"Who wants me to do what?" varied expectations from key stakeholder groups in the surgical intensive care unit creates a challenging learning environment.

BACKGROUND: Surgical intensive care units (SICU) require complex care from a multi-disciplinary team. Frequent changes in team members can lead to shifting expectations for junior general surgical trainees, which creates a challenging working and learning environment. We aim to identify expectations of junior surgery trainee's medical knowledge and technical/non-technical skills at the start of their SICU rotation. We hypothesize that expectations will not be consistent across SICU stakeholder groups. METHODS: Twenty-eight individual semi-structured interviews were conducted with six SICU stakeholder groups at a medium-sized academic hospital. Expectations were identified from interview transcripts. Frequency counts were analyzed. RESULTS: Forty-one expectations were identified. 4 expectations were identified by a majority of interviewees. Most expectations were identified by 7 or fewer interviewees. 23 (53%) expectations were shared by at least one stakeholder group. 2 (8%) expectations were shared by all groups. CONCLUSIONS: SICU stakeholder groups identified ten medical knowledge, ten technical skill, and three non-technical skill expectations. Yet, few expectations were shared among the groups. Thus, SICU stakeholder groups have disparate expectations for surgery trainees in our SICU.

Using Implementation Science to Adapt a Training Program to Assist Surgeons with High-Stakes Communication.

OBJECTIVE: Surgeons often conduct difficult conversations with patients near the end of life, yet surgical education provides little formalized communication training. We developed a communication tool, Best Case/Worst Case, and trained surgeons using a one-on-one resource intensive format that was effective but difficult to scale for widespread dissemination. We aimed to generate an implementation package to teach surgeons using fewer resources without sacrificing fidelity. DESIGN, SETTING, AND PARTICIPANTS: We used the Replicating Effectiveness Programs framework to guide our implementation strategy and tested our intervention with 39 surgical residents at 4 institutions from September 2016 to June 2017. The implementation package consisted of: (1) instructional video, (2) checklist to assess competence, (3) learner manual, and (4) instructor manual. We focused on 3 implementation outcomes: feasibility, fidelity, and acceptability to participants. RESULTS: Attendance rates ranged from 16% to 75%. Site leaders had little difficulty identifying suitable instructors; however, resident recruitment proved challenging. Sixty-nine percent of residents completed the post-training assessment and the mean score was 12.8 (range 8-15) using the 15-point checklist. Across sites, 69% strongly agreed that Best Case/Worst Case is better than how they usually approach high-stakes conversations and 100% felt prepared to use the tool after training. Instructors reported that the training provided residents with the necessary skills to perform the fundamental elements of Best Case/Worst Case. CONCLUSIONS: Using implementation science we demonstrated that a resource intensive communication training intervention can be successfully modified for group-learning and wide-scale dissemination. However, we identified barriers to implementation, including challenges with feasibility and programmatic buy-in that inform not only resident education but also communication skills training more broadly.

Improving surgical residents' communication in disclosing complications: A qualitative analysis of simulated physician and patient surrogate conversations.

BACKGROUND: In this study, we explore surgical resident communication with simulated patient surrogates (SPs), in an Objective Structured Clinical Examination (OSCE). METHODS: We use discourse analysis (DA), a qualitative approach to analyzing language, to evaluate our residents' interactions with simulated patient surrogates. After identifying problematic communication patterns, we apply communication theory to discuss our findings and provide suggestions for improvement. RESULTS: Residents consistently use bluntness, defined as delivering the news abruptly and without adequate preface, and evasiveness, defined as avoiding giving the news, to deliver difficult information. In addition, some residents use neutral language when empathetic language is warranted; and some try to direct the response of SPs, who then become defensive. Residents use evasiveness most frequently, followed by bluntness. These delivery methods often result in poor communication. CONCLUSIONS: We recommend further research in barriers to effective resident communication with patients, as well as future research on the positive effects of good communication on patient perception. Learning these skills will help residents to convey support and empathy to patients, thereby enhancing care.