Friday, November 21, 2014
Objectivity in Communication
By Jane Mock, Risk Management Specialist NORCAL Group
There is no doubt that physicians have a lot on their plates. Regular challenges include providing quality care to each patient within a fully booked schedule; keeping up with medical record documentation; learning new systems; maintaining current awareness of regulations and laws; and navigating reimbursement issues. In addition, physicians spend a great deal of time educating patients and managing expectations for treatment, yet they still encounter the non-compliant, demanding or dissatisfied patient.
These circumstances can create a charged environment. Add into the mix a disagreement with a colleague, an unanticipated outcome in patient care, or a notice of a lawsuit, and the environment gets even hotter. Many providers have rushed to confess their shortcomings or criticize a colleague’s care (which can appear to be self-serving), only to learn later that the outcome was unrelated to the care given or, in the case of criticizing a colleague, that there were additional factors that influenced treatment choices. In the tense environment after an adverse outcome, providers may say things to patients or document opinions in the chart that are not objective and do not serve to promote patient care.
Sometimes a subsequent treating physician (knowingly or unknowingly) acts as a trigger for the filing of a lawsuit when he or she makes a remark to the patient that is critical of a prior physician’s care. In addition to a physician verbalizing his or her subjective opinion to the patient, similar comments expressed in the medical record do not meet the patient’s clinical needs. Some physicians have actually found themselves pulled into the litigation process when they make remarks to a patient about another provider’s care, only to learn that there is an active suit in progress. The following scenario shows how disparaging remarks can help a plaintiff’s case that is already underway.
A surgeon performed an angioplasty and stenting on a 55 year-old male patient who had suffered an acute myocardial infarction. One week later, the patient experienced a pulmonary embolism and a chest infection. He also developed an aortic aneurysm. He was then treated at a clinic over a two-week period. The physicians at the clinic were able to resolve the chest infection with a drain, but did not address the aortic aneurysm. Following the patient’s clinic stay, he returned to the surgeon, who performed a second procedure to address the aortic aneurysm. Because the patient had enjoyed a good rapport with the physicians at the clinic, he decided to see them for follow-up care. During one of these visits, his primary treating physician told him that he was “lucky to be alive” because the surgeon clearly did not perform the first procedure properly. The physician documented this conversation in the medical record. Unbeknownst to the physician, the patient and his family had recently filed a claim against the surgeon, alleging negligence resulting in his poor post-surgical course and need for additional surgery.
In addition to speaking negatively about another provider’s care and documenting those comments, this physician—who did not know that the patient was entering into litigation with the surgeon—was soon subpoenaed for deposition by the patient’s attorney.
A physician’s ability to respond appropriately to patient care situations involving other providers is crucial. Expressing oneself objectively in both written and oral communication is key to promoting continued patient care and, if applicable, defense of a malpractice claim.
Risk Management Recommendations
Communicating with the Patient
• Contact your professional liability carrier’s risk management department for assistance with communicating with patients.
• If the patient asks you to comment on the treatment or role of other healthcare providers, only comment on your own care and interaction with the patient.
• When conveying to the patient and family what is known about an unanticipated outcome, avoid speculation and blaming anyone.
• If a patient asks a specific question about an unanticipated outcome, and the cause is not yet known, an honest answer might be, “I don’t know” or “I don’t know yet.”
Communicating with a Colleague
• Access your clinical quality committee or medical director/medical staff leadership, as appropriate, for assistance with handling concerns regarding clinical patient care provided or with patient inquiries regarding a physician’s care provided.
• Review the patient’s record, previous studies, etc., to prepare for the discussion. The better prepared you are with the facts, the more likely you are to maintain a cool head; conversely, plunging into a conversation with little information and a lot of emotion pulls attention away from proper patient care and management of the event.
• Find a quiet place to have a discussion; this demonstrates respect for the work environment and also protects patient confidentiality.
• Discuss disagreements about care objectively; ask for clarification.
Documenting in the Medical Record
• Document in a timely fashion.
• Focus your chart documentation on your care of the patient.
• Document discrepancies using objective language.
• If addressing the contents of comparison reports, prepare a formal, written report for all studies that includes review of previous reports and, if indicated, comparison of previous images when possible. State if previous reports and images are not available and any attempts to obtain them.
• DO NOT:
o Blame or disparage other providers or the patient in the chart
o Offer personal (other than medical) opinions o Speculate on causes of poor outcomes
o Make observations, notes or entries unrelated to patient care
o Make derogatory statements or use language that blames another healthcare provider (e.g., “error,” “mistake in judgment”)
o Engage in professional disputes in the chart
o Include references to incident reports, legal actions, and attorney or risk management activities in the medical record (These should be maintained in a separate, confidential file.)
In the Event of a Claim or a Potential Claim
• Never alter the medical record in any way.
• If you are involved in an adverse or unanticipated outcome, contact your professional liability carrier’s claims department to report the medical incident. An experienced claims professional can guide you through the process of how to communicate with your carrier and defense attorney, as well as how to document appropriately.