A friend who worked as an oncology social worker for many years told me of a paediatric oncologist who was working with a young cancer patient. The oncologist accidentally gave her a very large (and potentially fatal) dose of chemotherapy. The young girl survived this medical error. My first thought was that the girl’s parents would immediately go to an solicitor. However, that was not the case.
The oncologist spoke to the girl’s parents and explained what had happened. She said she felt terrible and simply said, “I’m sorry.” She also said, “Based on what happened, I think it would be best if your daughter worked with another oncologist.” The parents replied, “We don’t want another oncologist. You have been so wonderful to our daughter. You were there holding her hand when she was ill from the various treatments. We want you to continue treating our daughter – we won’t have it any other way!” By the way, they also told the oncologist they had no plans to take legal action.
Why did the parents have no intention of pursuing litigation? One simple reason – they liked the oncologist. In general, people don’t sue people they like. Generally, people who have great communication skills are well-liked.
A June 1997 issue of the Journal of the American Medical Association (JAMA) included an enlightening article called, “Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons.” The primary objective was to identify specific communication behaviours associated with malpractice history in primary care clinicians and surgeons. The research compared the communication behaviours of “claims” vs “no-claims” clinicians using audiotapes of ten routine office visits per clinician. The study consisted of 59 primary care clinicians (general internists and family practitioners) and 65 general and orthopaedic surgeons and their patients. The clinicians were classified into ‘no-claims’ or ‘claims’. There were significant differences in communication behaviours of the no-claims and claims clinicians in the primary care clinicians’ group (but no differences in the surgeon group). The behaviours exhibited by the no-claims primary care clinicians included:
Length of primary care office visit - The study showed a strong correlation between extra time spent with patients and lower frequency of malpractice claims. Since patients dislike feeling rushed or ignored, clinicians who are “too busy” to sit down, listen attentively, and respond to a patient’s questions may set the stage for problems further down the road.
Engaging in a dialogue - Clinicians should encourage patient-centred two-way communication, which includes:
- using orientation statements, which educate patients about what to expect and the flow of a visit. This includes statements such as, “First, we’ll talk about your stomach pain, then I will examine you, and then we will talk about ways to treat the problem.”
- applying facilitation techniques to obtain patients’ opinions, check for understanding and encourage patients to talk. These include questions such as, “what ideas have you had about the pain yourself?” or “what have you put it down to?”
- using applications of humour, laughter, and encouraging statements, such as “I’m happy to hear you are feeling better.” Use of humour and laughter expresses warmth, friendliness, and empathy, and helps to build a bond between clinician and patient.
- inquiring into psychosocial and lifestyle issues, and remembering previous facts the patient has stated, such as, “You said you went on an anniversary cruise last month, how was it?”
- providing relevant information that answers the patient’s particular concerns or questions, rather than giving a ‘generic, one-size fits-all’ explanation. This will usually help to increase retention of information, and also follow-through on actions such as taking the prescribed medication. This also includes providing written information, validated website content, educational literature, and suggesting organisations to contact. Imparting information and advice in a manner that demonstrates the clinician’s genuine care tends to defuse patient anger and resentment.
Clinicians who have been sued for malpractice often cite “unrealistic expectations” on the part of their patients during a medical visit. Encouraging two-way communication helps the patient develop appropriate expectations about a medical visit and prompts the sharing of critical information. Doctors need to explicitly uncover patient expectations early on in a consultation, rather than assume they know what the patient is hoping for. This can be done by checking “is there anything particular you are hoping for from this appointment today?” or “Is there anything specific you are expecting to happen today, relating to this problem, so that I’m clear what you’re hoping for?”
Many doctors don’t uncover expectations or address unrealistic ones appropriately – setting the patient up for disappointment. If the need arises, it’s important to disappoint safely by letting them know that what they’re hoping for isn’t possible, empathising with their disappointment, explaining clearly the reasons behind this and proposing alternative solutions/options where possible.
Breakdown in communication between clinicians and patients fuels distrust and pent-up anger. No one wants to feel that their concerns are ignored, nor that their problems have been minimised or disregarded. Factor in a bad outcome to the scenario, and we are setting the stage for a lawsuit. On the other hand, effective communication skills tend to enhance patient satisfaction.
The study identifies specific and teachable communication behaviours associated with fewer malpractice claims for primary care clinicians. Clinicians can use these findings to improve communication and decrease malpractice risk.
Seeing the person in the patient
This section is an extract from The Point of Care Foundation’s, ‘Seeing the Person in the Patient: The Point of Care’ 2008 report by Joanna Goodrich and Jocelyn Cornwell. It is reproduced here with permission.
The Point of Care Foundation is an independent charity with a mission to humanise healthcare, developed from the Point of Care programme at The King’s Fund, which ended in 2013. Its report, Seeing the Person in the Patient, published in December 2008, makes the case for treating patients with more compassion and kindness, and offers some advice about how this might be achieved. The following text is extracted from the report:
All the patients and relatives we interviewed talked about the importance of the patient being “seen as a person”. One woman, for example, had nothing but praise for the care she had received during her 24-hour stay in hospital, even though her well-documented need for a special diet had initially been entirely overlooked. In the course of her planned admission for surgery, the ward staff had been unable to offer her anything to eat in the evening. Nevertheless, her assessment after the event was that she had been exceptionally well looked after because staff had handled her so sensitively. The morning after the non-existent supper, the charge nurse had apologised directly, contacted the kitchen, and someone from the kitchen gave her a breakfast she could eat and an apology. “I felt,” she said, “that they took account of who I am and my needs.”
The opposite was also true. The failure to ‘see the person in the patient’ was very deeply felt. This was an ex-nurse, talking about the care of her 87-year-old mother on her admission to hospital following a fall:
“Significantly, the ambulance crew were the only people in the entire seven weeks who formally introduced themselves and asked what she would like to be called. Thereafter, for the first six weeks of her admission, she was called Elizabeth, which is her first name, which she has never been called in her life, ever. She’s only ever been called by her middle name. But the NHS IT system records your name. All her labels were wrong. In spite of the fact that on a daily basis all of us told the people caring for her that her name is Margaret, and that is what she likes to be called if they want to call her by her first name, all of them called her Elizabeth. And that became very significant when she became confused.”
By Surinder Singh, GP and clinical lecturer, UCL
Naming systems vary between minority groups and some are complex. A few basic principles may be useful:
It is more important to treat people with courtesy and address them properly than to try and learn all the different naming systems. Ask people how they would like to be addressed, how to pronounce their name and how to spell it.
Ask for full name: first, middle and last. Do not ask for “Christian” name or “surname”. Do not record or address a male Muslim or Sikh by his religious name only – Mohammed, Ullah or Singh, for example. Check in case these are last names.
In Britain, it is common for many Muslims to have a personal name followed by a family name. Do not record or address a female Muslim or Sikh by her religious name only – Begum, Bibi or Kaur, for example.
If in doubt, ask. A polite and well-intentioned enquiry about how to pronounce a name or about a particular religious belief or a language requirement will not be offensive when prompted by a genuine desire to get it right.