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The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.
Dr. Adam Cifu:
On today's episode of The Clinical Excellence Podcast, we have Dr. Kevin Roggin talking about breaking bad news in a surgical practice.
Dr. Kevin Roggin:
I try to prepare my patients from the moment I meet them to expect the unexpected.
Dr. Adam Cifu:
We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute. During this podcast, we discuss, dissect and promote clinical excellence, we review research pertinent to clinical excellence, we invite experts to discuss topics that often challenge the physician-patient relationship, and we host conversations between patients and doctors. I'm Adam Cifu, and today I'm joined by Dr. Kevin Roggin. Dr. Roggin is a general surgeon and a surgical oncologist who is an expert in complex upper GI and hepato-pancreato-biliary surgery. He has adopted cutting edge advanced robotic surgical techniques at the University of Chicago, including the robotic Whipple procedure, a robotic total gastrectomy and robotic for gut and liver surgery. Over his 17-year career at the University of Chicago, he has been an award-winning surgical educator, and has served for over a decade as the General Surgery Residency Program Director. Dr. Roggin is both a senior faculty scholar in the Bucksbaum Institute and a master in the Academy of Distinguished Medical Educators at the Pritzker School of Medicine. Kevin, thanks so much for taking the time to talk to me.
Dr. Kevin Roggin:
It's my pleasure to be here, Adam. Thank you.
Dr. Adam Cifu:
Did I totally botch the pronunciation of all this surgical?
Dr. Kevin Roggin:
No, I was quite impressed. You paused at the right spots.
Dr. Adam Cifu:
Pretty good, right?
Dr. Kevin Roggin:
And I don't know who you're talking about, but it sounds pretty good.
Dr. Adam Cifu:
Exactly. As an internist, get nervous talking to surgeons. So I've invited you here for a tough topic. And interestingly, I thought of you because of an experience that we had together over a decade ago. So my question, the first question, is I've been doing this for a long time, I've broken a lot of bad news in my career, but I feel like whenever I break bad news, it tends to be expected. People are coming in for visits, they've had time to prepare. They know that we're going to be going over a pathology report or a radiology report, or they've come into the office, concerned about something. And I'm almost reinforcing their fear. I imagine you've had experiences where you're talking to a patient or a patient's family about really unexpected outcomes right after surgery. And so I guess maybe so people have a sense of what we're talking about, without giving identifiable details, is there a case that you can think of that you've been a part of that this was an issue?
Dr. Kevin Roggin:
First of all, Adam, thank you for inviting me. It's a pleasure to contribute to this. And I'm really happy to share my experiences. And breaking bad news is one of the hardest parts about my job, both as a general surgeon and surgical oncologist. And I have numerous vivid details of patient scenarios that I try to think of in preparation for this podcast. But I'll just talk about one that happened recently. I operated on a patient with pancreatic cancer, we were set up to do a removal of the tumor. And we had explored her, we took her to the operating room, and put a laparoscope in. And unfortunately, there was metastatic disease, meaning the tumor had spread from the pancreas to the peritoneal lining.
Dr. Kevin Roggin:
So obviously, this is not uncommon in what I do as a surgical oncologist. And so I try to prepare my patients from the moment I meet them to expect the unexpected. And whether it's making sure that I go over the risks of a particular operation, or more importantly, and relevant to this discussion, I want to tell them that even though the CAT scan was clean, that there still is about a 15 to 20% chance that when we put the scope in that we might see spread.
Dr. Adam Cifu:
Yeah.
Dr. Kevin Roggin:
And if that's the case, doing or proceeding with the major operation with risk doesn't help her or him live longer. And so I try to prepare when I see them in clinic. And then on the morning of surgery, when I'm talking to the patient, right before they're about to go to sleep, I try to, say, remind them of what we talked about in clinic. Since most of the time, it escapes their memory. And I try to say that if we find spread of disease, you're going to wake up early. Instead of waking up around 2:00 PM, it's going to be 8:30 AM. And if we find that, we'll find another way to treat your cancer.
Dr. Adam Cifu:
Right.
Dr. Kevin Roggin:
It may mean that we can't cure your cancer, but I try to make sure that they understand that just because it didn't go according to plan that we'll find plan B and C. And if not, we'll be honest with them about what this means in terms of prognosis.
Dr. Adam Cifu:
So it sounds like you're almost preparing them for bad news rather than a surprise in that way.
