surgical team that aligns the

Communication in Surgery for Patient Safety http://dx.doi.org/10.5772/intechopen.79740 45

The tool begins with at the structure of communication. The structure is called multi-team system for patient care. Team is defined as two or more people who interact dynamically, interdependently, and adaptively towards a common and valued goal, have specific roles or functions, and have a time-limited membership [37]. The core team is a group of care providers with the closest contact with the patient. They work interdependently to manage patients from point of assessment to disposition. In the case scenario of Ms. Rono, this would include Dr. Otieno, surgical resident, intern, and the ward nurse. Contingency team is a time-limited team formed for emergent or specific events and composed of members from various teams. This will be the operating room team or the code blue team: a team comprising members are responsible for managing the operational environment that supports the core team. Ancillary Services provide direct, task-specific, and time-limited care to patients while also support services provide indirect service-focused tasks which help to facilitate the optimal health care experience for patients and their families. This includes nutritionist, physiotherapist, and

The role of administrators is to establish and communicate vision, develop policies, and set expectations for staff related to teamwork, support and encourage staff during implementation and culture change, hold teams accountable for team performance, and define the culture of the organization. The patient is as the apex of the pyramid, indicating every team is

The team structure is important because it identifies individuals among which information must be communicated, designates leaders, and mutual support is sought. In a complex scenario such as this, between-team communication and within-team communication about tasks and processes are important. Effectiveness of teams can be sabotaged by factors that are described by Lencioni in his book: The Five Dysfunctions of a Team. This includes inattention to results, avoidance of accountability, lack of commitment, fear of conflict, and absence of trust [38]. Therefore, team leadership with concomitant effective communication is key to

In this complexity, effective communication serves as the coordinating mechanism for the teamwork and is the lifeline of a well-functioning team. The skills to communicate effectively are essential for patient safety and are the mode by which most of the tools for TeamSTEPPS are executed. The sentinel event data reported by the Joint Commission between 1995 and 2005 indicate that ineffective communication was the root cause of 66% of the errors reported. The data from 2010 to 2013 indicate that ineffective communication remain among the top

Failure of communication within the team or department leads to failure to share information with the team, failure to request information from others, or direct information to a particular member of the team and also failure to include patients and their families in communication involving their care. This will be indicated by poor documentation, that is not timed,

surgical care well. This is called TeamSTEPPS [37].

involved in taking care of the patient (**Figure 1**).

social workers [37].

patient safety in such context.

three causes of sentinel events [5].


Give medical fact by knowing the level of understanding and using correct vocabulary. Avoid excessive bluntness that may leave the patient isolated and later angry with a tendency to blame the surgeon-such language as—"your cancer is very bad and if not treated immediately you are going to die". Give information in small portion, check patient understanding at every step, and finally, even if prognosis is poor, avoid using phrases that discourage such as 'there is nothing we can do for you', because the goal of pain and symptom relief is still options.

**e.** Being empathetic

This has been addressed above, but for emphasis, patient emotional reactions may vary from silence to disbelief, crying, denial, or anger. The physician can offer support by giving empathic response in four steps.


A clear plan and strategy may make the patient less anxious and more certain. However, the treatment options should be discussed with the patient who is 'available' emotionally. If the physician continues, it may appear like the physician's preferences are more important than patients. Shared decision-making model engenders shared responsibility and reduces sense of failure when treatment is not successful. Ensuring the patient has understood, documenting the finding, and recording all that is said and done are important.
