I am a “mature” doctor who, mid-career, shifted from reconstructive plastic surgery to palliative medicine. Although the two specialties are seemingly very different, I actually see them along the same continuum: both deal primarily with “quality of life” issues. My new specialty just doesn’t happen to involve cutting into people.

Before I got to palliative medicine, I had 4 years of medical school, 9 years of general surgery and plastic surgery training, and 15 years in a reconstructive practice. And in all that time I did not have one lecture, class, or CME (continuing medical education) course on communicating with patients. To be truthful, I can’t say that this deficiency gave me pause. I never really thought much about it.

Perhaps because doctors are human beings, and human beings communicate with one another regularly, everyone assumes that doctors are effective communicators. But I think we know the fallacy of that logic. People are people: some are wonderful at communication, some are so-so, and some are terrible. The same is true of health-care providers—but the stakes of poor communication may be higher in health care than they are in most other professions.

Because there is typically more than one reconstruction option that is appropriate for a patient, I—as a plastic surgeon—needed to have a good understanding of my patient’s expectations in order to make an effective surgical plan. What was the patient’s hope for the final outcome? What burdens inherent to the procedure were he or she willing to live with to achieve that outcome? Matching the appropriate reconstruction option for each patient was critical. When you are the operating surgeon, there’s nothing more unsettling than having your patient upset because of unfulfilled expectations, even though you deem the outcome to be a wonderful cosmetic and functional result. Getting to this understanding takes both time and effective communication skills, as patients often don’t really think about the precise result they will be pleased with. They just want you “to make them better”(i.e., to “fix it”).

Here is a common scenario from my career as a plastic surgeon: I would be consulted by an orthopedic surgeon to help in the care of a patient with a complex lower-extremity fracture. Typically, soft tissue is needed to cover the area of injury so the stabilized fracture site will heal. With extensive injuries, even if all goes well, the patient is in for a long recovery (months or even a few years). And even after considerable recovery time, depending on the extent of injury and the patient specifics, the patient could still be left with significant disability.

Not everyone has the luxury of being able to go through such a long recovery process. For those who need to get on with their lives (i.e., back to work) a lengthy recovery can be enormously burdensome. And if complications set in, the entire process can be even longer and more difficult.

I always felt in such situations that my discussion with the patient and his family had to include an option other than trying to salvage the leg with bone stabilization and soft tissue reconstruction—and that option is primary amputation. Amputation, in many cases, could achieve an acceptable functional result in a significantly shorter period of time. I was astounded how often I was the first person to bring this up with the patient, and I was reprimanded a number of times by referring providers for doing so. To me, however, the basis for true informed consent involves honest communication about the full range of options open to the patient; this is the only way to promote true shared decision making. Presenting amputation as an option did not always make me popular with referring orthopedists, however.

So despite my lack of specific training in communicating, I thought my communication skills were pretty good.  During my fellowship in Hospice and Palliative Medicine I would learn otherwise.

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