Dr. Kevin Roggin:
I think if experienced surgeons always expect the unexpected, and they also try to game the system in some ways so that patients go into any operation with the possibilities. But when I was a resident and doing trauma surgery, there would often be cases where you would take someone to the operating room urgently.
Dr. Adam Cifu:
Yeah.
Dr. Kevin Roggin:
And maybe there was a 50/50 chance that they wouldn't survive. And so I have definitely been in scenarios where you have to leave the OR and you can't save the patient, and then have to face a family that is hearing the worst news that they could possibly hear. And I do think there are strategies on how to manage that situation.
Dr. Adam Cifu:
Yeah. Maybe I'll get to that, but I want to step back for a second and ask you, because we've all had the experience where we know we say things in the office and we feel like, "Boy, we've done an amazing job preparing people." And then in the next conversation, it's like you never had that visit. I imagine that happens to you sometimes.
Dr. Kevin Roggin:
Absolutely. I think as a surgical oncologist, I'm meeting patients on the worst day of their life.
Dr. Adam Cifu:
Right.
Dr. Kevin Roggin:
And it's a shock to them and the reference to the Peanuts, cartoon, where the adults are talking in tones and you don't hear the words, I think often you say the word cancer and they forget everything that I say. So I've learned not to repeat myself over and over again in clinic. I usually encourage family members to take notes or other people to be there. But often, I follow up a conversation over the phone so that I highlighted the important points, the take-home messages. I think through repetition and making sure that once they've gotten over the initial shock of the cancer diagnosis, I then want to circle back and make sure that they understood what I was saying and answer additional questions. So it's often multiple conversations in advance.
Dr. Adam Cifu:
Right, especially if they're having to make decisions that probably first conversation is not a deciding time.
Dr. Kevin Roggin:
Right. And sometimes people come to my office and they're completely unprepared for the news, and other times they've heard it from their referring physician or primary doctor.
Dr. Adam Cifu:
Right. Or some primary care doctors just leave it to the surgeon.
Dr. Kevin Roggin:
That happens. But I understand, and it's a really tough conversation and I have experience to deal with that I think.
Dr. Adam Cifu:
So I'm going to switch around on how I was going to ask the questions. But since you brought up the maybe post-trauma experience, where you go in with a patient who's terribly unstable but alive, and come out after a patient has died and have to face one or more family members. I imagine that occasionally there's not only shock, but real anger in that sort of conversation.
Dr. Kevin Roggin:
I think there's some practical tips.
Dr. Adam Cifu:
Yeah.
Dr. Kevin Roggin:
One is that you need to make sure that wherever you're having the conversation, you know where the exit is. You need to make sure that you have a team around you, and you need to protect the trainees and the other people that may be coming in. But I've found that in those situations, you have to be direct.
Dr. Adam Cifu:
Yeah.
Dr. Kevin Roggin:
You can't use euphemistic terms, "Someone died." You have to explain to them. And I've seen the whole range of reactions from the most positive, where people who are of faith and have understanding that there's a place that their relative has gone to, you drawn unto their religious right beliefs to help them assist them through that time. And so I've been amazed by how powerful that is and getting people through difficult times. I've had outright anger where people throw things and are screaming. And as long as you feel safe, I think that you just have to be in that situation, you have to give them the opportunity to let their feelings out.
Dr. Kevin Roggin:
Often, they misplace their feelings of anger onto you or your team. And I think you have a duty to protect your team and make sure, and I've had to get up and then circle back. But I think when you go into that room, especially when you're breaking the worst news, I think you just have to be on guard, you have to be aware that this is the worst time in this family's life. And you want to try to do everything that you can to help them navigate this tragedy.
Dr. Adam Cifu:
Right. Your point of misplaced anger is so good because as I think back to interactions like this, where I've taken the brunt of anger, it's actually usually from a family rather than a patient, it's often in the weeks or months later that people are apologizing to me about that first reaction. And of course, our reaction is, "You certainly don't need to apologize to me." But right, they're angry about the situation, they're angry about the disease, they're angry about what's happened. And you're the representation of it that's easy to go after at the time.
Dr. Kevin Roggin:
Yeah. I mean, you have to be a true professional in this situation, and you just have to take it sometimes and let people air out. And I believe in human beings to be kindhearted and good, and they always come back. And if they don't, I understand that as well. I'm not offended either way.
Dr. Adam Cifu:
No.
