The Doctor-Patient Relationship: A Personal View
| Gareth Scott |
London, United Kingdom
"A man should never be ashamed to own that he has been in the wrong, which is but saying in other words that he is wiser today than he was yesterday." Alexander Pope, 1688- 1744
Licencing bodies around the world clearly define the boundaries of the profession’s emotional and physical engagement with patients. Essentially we should never exploit our position of authority, knowledge or respect, to obtain any type of advantage over our patients. It is a simple moral code with clear limits and should present no difficulties. A less well taught subject is how to address adversity which is the subject of this essay.
All health-economies are faced with serious problems managing the escalating financial costs of providing care against the background of technological advances which extend the treatments we can offer. This is compounded by increasing life expectancy and demand (driven by expectation), and perhaps by an element of self-neglect through a rising incidence of obesity. The consequences of trying to balance the books has been to change the style of the surgeon’s work, with admission of elective patients on the day of surgery and locating the operative venue in some cases away from one's usual place of work, in an elective centre. In addition, many previously defined medical duties have been transferred to trained allied professionals. In short, we now spend less time with our patients than would have occurred 25 years ago, when patients were admitted the day before surgery and remained in hospital for a lengthy period. The old pattern of working enabled a series of ward rounds to occur with the consultant leading a team of junior colleagues. During these ward rounds the opportunity to observe the “bedside manner” in action presented itself. The lessons learnt from hours of, what with hindsight were causal, observation, do not yet feature on the postgraduate specialist syllabus.
It will be unusual for a surgeon to complete a career without some adverse outcomes. It is a simple fact that surgery is associated with risk. We must all recognise the limitations of our skills but there will always be unusual circumstances where we meet some new permutation of a problem and have to bring strands of our knowledge and previous experience together to manage that situation. However, we must know when to call for help and a lack of insight in this area is likely to lead to accusations of negligence. With careful planning, risks can be minimised but not entirely eliminated. We therefore need to ensure that our patients know about the hazards they face, but in the pressured environment of an overbooked outpatient clinic this might not be done as well as we might wish. A recent legal ruling in the United Kingdom has increased the responsibility to ensure any explanation is provided in a manner which suits the individual patient’s comprehension . All this takes time but is vital. Obtaining consent to operate is a process not an event and needs to be initiated when surgery is first recommended. At each stage thereafter the consenting pathway should continue using supplementary materials such as information leaflets, pre-operative classes, drawing pictures and diagrams, and digital media. Ultimately you, the surgeon, will have to be satisfied the patient is providing informed consent. Involving family members, if it is acceptable to the patient, can be helpful, but one should be wary of coercion by the family. It is therefore a good policy to obtain the consent yourself for everyone upon whom you are operating or at least personally confirm that the patient is satisfied with their explanation of the likely outcome and potential risks.
Managing the situation when something does go wrong is one of the hardest aspects of the surgeon’s job. This is a real test of character. If you do not feel slightly upset by something going wrong, such as an iatrogenic nerve injury or periprosthetic fracture, your callous indifference marks you out as having psychopathic tendencies which make you unsuitable for a surgical career. That is not to say you should collapse under the emotional pressure; you have to be resilient. The immediate surgical situation must be controlled but post-operatively you must remain with the patient until they are sufficiently alert that you can personally explain, in a way they can understand and without abbreviation, what has happened and answer any questions. You may need to speak to the family at this point. It is said that sorry is the hardest word. It is simply not true. A heartfelt apology delivered without delay will make you feel improved even if not completely better. The benefit of this openness is that your patient will more likely trust you. They will recognise your sincerity and see you as someone who is honest. You will probably have disturbed sleep for some days but you will recover unharmed and wiser. The sheepish individual who avoids eye-contact and gives a limited mumbled explanation and deflects blame onto others will be spotted immediately. The long-term outcome for the latter individual is likely to be protracted litigation.
The day following the adverse event you should visit your patient again with some members of your team, but not so many that the experience intimates the patient. Repeat your apology and answer questions which may arise. Bad news is hard to assimilate in full, so be prepared to repeat any explanation several times. You should offer them the chance to have their care transferred to a colleague if they prefer. The patient may be angry which you should understand if you consider the situation from the patient’s perspective. You should respond to their anger by remaining calm and not shout. You should also ask them if they have had any ideas on how the problem can be put right. They are unlikely to have thought that far ahead but you should have done so. You can then offer your views if they are interested. You should do so using appropriate body language. Sitting in a chair set slightly lower than the patient’s bed will make the patient feel less vulnerable. Nothing should be rushed even if you have a packed schedule to manage. Involving the patient in establishing the solution empowers the patient and gives the message that you are concerned they still achieve the best possible result. Thereafter you can remedy the situation and should remain heavily involved in their aftercare in outpatients.
My description is not about avoiding litigation that is just a possible bonus. The purpose of displaying some humility is to maintain a healthy environment where you can perform at your best offering continuity of care to the advantage of your patient whose needs are your duty to address. Managed well, you and your patient should continue to have a convivial relationship and any financial recompense is likely to be limited to the true value and not some inflated claim driven by the legal process. Furthermore, each time something does not go to plan you should analyse the situation so you learn from it, become wiser and share your new insight.
The most straightforward way to cope is to place yourself in the patient’s predicament and consider how you might feel and what you would expect for yourself. You should appreciate how difficult it is to understand something outside your own experience. When things go wrong you must face the problem and share it emotionally by offering a full explanation with an apology to the patient and involving them in making the future plans. Above all, know your patient well, which can only be achieved properly by talking to them and not treating them as an object with certain radiological changes. If you do not lose your patience you will not lose your patients. No surgeon is too old to learn.
- Montgomery (Appellant) vs. Lancashire Health Board (Respondent) (Scotland). Supreme Court Judgement, 11th March 2015, London