There are many factors which contribute to the risk of complaints and claims – both before and after the event – and Medical Protection will publish several articles about how Healthcare Professionals can minimise this risk.
Managing patient expectations is vital to minimise the risk of patient disappointment; disappointment which can in turn lead to complaints and claims. Following on from a recent webinar on the subject, Dr Zarina Sonday, Medicolegal Consultant, outlines some key advice.
We are all unique, each with our own personality, insights and perspectives. As healthcare professionals we get to see and experience these differences in action daily; patients with similar symptoms but vastly different pathologies or similar pathologies but varied presentations and everything in between.
A review of cases here at Medical Protection has made clear that expectations of outcomes between patients and practitioners are sometimes not aligned. As clinicians we tend to measure successful care in terms of clinical outcomes and thus our expectations often tend to begin and end here. However, patients tend to have expectations that go beyond the outcomes of the clinical care such as waiting time, duration of consultation or even interactions with your staff. There is an important distinction here between standard of care – which we as clinicians strive for – and perceived quality of care – which patients likely judge us on. Patients have perceptions about the care provided, for example they might think something went wrong when in fact it did not, or that you didn’t show enough care or concern. Importantly, perceptions and the emotional impact thereof can drive patient expectations. As such, it becomes increasingly important for doctors to understand some of the factors that shape patient expectations to enable better expectation management from the outset.
Patient expectations are shaped by some of the following factors:
Just think of all the information available online. I am almost certain you have encountered patients who volunteer that they have Googled their symptoms. No wonder patients arrive at the rooms with preconceived notions of the examination, special investigations, diagnosis and even treatment. It’s important to also think about our social connections and how that allows patients to make comparisons. Peter thinks his back pain is the same as Paul’s and Polly’s, both Paul and Polly had surgery. Naturally Peter expects that he should get the same treatment as the others and so Peter arrives at your rooms with a clear and perhaps unrealistic expectation.
When patients have insufficient and/or inappropriate information about what to expect they could have unrealistic expectations related to all aspects of both clinical and non-clinical care. This ranges from waiting times and billing to diagnosis and medication.
Along with having ease of access to information is the risk of misinformation and information that contradicts best practice. Patients also have access to many different doctors. They can ‘doctor-shop’, hoping to find what they think they want or need to hear. A huge drawback of varying clinical opinions and at times inconsistent advice, in a patient without a proper understanding of medicine, is that this results in patient uncertainty. An uncertain patient is more likely to consider that one or more of their doctors are wrong or have erred. This is an incredibly difficult position for a doctor, there really is no way of knowing what the patients expect as they are unsure themselves.
It is common knowledge that anxious patients are less likely to hear even when they appear to be listening. Inevitably this will result in some misunderstanding of the information communicated and thus contributes to misalignment in expectations between doctors and patients.
Patients are incredibly sensitive to feeling pressured by their practitioner, whether it’s hurrying them along to your room from the waiting area or cutting them off while describing their complaints. Often, what may seem like a rather simple diagnosis to you may have caused the patient significant emotional distress. More than the diagnosis or the medication, the patient needs the opportunity to be heard and to feel heard by you. Have you given them sufficient opportunity to fully explain their concerns, do they understand all aspects of their care or the complexity of their situation? At Medical Protection, we remain acutely aware of how busy South African doctors are and how many competing pressures they face. However, we cannot discount the number of complaints we have seen arise when complex cases present to a practice with a packed waiting room and staff under pressure.
Understanding patient expectations is essential for better expectation management. This not only maximizes patient satisfaction but can also help you minimize risk to yourself and your practice. When you lack insight and understanding of your patients expectations and you fail to manage them appropriately, patients tend to have inflated, perhaps even unrealistic expectations quite far removed from the more realistic clinical outcomes you are able to provide. A useful way to think about this in terms of risk management is to consider the following equation:
The larger more grandiose these (unmanaged) expectations, divided by a more modest realistic outcome ends up in a huge amount of disappointment. Conversely, the more managed and realistic the expectation over the actual outcomes you can provide, the less disappointment patients experience. A disappointed patient inevitably impairs the trust on which a doctor-patient relationship is built and on a more practical level this translates into complaints (to you, your practice or the HPCSA), and more commonly these days negative reviews on social media platforms.
Practical Steps for managing expectations
There are several practical measures that can be taken in order to maximize patient satisfaction and to minimize the risk to yourself and your practice.
Start to think of information provision as a continuum: before, during and after consultation, rather than a one off event. Given time and resource constraints, consider alternative sources of information: information leaflets, reliable sources of information online, or providing access to an onsite nurse – if available – to answer questions. Clear and consistent information should be provided by all staff at the practice, particularly with regard to waiting times, billing practices, follow-ups and repeat scripts. Make sure that information around your practice hours, appointment scheduling and call back times is readily available on posters in your practice, on pamphlets and on your website and social media channels if applicable.
Each patient is different, each with their own needs and level of understanding. This is not a one size fits all scenario. Only you know your patient, so you must decide how to frame your explanation of their condition. Try your best to avoid medical jargon, abbreviations or terminology that can lead to misunderstanding. If you have concerns about the patient having a lack of understanding and insight, consider involving a family member in the discussions – you must get the patient’s consent to do this.
Before the patient leaves your rooms, check their understanding. Make sure you have given them an opportunity to ask questions and voice concerns – this is an important part of feeling seen and heard. As mentioned earlier, provide resources they can take home or engage with in their own time. A consultation can feel overwhelming for many, in allowing them time and space to process information they are less likely to call the practice or book another consultation with minor queries.
The importance of trust in a doctor-patient relationship cannot be overstated. Having a good rapport and ensuring the patients feel seen, heard and understood can only build and reinforce trust in this professional relationship. Remember empathy in action is compassion.
You must be open to feedback. Encourage your patients to provide feedback that will be received in a non-confrontational manner. Having open constructive conversations with patients around concerns they may raise can often be the significant step in avoiding escalation to a formal complaint, it provides you with a window of opportunity to address issues early and effectively. If you receive feedback in a constructive manner, it may even lead to positive changes in your practice with long term benefit to both you and your patients.
Different perspectives between patients and doctors are inevitable. Understanding the relationship between expectations, outcomes and potential disappointment highlights the importance of early expectation management. Hopefully this article will help you anticipate their concerns and therefore better manage their expectations and continue to build trust.