 This off is Dr. Gretchen Schwarzie. Gretchen is assistant professor of surgery at the University of Wisconsin. She's currently funded by the Greenwall Foundation, has a K Award from University of Wisconsin, CTSA for her research on surgical buy-in. She'll be speaking today on its big surgery, pre-operative expressions of risk, responsibility, and commitment to treatment after high-risk operations. Welcome, Gretchen. Thanks, Peter. I'm sure you're as overwhelmed as I am about all the other talks today. They were just so fantastic, and I'm really honored to be invited and to be part of this. I was saying to Peter before this started, I'm pretty sure this is my block time at the McLean Center, because I'm always in the last session on Saturday. But my talk today actually starts, the story of my research talk today actually starts here at the McLean Center when about five years ago, I was talking on some very different surgical topic, and at the end of my talk, Rochelle Bernaki, who I think many of you know, stood up and said, Gretchen, why is it that surgeons have such a hard time withdrawing life-supporting treatments on their post-operative patients? Is it just because they're so worried about their mortality statistics, or is there something else to it? And at the time, I really didn't have much of an answer to her, and I said, you know, Rochelle, my hunch is that it's something a little bit more than mortality statistics, but I just don't know what it is. And so I set off trying to answer Rochelle's question after leaving this meeting. And what it came up with after our first endeavor is this issue of surgical buy-in. So, and I'll show the data that supports surgical buy-in, but I wanna just briefly describe what it is so that I can describe our newest project. So surgical buy-in is something that we call an informal contract, formed between the surgeon and the patient, in which the patient not only consents to the operation to be performed, but commits to the post-operative surgical care anticipated by the surgeon. And this was something we defined after talking to surgeons, both in a qualitative study and in a quantitative study that we were able to validate with a large national sample of surgeons. And here's the data from our qualitative study. Surgeons talked about how before a big operation, it was important to establish the patient's commitment to post-operative treatment, that this was actually agreed upon as part of the process of getting to do the operation. So one surgeon said, during a big operation, surgeons feel that there is a commitment made by both the patient and the surgeon to get through the operation as well as all of the post-operative issues that come up. Surgeons talked about negotiating about post-operative life-supporting treatments or contracting for a level or amount of time of care afterwards. And they reported that they were quite surprised if post-operative treatments were refused. So we went on to do a large national survey of surgeons sampling almost 1,000 cardiothoracic, vascular and neurosurgeons. And the reason we chose this group is because we wanted to be sure to sample people who routinely took care of patients who are gonna have post-operative intensive care. And one of the things we did within our survey was to embed a vignette. And the vignette was about a 75-year-old woman who had had an operation. And after the operation suffered a severe left hemipiridic stroke. In addition to this she had a post-operative pneumonia for which she was intubated twice. So intubated, extubated and re-intubated. And on post-operative day seven the patient says to the surgeon, I've had enough, I can't do this anymore. I'd like you to withdraw all life-supporting treatments. And we asked the surgeons, what would you do? Well, only 40% of surgeons said that they would honor the patient's choice to withdraw life-supporting treatments at that time. And if you look here at this slide their reasons for doing this were difficult to pin down. Many of them were optimistic or felt that the patient didn't understand the future quality of life she would be able to have. But all of them, whether they chose to honor the patient's preferences to withdraw life-supporting treatment or decided to delay or refuse to honor this request said that the reason for doing so depended entirely on their preoperative conversation with the patient or the family. And you can see 97% of surgeons who withdrew said this was dependent on their preoperative conversation and 94% who favored not withdrawing also said that this was dependent on their preoperative conversation. So this left us with a question about, well, what's happening in these preoperative conversations? How do surgeons get buy-in? And then we proceeded with our current study. And the objective of this current study was to assess whether surgeons ask patients to buy-in to postoperative life-supporting treatments in the preoperative setting. And to do this, we did another qualitative study. And this time we did a multi-site study in Toronto, Boston, and Madison, Wisconsin. We had three surgeons at each site, surgeons who we knew regularly treated patients who would require postoperative intensive care, like cardiac surgeons, thoracic surgeons, vascular surgeons, neurosurgeons, and surgical oncologists. We also purposely sampled surgeons who were reported by peers to be good communicators, thinking that if anybody was gonna ask patients to buy-in, it was the surgeons who were good communicators. They would talk to the patients before surgery about what they were doing. We recorded between three to seven conversations per surgeon, and our coders had extensive experience with postoperative ICU patients, including a postoperative critical care nurse and a medicine resident who is going into critical care. And we used inductive content analysis. So what do surgeons say to patients prior to high-risk operations? Oh, sorry, this is the patient cohort that we ended up with. We had a very nice mattering of ages and a fairly good diversity of education level, likely socioeconomic status as well. So what do surgeons say? Well, they say it's big surgery. Say it's a reality. This is what they say to patients. It is a reality when you have big surgery. This is inherently dangerous business, and my job is to make it turn out right. That's what we do, but it's still dangerous to go through it just so you understand that. And we found this again and again as surgeons were talking to patients before very high-risk operations, that they would explicitly talk about how dangerous the operation is