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 limits of the resources available. 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 and be cognisant of the fact 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 for most doctors, comprehensive training in recognising the key elements of, and designing effective strategies to work with, patient disappointment has been absent or rudimentary. In this most challenging area, many doctors report that their only form of teaching or training was ad hoc observation of a senior colleague whom they either copied or vowed never to copy!
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 and promulgating the key expectations they have of a doctor’s response following a serious patient adverse outcome. In New Zealand, the Health and Disability Commissioner and the Medical Council of New Zealand have released public documents outlining these expectations.1, 2
These rising expectations have been a major contributor to the development of movements calling for greater transparency and more effective communication after an adverse outcome – often called “open disclosure” or “open communication”. Providing the highest quality of care is an ethical duty that does not decrease because a patient is disappointed, angry or upset. Doctors intuitively know their ethical duty is to respond effectively to an adverse outcome, as doing so:
- Helps patients to recover psychologically
- Ensures patients are fully informed when making decisions about future care
- Provides opportunities for self-reflection and analysis, so that lessons can be learnt and practice improved, if required.
Research undertaken into patient expectations following an adverse outcome clearly shows that patients wish to be told the truth, to have their experience acknowledged by their doctor, have their questions answered, and to negotiate an agreed plan for ongoing care and follow-up. In addition, patients often expect an expression of regret or sorrow and information on how similar outcomes could be prevented in the future, if possible.3
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 able to communicate important messages effectively to the patient and family. A doctor may also be grappling with acknowledging that they have made an error or mistake – something that is never easy to do. So, while patients’ needs are easy to define, doctors may find responding effectively difficult, given these feelings and concerns.
Important research into the motivating factors as to why patients commence action against a doctor following an adverse outcome is now widely available, and identifies communication failure as one of the most important precipitating factors leading to a patient making a complaint or claim against a doctor.4
A common concern expressed by doctors about discussing an adverse outcome with a patient, particularly where an expression of regret is considered, is that harm may be done to their chances of successfully defending an action taken against them by a patient, or that MPS may take a negative view of undertaking such a conversation. It is important that this widespread misconception is challenged. In the MPS member handbook, the following advice appears: “In our experience many complaints arise from poor communication. Once you have established the facts we advocate a policy of full and open communication. An explanation may be all that is needed to reassure a patient and avoid any escalation.
“A wall of silence after an adverse incident can provoke formal complaints and legal action. If it is clear that something has gone wrong, an apology is called for and it should be forthcoming. Contrary to popular belief, apologies tend to prevent formal complaints rather than the reverse. We can advise you on how to handle such a situation if you are concerned.” The ethical undertaking of an effective conversation with a patient after a serious adverse outcome is fully supported by MPS. It is, however, essential 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.
Doctors should also confine any discussion to care provided by themselves alone and should not seek to represent the actions of another clinician or institution, without their prior knowledge or consent.
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 New Zealand, MPS Educational Services will soon be offering the Mastering Adverse Outcomes workshop to address this need. This interactive three-hour workshop is a comprehensive examination of the issues that arrive in undertaking an effective discussion with patients after an adverse outcome and includes:
- An examination of the latest research findings
- An exposition of important regulatory and legal issues in New Zealand that doctors should be aware of in undertaking such discussions
- An exploration of the key expectations that patients have following an adverse outcome
- A discussion of the emotional and psychological impacts of an adverse outcome on a doctor
- Comprehensive and easy instructions on the key communication tasks and skills required.
Any member is able to contact MPS to seek specific advice on the management of a patient adverse outcome, particularly if they are uncertain as to the correct way in which to respond. MPS encourages members to make such contact.
References
1. Paterson R (Health and Disability Commissioner), Guidance on Open Disclosure Policies (March 2007).
2. Medical Council of New Zealand, Good Medical Practice (December 2004).
3. Vincent C, Young M et al, Why do People Sue Doctors? A Study of Patients and Relatives Taking Legal Action, The Lancet 343: 1609-13 (1994).
4. Beckman HB, Markakis KM et al, The Doctor–Patient Relationship and Malpractice: Lessons from Plaintiff Depositions, Arch Int Med (1994).