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Managing the gap: Patient expectations and reality

Dr Nancy Boodhoo, MPS head of operations (Caribbean and Bermuda), advises on how to manage the gap between patient expectations and reality

19 May 2015

In a hectic clinical environment, patient loads are continually increasing and doctors can see many patients in a week. While focusing on trying to see and treat them all, one is also trying to meet many expectations – those of our patients and colleagues, as well as those utside work, including family and friends. But when we have too many demands placed upon us, it can lead to gaps between meeting expectations and what is actually possible in reality. Unfortunately, and as most of us would have found out the hard way, this can cause patient resentments if and when expectations are not met.

The gap can be closed by taking the time to focus on the basics of expectation management – a process that begins and ends with good communication. Poor communication can be found in 70% of clinical negligence claims, and international research shows doctors have the potential to reduce the risk of litigation by improving their communication skills and better managing patient expectations.

The following tips reinforce how important good communication is before, during and after treatment:

Build good relationships with your patients

While it’s tempting to spend more time with ‘happy’ patients, it is in your best interests to make an effort to build a good rapport with patients who seem unhappy or nervous. These are the patients who are more likely to make a complaint about you if something goes wrong down the track. Greeting your patients warmly and treating them courteously and with empathy will help you form a positive connection. It will also encourage them to talk openly about any issues they have been experiencing with regards to their condition.

Employ two-way communication

Shared decision-making is where doctors and patients make decisions together, and is a widely regarded approach for patient communication. Patients are encouraged to engage with the healthcare process and consider the options to treat or manage their condition (and the likely benefits and harms of each) so that they can help select the best course of action.1 Most patients will have an idea about what is wrong with them and what treatment they anticipate you will provide. It is recommended that you seek to understand what the patient already knows, what is important to them and what their expectations of treatment are.

Only then should you add your own views, based on their clinical assessment, as well as such information as is necessary to add to – or correct – the patient’s existing knowledge. The next step is to discuss diagnosis and treatment options and address the patient’s expectations – even if this means explaining gently why they cannot be met. This is a very important step in preparing the patient for what is to come and could mean the difference between a happy patient and an unhappy patient after treatment.

An excellent example is laparoscopic surgery. Patients often have high expectations and work on the assumption that a brief hospital stay and small scar implies that it is complication free. The benefits and risks of all various options available should be discussed, including the option and possible consequences of no treatment.
Assume the patient has no background knowledge whatsoever about their options and think about what you would want to know about the procedure if you were in their position. Certain information should also be shared including possible sideeffects, complications and any considerations relating to their individual past medical and present social and occupational history.

Good medical practice requires you to check that the information you provide has been understood by the patient. This is especially pertinent in the Caribbean, where there are a number of official languages. The use of an interpreter should be considered where a language barrier exists.
As the discussion proceeds, the range of options will narrow as the patient or the doctor express a reluctance to proceed with some. This will usually lead to one, preferred and mutually agreed decision. Any recommendation made should take into account the preferences, values and expectations of the patient. If agreement cannot be reached, then it may be time to get a second opinion or otherwise stop the process.2

Be proactive when things go wrong

When we hear the words: “I wanted…, but…,” it can be easy to feel stressed or overwhelmed and act in a defensive manner. If you do find yourself being questioned after a clinical adverse event, mistake, delay, system error or provision of incorrect care, there are certain things you can do to improve the patient’s level of satisfaction, minimise the damage to the doctor–patient relationship and reduce the risk of litigation.
The first step is to listen to your patient and understand why they are upset – they want to have their story heard and their distress acknowledged. Pay particular attention to non-verbal signs of feelings and emotions and attend to their comfort. This will go a long way in beginning to repair the emotional damage that has been caused.

Next, it is important to demonstrate an expression of regret or sorrow. You could use an apology of sympathy (for example, “I’m sorry this happened to you”) or an apology of responsibility (such as “I’m sorry I/we did this to you”). In some cases, an apology is all that unhappy patients seek from their doctor.

An open and truthful discussion should follow, including a factual explanation of what happened and any anticipated consequences so the patient is prepared for what to expect going forward. If required, propose a management plan for ongoing care. If you can’t provide this, explain how the patient can obtain further help and assist with these arrangements by providing contacts and resources.

Finally, offer some comments on what has been learnt from the incident as well as information on how recurrences will be prevented in the future. If the patient is still unhappy and you suspect they will make a complaint, contact MPS as soon as possible. A medicolegal adviser will be able to provide you with advice specific to your individual situation.

While these recommendations may seem basic, the current litigation environment is a reminder that good communication and expectation management are now more important than ever. They are some of the most important risk management tools a doctor can employ.


  1. Elwyn G, Laitner S, Coulter A, Walker E, Watson P, Thomson R. Implementing shared decision making in the NHS, BMJ; 341c5146 (2010)
  2. Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley , Cording E, Tomson D, Dodd C, Rollnick S, Edwards A, Barry M. Shared decision making: A model for clinical practice, J Gen Intern Med 27(10): 1361-7 (2012)
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