and use the words big surgery. And if they didn't use the words big surgery, they used analogs of the world, of the word, saying things like it's not small surgery, it's not day surgery, it's a really big deal, or this is heart surgery. You can see as we went through our transcripts, we tried to sort of peel out the meaning of what big surgery was. So one thing that they were saying when they were talking about big surgery was that the surgery hurts, that it would be uncomfortable or it would be difficult for the patients to go through. Big surgery also meant that surgery had risk. Now as one heart surgeon say, what can go wrong? Well, lots can go wrong. This is heart surgery. Or that the operation was technically difficult. And as the surgeon says, well, we have to make an abdominal incision, that we're making incisions in each groin, and then we clean those arteries out. And sometimes we have to bring the graft down and actually go into the groin and do a bypass. It's a pretty big operation to go through. And finally, the other meaning we saw was that the patient may experience a profound change in their quality of life after surgery. One surgeon said that's just forgetting about the whole patient, who's maybe older and their lifestyle, what they're capable of doing, what the dangers are, the time to recover from surgery, like it's a big, big decision. Surgeons also discussed informed consent, but this was actually in a separate part of the conversation. It was more towards the end of the conversation after deliberation about surgery had occurred. And this is fairly typical of how informed consent went down. The big risk that we worry about surgery, it may sound terrible, you know, heart attacks, stroke, bleeding, infection, death, kidney trouble. Risks were typically listed and the complications were named, but not described. Surgeons also talked about the routine use of post-operative life-supporting treatments, but they talked about them in a very regular routine way. As one surgeon said, you're in the ICU for a day or two afterwards, usually a couple of days. Many times we let you stay on the ventilator overnight so we can wake you up gradually and it's not too stressful. Then that evening or the next morning we take the breathing tube out of your throat. So they were preparing patients for a routine post-operative course, but did not mention what would happen if it was a complicated post-operative course or if the patient required prolonged, aggressive life-supporting treatments. So did surgeons ask patients to buy in? Well, my answer to that is sort of. In one case, we did say a surgeon explicitly asking a patient to buy in and what he said was, if we decide we're going to be there, then you and I have sort of a verbal contract and we're going to do everything that we can to have the outcome that we want. So if we're going to go forward with that, then we have an understanding that everybody is going to do their utmost and this was the most explicit buy-in that we saw. We saw a few examples of implicit buy-in where the surgeon said, if you need to be here longer, you're here longer or sometimes it's a war and you have to fight the battles to win the war so you have to be prepared for that on some levels. But most of what we saw was an assumed buy-in that the patient agreed to move forward and that this was part of their understanding that risks could occur and that surgery was a package deal and this sounds a little flippant but in fact what this surgeon is saying is a little bit more complicated than the quote here. So she says, this is a form that basically says we've gone over the risks and that you agree to go forward. It's not a contract by any means. You can always just not show up but what she really means is that once you've shown up, then you're committed. So what did the patient say? Well in fact, you might imagine probably this is maybe a surprise more so to me, the surgeon than to many of you but most of these conversations, in fact all of these conversations were dominated by the surgeon. 75% of the time the surgeon was talking and only about 25% of the time was the patient talking. There was some variability in there but really these were very much surgeon dominated conversations. So how did the patients react? This is pretty typical of what we saw. This is a wonderful neurosurgeon who is fantastic with his patients and says very clearly this is an area for vision smell, function of legs and bladder. You could even have a stroke or damage to the vision. You could have an infection or trouble with healing and then he says in a perfect way, what questions do you have for me? And the patient comes in and says, well, washing my hair. And the doctor very politely responds to her question and explains her how to use the baby shampoo and he says don't scrub the stitches and the family pipes in with are you gonna use stitches or staples? And so here you have a pretty classic description of what we saw, a very intense conversation about the burdens of treatment, the potential complications and the response of the patient or the family coming in with logistic or technical concerns and very limited discussion about what would we do if something went wrong. So did we see patient buy-in? And again, a little is what I might conclude here. So these are the levels of patient buy-in that we saw. We saw some explicit acknowledgement that the surgeon could do whatever is necessary around the time of the surgery. You do what you have to do, I have complete faith in you or you're the boss. We did see some general recognition that death or other complications would be somehow tolerated. It's God's will, I've led a good life or something about your lifestyle changes and you adjust to it. But mostly what we saw was a willingness to proceed with surgery and acknowledgement that risks this. As one patient says, there's a risk to everything. So what can we conclude from this data? So surgeons certainly explain the risks of the procedure, their commitment to patient survival and the seriousness of the patient's decision to proceed. And I can understand how these efforts may confer a sense that the patient has agreed to participate in all postoperative life supporting treatments. However, we had limited evidence that the patient had truly bought in to the use of aggressive interventions beyond surgery itself. And as such, I don't think we can use whatever we think is being said in these preoperative conversations to make postoperative determinations about life supporting treatments. In qualitative research, often what we're looking for since