Being honest and open

Providing care after an adverse outcome poses major challenges to any doctor. Mark O’Brien, of MPS’s Educational Services, offers some advice on how to proceed

One of the most difficult challenges a doctor faces in clinical practice is responding professionally and effectively to a patient who has suffered a serious adverse outcome under their care – whether it be  the result of a recognised complication of treatment, the unfolding consequences of serious underlying pathology or, most challengingly, an error.

How effectively a doctor does respond can be significantly influenced by their emotional reaction, their communications skills competence and the degree of specific training they have received in how to manage such situations.

Every day, doctors begin with the best of intentions to improve the quality of their patients’ lives within the resources available to do so. However, despite these best intentions, not all patients will do well. Recognised risks will occur, serious pathology will manifest and errors and mistakes will be made. As doctors, we need to acknowledge that no matter what our intentions or how hard we work, a small but important part of our professional practice will always reside in the “disappointment business”.

Yet most doctors lack comprehensive training in recognising the key elements of, and designing effective strategies to work with, patient disappointment. Patient and societal expectations of the standard of professional and ethical behaviour required of doctors when disappointment occurs have been climbing significantly. Professional regulatory authorities and healthcare systems across the world have been increasingly defining the key expectations they have of a doctor’s response following a serious patient adverse outcome. These rising expectations have been a major contributor to movements calling for greater transparency and more effective communication after an adverse outcome – often called “open disclosure” or “open communication”.

Patients often expect an expression of regret or sorrow and information on how similar outcomes could be prevented in the future if possible.¹ This is nothing less than we ourselves would expect if we suffered an adverse outcome while under the care of a healthcare professional. However, responding effectively can be easier said than done. Doctors have no difficulty in recalling the intensity of feelings and emotions they experienced when a patient suffered a serious adverse outcome under their care – especially where they believed an error or mistake on their part may have contributed. Doctors can have well-founded fears that patients may take some sort of action against them, that their reputation could be damaged and that they may not be adequately able to communicate important messages effectively to the patient and family.

Important research into the motivating factors as to why patients commence action against a doctor following an adverse outcome is now widely available. Communication failure is recognised as one of the most important precipitating factors leading to a patient making a complaint or claim against a doctor.²

A common concern expressed by doctors about discussing an adverse outcome with a patient, particularly where an expression of regret is considered, is that this may harm their chances of successfully defending an taken action against them by a patient, or that MPS may take a negative view of undertaking such a conversation. Full explanations and showing empathy to a patient after a serious adverse outcome is fully supported by MPS.

It is, however, important to highlight the importance of discussing facts – not speculation. Speculation should be avoided. Questions should be answered honestly, including an acknowledgement that a question cannot be answered with the current available information if this is the case. As mentioned earlier, very few doctors have received formal training in the most effective way to undertake the often difficult and emotionally-charged discussions that are required following a serious patient adverse outcome.

Fortunately for MPS members in Singapore, Hong Kong and Malaysia, MPS Educational Services will soon be offering the Mastering Adverse Outcomes workshop to address this need. Any member is able to contact  MPS to seek specific advice on the management of a patient adverse outcome, particularly if they are uncertain about the correct way in which to respond.

References

1. Vincent C, Young M et al, Why do People Sue Doctors? A Study of Patients and Relatives Taking Legal Action, Lancet 343:1609-13 (1994)

2. Beckman HB, Markakis KM et al, The Doctor–Patient Relationship and Malpractice: Lessons from Plaintiff Depositions, Arch Int Med. (1994)