June 1st, 2017
Lauren Taylor, MD is a general surgery resident at the University of Wisconsin and a research fellow in the Wisconsin Surgical Outcomes Research program. She is lead author of the abstract that won Best Abstract Award at the 2017 Lown Institute Conference and one of the winners of the 2017 Right Care Vignette Competition. We spoke with Lauren about the Best Case/Worst Case shared decision-making tool, highlights from the Lown Conference, and next steps for her research.
Lown Institute: In your presentation at the Lown Conference on barriers to shared decision making, you said that many doctors in your pilot study missed the opportunity to break bad news. Why do you think this was so difficult for doctors?
Dr. Taylor: These conversations are really challenging, even for experts. The patients are often quite sick and the amount of new medical information they receive can be overwhelming. Also, for these acute surgical problems the surgeon doesn’t have the benefit of a long-standing relationship with the patient – often the surgeon is meeting the patient and their family for the first time in the hospital, which can make discussion about serious issues like end-of-life care really difficult.
I think that while the clinician may see how bad things are, in some cases we assume this understanding is shared, when in reality patients and families aren’t on the same page. They may not realize that a certain diagnosis is life-threatening. As part of our original pilot study we interviewed patients and families after their hospital stay and it was fascinating to see how many didn’t fully appreciate how serious things were – that the possibility of death was real.
Lown Institute: Are these barriers to shared decision making unique to surgery or similar across specialties?
Dr. Taylor: There are some aspects of these decision-making conversations unique to surgery – specifically acute life-threatening surgical conditions. For example, patients don’t have several interactions with their doctor and there are often serious time constraints. But I think other aspects apply widely. Most doctors want to fix things and heal people, rather than tell people bad news.
Lown Institute: How have these findings changed the Best Case/Worst Case tool?
Dr. Taylor: The Best Case/Worst Case video we created incorporates a lot of the changes we made to the tool after the pilot. For example, the video contains a formal “Breaking Bad News” component. We made it clear in the video that surgeons should be making a treatment recommendation, not just presenting options and expecting patients to choose. Another change we made was to add the words “What is important to you now?” at the bottom of the graphic. Surgeons weren’t asking patients this question, so having it written down at least prompts patients to think about it.
The video also instructs the surgeon to make a graphic aid showing what would be the best case scenario and worst case scenario for each treatment option. Patients and their families loved having the graphic aid. We talked to patients three months after the treatment conversations and lots of them brought out the graphic aid which they had saved from their hospital stay. It’s a great reference for them after the surgeon leaves.
Lown Institute: What are your next steps for this research?
Dr. Taylor: We have several studies ongoing currently – we’re testing a new training package with four surgical residencies across the country using the training video, pilot testing the tool with nephrologists at UW, and collaborating with trauma experts to determine how to use Best Case/Worst Case for older hospitalized patients who have suffered a serious traumatic injury.
Lown Institute: What were some of your favorite moments or things you learned at the Lown Conference?
Dr. Taylor: I thought the research presentation on the amount of time it takes for doctors to interrupt patients was extremely interesting. Doctors interrupting patients quickly is something pretty common, it applies to every medical and surgical specialty. I’m positive I do that myself!