we can't get generalizability is resonance. And after we sort of pulled our issues of big surgery together, one of my research colleagues was listening to Mike and Mike on the radio. It's a ESPN sports show. And what we heard was about RG3, who was the quarterback for the Washington Redskins. And RG3 had a terrible devastating knee injury at the end of last year. And they got a surgeon on to talk to Mike and Mike about his surgery. And the surgeon says, you don't understand. This is a major ordeal. This is redo surgery in a top flight athlete and he may never be the same again. But really, the surgical consult that they got on Mike and Mike was talking about big surgery. So I do think that this issue of big surgery does resonate with surgeons. How well it resonates with patients, I'm not so sure. And that's our for our future study. I wanna just acknowledge a few people from McLean Center who are in my research team. One is Caleb Alexander, who has been a phenomenal mentor to me and without whom I could not have gotten to this point. And the second person is Martin McNeely, who obviously supplied all of the patients in Toronto and has been a really fantastic research collaborator. So thank you very much for letting me present. Thank you. Great paper. I'm wondering if you're being explicit enough for you and your surgical colleagues. The first time I ever saw the buy-in situation was in 1973. I took a patient out to the Hutch in Seattle, Washington for a bone marrow transplant. And the Hutch was the only place in the world in 1973 under Don Thomas doing bone marrow transplants. And they simply made a deal with the patient at the outset that they would ignore what the patient said for the first 45 days. If the patient wanted a bone marrow transplant and the only place in the world that was doing them. I mean that, it wasn't a signed contract but it was that sort of agreement that we're gonna go all out and you may not be in the situation to make good decisions for yourself. But that was an explicit question and answer. I'm wondering if you're beating around the bush with some of these big surgery and so on. Yeah, I mean so I think the question is are the surgeons beating around the bush? And my answer is yeah, I think that they are to some degree and people when I present this ask me to sort of say well what should we be saying? And right now I really think I can just be descriptive and not particularly proscriptive. I do think that patients are often very afraid before surgery and sort of throwing down their throat what it would be like if a major complication occurred would be difficult. I think the other piece of it is we are actually interviewing patients now before their big operations and interviewing them after surgery. And so we don't have enough data to say what needs to be said or what could be said or what their decisional needs are before surgery. So it's still sort of up in the air about what patients need. I think it's really important for surgeons to understand that even though they think they've had this conversation, they probably haven't. And that's sort of where I am right now. Karen. Hi, Karen Devon, University of Toronto. I'm a surgeon there. Great research. I'm wondering if perhaps it might inform a case that someone called me about a week ago. This is a hepatobiliary surgeon who has a 60-year-old healthy patient who has a resectable pancreatic adenocarcinoma. The patient does not wish to know their diagnosis and wants the family to make all the decisions about having a Whipple procedure or high-risk surgery. And the surgeon called me saying, you know, I know she's sort of deferring. She's using her autonomy to defer the decision, but I just feel so uncomfortable that I can't do this. So I'm just wondering what you think about that. Yeah, I mean, I feel like I've heard this case in multiple iterations before, and I think Lainey actually does a good job with this sort of deferring decisions to family members. And I think for some people, that actually is a very reasonable thing to do. I think surgeons actually are very much face-to-face with this idea of how afraid people are before their operation. And I can understand why your surgeon is so frustrated and scared about this because he feels like, if I go and do this big operation on this patient, how are they, and they're not ready for it or they don't get it, then it's not gonna go particularly well for that patient. And I don't have the perfect answer for you, but I do think I can certainly understand why the surgeon is upset about that. That was a great talk, Retchen. I have one question. And when I saw your slide regarding the implicit surgeon buy-in, the comments included the analogy of to war. And I'd like to think that there may be some gender bias in terms of what's discussed with patients. I'd like to think that with more and more women going into surgery, we're getting away from the war analogies with battles and action heroes being the surgeons. Was there a difference in terms of men versus women's surgeons? Yeah, so I mean, it's a great question. You know, we did this large national survey of vascular surgeons, cardiothoracic surgeons, and neurosurgeons, three groups. And 95% of our respondents were male. And so while I think that maybe things will change over time, buy-in large surgeons who do very high-risk procedures are still male. We see a lot of war metaphors, a lot. Retchen, that was great. The hardest cases I've been involved in, and of course I always harp on this topic, I know, but I've been at cases where the patient consented to surgery and then had a serious complication and wound up intubated and on the ventilator. And it was actually the family who asked to withdraw. And I wonder about the challenge of the fact that the family may or may not be there for the pre-op consent process and yet later maybe horrified at the course of treatment or want to stop before the surgeon does. Yeah, I mean, I think that's a great question. I would say, Lexi, at least in our group, we had a lot of family members present. I would say at least in two thirds, maybe a little bit more than that. And we've even had them present for our preoperative interviews. So fortunately, at least in the elective setting, I don't know how elective you can call this, but at least in the outpatient clinical setting, it does, for these patients, it does seem that they often come with a family member. And so the family member is actually not necessarily participating in this discussion, but certainly has heard it. It's a great question. Thanks, Gretchen. That was great. Thanks.