Dr. Kevin Roggin:
I just want to be in the moment, be there for them, share the news directly, and look them in the eye when I'm talking to them. And if their reaction is one of anger, I can deal with it. I just need to protect myself and my team. And there's also been situations where family members have passed out. And so you can instantly shift from being a bad news bearer to a physician, trying to help resuscitate someone. So that was another memorable event that happened breaking bad news.
Dr. Adam Cifu:
So you're also obviously very involved in medical education and surgical education. And part of that is obviously teaching trainees to do this well going forward. How does that happen? I mean, clearly through observation at first, but how do you transition to trainees taking a real role in these conversations?
Dr. Kevin Roggin:
That's a great question. Well, one of the benefits of working at the place I have, especially the University of Chicago, is that there are tremendous number of mentors all around, and I've seen you in practice and your colleagues, and colleagues in surgery. And I feel like we're always learning how to be better. So number one, I try to model the appropriate behavior. So you have to emphasize, in your own actions, and then take a moment after you've had that encounter, step outside. And all it takes is a minute to make sure you highlight the important details. So things like sitting down on the level that the patient's at, inviting family into the room, inviting them to record your conversation.
Dr. Adam Cifu:
Yeah, yeah.
Dr. Kevin Roggin:
It's not a litigious situation, it's that they may forget. And encouraging them to feel like they have the ability to take down the notes or record the conversation so they can go back to it in the future, and then looking them in the eye. And again, as I said before, I try to be direct, I try to think of myself as, "I'm in this moment and I don't want to use euphemisms or be somewhat non-committal.
Dr. Adam Cifu:
Yeah.
Dr. Kevin Roggin:
I also highlight the limits of my knowledge and understanding. And when I have the conversation, I take a moment to make sure that I answer all their questions, and also offer the opportunity to circle back either by phone or in person to help sort some facts out or to help make sure they're understanding it. I think that's how I've done it. And when I look at how I learn that, it was from observing people and watching their style, and I think all of our ability to do that is an amalgam of the experiences we've had, the intentional and unintentional things, the non-verbal verbal cues, and ways of communicating with patients. And sometimes, it's reaching out and putting your hand on their shoulder, or grabbing their hand, or showing compassion. I think that helps a lot. And I think trainees understand that, but I want to make sure that when I'm done, that they know what they just saw and have the opportunity to ask questions.
Dr. Adam Cifu:
Yeah, I do think so much of, especially postgraduate medical training is making sure that the experience ends up being some deliberate practice. And often, it is that time of, "Okay, even if it's just a couple of minutes," reflect sounds so bad, but it is that. It's, "Let's reflect on what happened." And even sometimes it's calling attention to yourself, and this is what I did, and this is why I did it. Even if it goes badly, I can still picture the place in the hospital that I brought a student in once for a family meeting. And it goes down in history for me as the worst family meeting I ever had, where the family ended up voting on something and I lost terribly in the vote. And the student and I went to another room and sat down, and I said, "Well, that was the worst family meeting I've ever had and this is why." And this student actually sent me a note a few years later that, "Boy, I was just in a similar family meeting, and I remembered that one."
Dr. Adam Cifu:
And although I felt terrible that he still remembered, and it was kind of wonderful to hear that.
Dr. Kevin Roggin:
I mean, we've all had difficult situations, the ones that didn't go as planned. And I think recognizing that as well and admitting, "Look, if I could have done this over again, I might have done X, Y, and Z." But I think when you're dealing with adult learners, oftentimes, they're at a much higher level of understanding, and I think sometimes, they nod and are approving, but they're actually going through that experience as well.
Dr. Adam Cifu:
Right.
Dr. Kevin Roggin:
They're feeling those emotions. And so another key component is making sure that the people you're teaching or observing are okay. And we often have a pause where after a code or a death, or even a difficult conversation in a medical morbidity or mortality conference, that we make sure that we take care of the people that are learning because it's often very difficult for them to hear some of these things or have family experiences that it evokes memories of.
Dr. Adam Cifu:
Right. And of course, you learn from good experiences as much as bad experiences. And seeing things that didn't go well, you learn a ton from, whether it's surgical or decision making or in human interaction, right?
Dr. Kevin Roggin:
Mm-hmm.
Dr. Adam Cifu:
And so Kevin, thank you so much. That was a great conversation, and really all I wanted to tease out of you. So thanks again for joining us for this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page. The music for The Clinical Excellence Podcast is courtesy of Dr. Malin Martinez.