Communication, caring are best ways to manage patient disappointments

March 18, 2013

To address a medical mistake or unsatisfactory outcome, Neil S. Prose, M.D., has a unique suggestion: “Imagine yourself on the opposite side of the table from the patient, with the problem in the middle. Then imagine what it would take to get on the same side of the table, working together.”


Durham, N.C. - To address a medical mistake or unsatisfactory outcome, Neil S. Prose, M.D., has a unique suggestion:

“Imagine yourself on the opposite side of the table from the patient, with the problem in the middle. Then imagine what it would take to get on the same side of the table, working together,” says Dr. Prose, director of pediatric dermatology at Duke University Medical Center, Durham, N.C. “I’ve come to realize, through difficult situations in my own practice and observing other doctors in action, that half the work we do as dermatologists is about communication.”

The vast majority of patient disappointments arise from situations in which no medical mistake occurred, Dr. Prose says. In other words, patient disappointment can stem from unrealistic expectations.

“In my clinic, the classic example would be if a parent says, ‘My child has eczema. When I use the cream, it gets better, but when I stop, it gets worse. And I stopped it for a week to show you how it really looks.’” Such complaints reflect upon physicians’ ability to explain, “We’re trying to control the disease, not cure it,” he says.

Other reasons for patient disappointment can include biologic variability between patients, Dr. Prose says. Additional causes can include incorrect judgments without negligence. As a tertiary referral center, says Dr. Prose, “We deal with children who come in with very difficult problems. Sometimes we just get the diagnosis wrong. It may be a few months later when we make the correct diagnosis. We make mistakes, but they’re mistakes that any honorable colleague would also make.”

Explanation not needed

“Imagine a situation in which you inadvertently prescribe an antibiotic to which the patient is allergic, and it was on a chart, but you failed to notice,” Dr. Prose says. Such a patient could develop urticaria and perhaps miss important social engagements.

Upon her return to the office, “Our intuitive way of approaching these conversations is to try to talk patients out of the way they’re feeling,” he says. When a patient seems unhappy, for whatever reason, “We’re all ‘explainaholics.’ We have a strange belief that if we give enough information, the person will feel better. This approach often goes awry.”

Instead, Dr. Prose recommends developing a partnership with patients from the beginning. It’s not sufficient to merely point to the fine print on a consent form, he explains. Rather, he says that dermatologists must describe risks and benefits of proposed treatments in clear, specific terms such as, “Your child has severe psoriasis. The medication I’d like to recommend is called methotrexate. It has some side effects, so I need to tell you about those. Then we need to decide together where to go from here.” The concept of deciding together creates a different mood and feeling between the doctor and patient, he says.

To confirm that the patient understands your recommendations, “You might want to ask the patient to repeat back what he or she heard,” Dr. Prose says. “This also helps in situations where I’m not sure about the patient’s health literacy, which can be a problem that we frequently gloss over.”

After a disappointment has occurred, “Notice how you feel about the situation before entering a room with the patient,” he says. “A tiny bit of self-awareness goes a long way. What do I tend to do in these situations? What do I know about myself?”

At one extreme, Dr. Prose says, some physicians become defensive, perhaps blaming the patient. “On the other side are doctors who eagerly fall on their own sword” and apologize for more than they need to.

Dr. Prose also recommends knowing what kind of patient pushes your buttons. “For me, it’s the entitled patient. For example, I walk into the exam room, and the dad is sitting in my chair, working on his BlackBerry, and says, ‘Hi Neil,’ though we’ve never met.” In such instances, “I have to consciously decide to not get ruffled.”

Communication savvy

When discussing the specific disappointment, “It starts with body language - sitting, making eye contact and being somewhere where you’re not going to be interrupted,” Dr. Prose says. “Studies show that when the doctor sits down, the patient perceives that the doctor spent more time than they really did.”

The next critical tool is listening carefully. “The average doctor interrupts within the first 17 seconds of a medical interview,” Dr. Prose says. Instead, he suggests beginning the discussion with an empathetic tone and an open-ended prompt such as “I’m sorry to hear you had a difficult weekend. Tell me what happened.” The doctor already may already have an idea of what happened, and the story can be difficult to hear, “But giving the patient the opportunity to tell his or her story is very important.”

Some physicians may avoid open-ended questions “because we’re afraid the answer will go on forever, and we’ll never get to the next patient,” he says. For a tactful exit strategy, Dr. Prose suggests asking the patient if it would be OK to interrupt with specific questions. It’s also crucial to listen to the answers actively, repeating back what you’re hearing so that the patient knows you understand.

At this point, “It’s OK to say, ‘I can see you’re very upset.’ If it feels authentic, you could also say, ‘I imagine I’d feel the same way in your shoes.’ It helps people to feel both recognized and normal,” he says.

Delivering an apology requires caution, Dr. Prose says. “The ‘I’m sorry’ is very important.” Fortunately, he adds, a benevolent expression of sympathy is usually legally protected. Examples include “I’m sorry you had a difficult reaction to the medication.” Safer yet may be “I wish” statements, such as “I wish we had better treatments.” Such statements “put you on the same side of the table. And ‘I’m sorry’ can be mistaken for an expression of pity or an admission of guilt,” Dr. Prose says.

Finally, he says that before launching into an explanation, “It’s not a bad idea to ask permission:  ‘Would it be OK if I explain what I think went wrong?’ It’s a wonderful segue into the next part of the conversation. Then it’s time to be transparent and answer questions openly and honestly,” without being drawn into extraneous controversies such as how another doctor might have treated the problem, he explains. DT


Disclosures: Dr. Prose reports no relevant financial interests.