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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
The impact of "relationship mistakes"
Commentary
Commentary by Aita
Teams, Trust and Patient's Responses to Preventable Medical Problems.
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Anton J. Kuzel, Richmond, VA, USA Chair, Department of Family Medicine, Virginia Commonwealth University
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I am so pleased to see the work of Nancy Elder and colleagues, which both confirms and expands upon the stories of preventable problems and associated harms in primary care that my colleagues and I heard from patients in Virginia and Ohio. For those who might question whether such events and the negative emotional responses they engender are "medical errors," Elder and colleagues show that there are serious implications that plausibly affect the quality of care patients receive and likely affect health outcomes. I am attracted to the notion that the kinds of problems reported in this study are "relationship mistakes" and clearly have an impact on the formation and maintenance of caring relationships between patients and clinicians. Empathic relationships are associated with more thorough diagnostic evaluations, greater effectiveness, less provider "burn-out," and may not take much more provider time. As others have suggested in this commentary stream, this paper shows how important it is for us to strive to make our offices places where our patients have a transforming experience. Competing interests: None declared |
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Shersten Killip, Lexington, KY, USA Assistant Professor University of Kentucky Family Medicine
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The article by Elder, Jacobson and Zink in this issue highlights some differences between physicians perceptions and patient perceptions. In their patient-derived data, as in Kuzel and Woolfs(1), communication issues were the most frequently reported errors. In contrast, in Dovey and Meyers 2002 (Preliminary taxonomy of medical errors in family practice), which used 330 error reports from 42 physicians(2), only 43 reports concerned communication issues (message handling, appointments, and communication). Doctors do realize that communication problems can affect not only patient care but patient satisfaction. What this paper starts to show is exactly how these problems can be tied into having effects on patient safety as well. Elder et al have shown there are four major patterns of behavior following a preventable problem with primary care, one of which is avoidance. While no interaction with the health care system can lead to no harm from the health care system, neglecting a disease can lead to serious health consequences in the long run, and so such a chain of events (miscommunication leads to avoidance leads to worsening illness) can impact patient safety negatively. I agree with Dr. Greens comment that the relationships of front office staff, telephone staff, and nursing staff with patients are critical to the health of the doctor-patient relationship, and that more attention needs to be paid to these areas. I also agree with Dr. Aita, who notes correctly what falls by the wayside first when the system is stressed by economic and time constraints. I think the most important point of this paper for those of us in the field is a reminder that we must broaden our focus, and remain aware of not only our own thoughts, desires, and opinions on patient safety, but also those of the patients themselves. Courteous, clear, communication and excellent service are as important to patient safety as technical excellence and systems issues. After all, a patient who is no longer coming in for any care may be the least safe of all. 1. Kuzel AJ, Woolf SH, Gilchrist VJ, Engel JD, LaVeist TA, Vincent C, et al. Patient reports of preventable problems and harms in primary health care. Ann Fam Med. 2004 Jul-Aug;2(4):333-40. 2. Dovey SM, Meyers DS, Phillips RL, Jr., Green LA, Fryer GE, Galliher JM, et al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002 Sep;11(3):233-8. Competing interests: None declared |
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Virginia A Aita, Omaha, NE Associate Professor (ethics/humanities), University of Nebraska Medical Center
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The article by Elder, Jacobson, Zink and Hasse has some important implications. Investigators looked at preventable problems in out-patient settings and conducted qualitative interviews with 24 out-patients who could recall a preventable occurrence that they were willing to discuss. The most common findings related to problems associated with office administration and communication that resulted in anger, mistrust and resignation. Strategies to improve care, based on studies of in-patient medical errors, often focus on reforming systems. Elder et al. provide us with a different focus, one that uncovers the need for improvements in the interpersonal aspects of health care at the office staff and provider levels, which emphasizes the importance of genuine, caring communication and kindness. Sincere communication depends on choices each person makes from moment to moment and day to day. Some might say that in the rush of the busy practice there isn’t time to be as kind as one might wish, or to spend time listening to patients. If that is the case, what is the purpose of practicing medicine? Does the assumption still hold that most physicians, nurses, and others in the health professions pursue the kinds of work they choose to try to help others, to be kind, to listen? Or, has the rabble in today’s healthcare industry all but drowned out such high ideals? Some might say that the reluctance to take time to communicate effectively is embedded in society at large where “manners” no longer seem to count. Informants in this study seem to be painting their experiences of care with this brush. They also seem to be saying that they expect caring communication and kindness and not just technically proficient service. What would it take to make this a reality? What would choosing to slow down the pace of patient visits mean? Certainly it would have economic and other consequences. Would that be such a bad thing? What overall benefits might be accrued? Whether in the clinical setting or not, each of us must answer these questions for ourselves. Each person has the power to choose to take time to communicate effectively and with kindness. Setting appropriate expectations for what can be accomplished in a day, prioritizing what is important while letting go of that which is less important, are part of making such a choice. It is something worth thinking about. Competing interests: None declared |
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Michael E Green, Kingston, Ontario, Canada Assistant Professor, Depts of Family Medicine and Community Health and Epidemiology, Queen's Univ
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The article by Elder et al. on patient experiences with preventable medical problems provides an important first glimpse into a previously unexplored area in patient safety. That the level of trust/loss of trust in the health care system impacts on patients’ reactions makes intuitive sense. It is consistent with the messages on the importance of trust in the physician patient relationship which we are taught from early on in medical school and that is reinforced by regular reminders from regulatory agencies and medical malpractice insurance providers that open communication and a high level of trust protect against formal actions or complaints. As many of the preventable problems reported involved other players, this trusting relationship needs to extend beyond the bond between doctor and patient and include other members of the team, such as front office staff and other support staff. A quick search of PubMed using the MeSH headings “medical receptionist” “professional-patient relations” ‘physician-patient relations” and “nurse-patient relations” in combination with the terms “primary care” or “family practice” shows that while there are many studies about the relationships between primary care physicians and their patients (4920) there are far fewer dealing with nurse-patient relationships(523) or receptionist-patient relationships(52 if you include any article about receptionist roles, only 8 if you limit to a focus on professional-provider relationships) in primary care. More work is required in this area, particularly as there is a move towards models of care based on multidisciplinary group practices and away from traditional models based on the relationship between a patient and a single physician. There are clearly many factors that go into determining which strategies patients choose in reacting to experiencing a preventable problem. For example, low trust was associated with both avoidance, which I think most of us would agree is not a desirable reaction, and advocacy, which is supported as a laudable response by interest groups such as the National Patient Safety Foundation. What is not yet clear is what other factors help to steer some patients towards one response and others towards the other. This paper provides a starting point for the design of further studies to determine what these factors are, if they really matter, and which may be targets for interventions to encourage all players in the delivery of care to both actively work towards preventing such problems and to develop strategies for effectively dealing with them when they occur. Competing interests: None declared |
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