Best Case/Worst Case Framework Helps Surgeons Communicate With Frail Seriously Ill Patients Interview with:

Margaret L Schwarze, MD, MPP Associate Professor Division of Vascular Surgery University of Wisconsin

Dr. Margaret Schwarze

Margaret L Schwarze, MD, MPP
Associate Professor
Division of Vascular Surgery
University of Wisconsin What is the background for this study?

Response: Surgery can have life-altering consequences for frail older adults, yet many undergo an operation during the last year of life. Surgeons commonly rely on informed consent to disclose risks of discrete complications; however, this information is challenging for patients to interpret with respect to their goals and values.

Our research group developed a communication framework, called Best Case/Worst Case, to change how surgeons communicate with patients facing serious illness.  Surgeons use the framework to describe the best, worst, and most likely scenarios to present a choice between valid treatment alternatives and help patients imagine how they might experience a range of possible treatment outcomes. What are the main findings?

Response: We conducted a pre-post study to evaluate the proof of concept of an intervention to teach surgeons to use the Best Case/Worst Case framework. We audio recorded decision-making conversations between surgeons and frail, older adults with an acute surgical problem and analyzed the data using a mixed methods approach.

We found that after training, shared decision making improved on an objective measure.

Furthermore, these conversations improved such that after training surgeons focused on presenting a choice between treatments, described how a patient might experience treatment outcomes and engaged patients and families in deliberation. What should readers take away from your report?

Response: Using Best Case/Worst Case changed how surgeons discussed difficult treatment decisions with older adults, shifting the focus from an isolated surgical problem to a conversation about treatment options and outcomes. Surgeons can use Best Case/Worst Case to engage patients and families in high-stakes decisions. What recommendations do you have for future research as a result of this study?

Response: Future research should focus on determining a measurable health outcome to assess the clinical impact of this intervention beyond shared decision making. We are currently adapting the Best Case/Worst Case framework to help nephrologists talk to older patients about the decision to start dialysis and testing implementation of a group training program with surgical residents at institutions across the country.  We have also developed an instructional video to introduce the Best Case/Worst Case framework ( Is there anything else you would like to add?

Response: No disclosures, this was funded by the NIA – the GEMSSTAR program and the AGS and SVS, they had no role in the study. Also, the Cambia Foundation. Thank you for your contribution to the community.


Taylor LJ, Nabozny MJ, Steffens NM, Tucholka JL, Brasel KJ, Johnson SK, Zelenski A, Rathouz PJ, Zhao Q, Kwekkeboom KL, Campbell TC, Schwarze ML. A Framework to Improve Surgeon Communication in High-Stakes Surgical DecisionsBest Case/Worst Case. JAMA Surg. Published online February 01, 2017. doi:10.1001/jamasurg.2016.5674

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on February 1, 2017 by Marie Benz MD FAAD