By now you’ve probably read Anesthesiologist trashes sedated patient — and it ends up costing her or seen it mentioned somewhere. I won’t rehash the specifics. You can hear audio clips of what the doctors said while their patient was anesthetized and a cell phone audio recorder captured everything. There have been a variety of reactions from outrage to “this happens all the time” (not mutually exclusive perspectives). I would like to add a few thoughts to the mix and raise some questions:
1. What are we to make of doctors venting rage towards patients when they think they are out of earshot or unconscious? What are the triggers? Here are several:
a) Judgmentalism: Rather than seeing patients as struggling with life long challenges, phobias and neurosis (all characteristics health care providers amply share), they are judged for their personal qualities. In the audio, the patient is called a “retard” for fearing insertion of an IV into his arm.
b) Lack of engagement: Engaging with other people means interacting with them as fellow human beings, without pretention, or judgment, and as an equal. It does not mean that the doctor forgets that s/he is there to help and to heal. It is unselfconscious. When we engage we come to know each person as an individual and they come to know us as an individual. It is not something that takes more or less time than non-engaged interaction. It’s just a different way of relating to people.
c) Lack of boundary clarity: Boundary clarity gives us the perspective to know how to set limits in interactions without cause for offending other people. It’s knowing what’s you and what’s the other person. When a resident says to me “I couldn’t get him to stop talking. I just couldn’t get out of that room” they are exhibiting a lack of boundary clarity. They could extract themselves saying “Mr. Jones, I’m sorry to interrupt you. But I have another patient to see.” Actually, it’s not quite that straightforward, which is why they are at a loss. Cutting off an encounter abruptly without preparing for it would not serve the patient well. Ideally, from the start of the visit when a doctor first perceives that their patient is talkative to a point that could undermine care, they should alert him to the parameters of the visit: “Mr. Jones, unfortunately the schedulers only gave you 15 minutes of my time, so I want to be sure we cover everything that’s important to you.” If there is more to cover when time is up, ideally the most critical issues will have taken priority and the others can be scheduled into another visit, or phone call, or referral.
Not being judgmental, engaging with others and being clear about boundaries adds up to respect. These three elements are not always easy to come by though. The first — being judgmental — is deeply ingrained in many people. It’s possible to get past it, but that requires considerable self-reflection. The second, interpersonal engagement, is especially uncommon. It tends to occur when people let their guard down. When two people who don’t know each other get stuck in an elevator, they are primed to engage. It doesn’t matter if one is a CEO and the other a janitor. If enough time passes, they are like miners stuck underground. They share a common humanity. In health care, patients enter feeling vulnerable and are open to engagement. Their doctors may not be inclined to engage or simply don’t know how to. Finally, the third — boundary clarify — is also quite rare. In fact, not knowing how to set boundaries is likely a prime reason why clinicians don’t engage in the first place. If you don’t reveal who you are, then the need to set boundaries doesn’t arise. Instead interactions are formalized. They pass for respectful. The doctor who does not engage can appear engaged and perform in a manner that will leave most patients feeling like they got good service. But something is missing that neither can likely quite put their thumb on. The patient has received a service, but not a healing encounter. The clinician has delivered a service but the interaction is not nourishing and over time many such interactions lead to burnout.
The audio recording reveals rage, scorn, and repulsion. The medical team talks about how so many patients are like the one on the table. What stands out is their inability to manage boundaries. They talk about the lengths they go to get away from them by, for instance, pretending that they got a page. Had the patient never heard the audio, the comments would not have likely caused any direct harm….except for one thing: the rage turned into malice. The doctor put a false diagnosis in the chart, noting that the patient had hemorrhoids. That was the indisputable harm, and reflects what happens when providers are judgmental, do not engage, are unclear about boundaries, and cannot control the negative emotions that follow.
Words of wisdom, particularly a definition of engagement that treats the patient as an equal person.
Thank you. Sometimes I hear doctors say “but, we are not really equal in terms of our expertise around health care. That’s why the patient came to me in the first place.” That’s true, I would reply: but you are fundamentally equals….you have a shared humanity. In another setting, the tables would be turned. If your patient is a tow truck driver, and you were stuck on the side of a road….guess who would be in the driver’s seat?
There is so much we can learn if we listen to what people say. This is true in health care and in life. Some people are naturally good at listening while others need to acquire this skill. Alternatively, there may be ways that we can help providers to identify these cues so that those that are less skilled have other means of obtaining this information. Our ongoing research is testing one of these strategies currently.
Yes, I agree that when people have trouble listening, sometimes you can prime them…find a way to get their attention. There is so much lost opportunity during the clinical encounter. The approach your group is taking, which is to introduce strategies that empower patients to identify life challenges that may be relevant to their care plan, and then call those challenges to the attention of their often distracted physicians, is an important potentially fruitful strategy.
Thank you for shedding light and insight into an important topic that will likely increase in importance as the push toward increased transparency continues.
I think it is important to note that in the example provided above (anesthesiologist and sedated patient) that the patient intended to record the post-procedure instructions from the provider. The patient did not record the visit with malicious intent.
Although not identical, it does seem that the initial resistance to allowing patients free and ready access to their medical record (personal health records) online (rather than having to go to a records release office each time they want access) including access to their clinical notes via OpenNotes shares some similarities.
Much of the initial resistance (especially in primary care and mental health) involved fear of ‘patient retaliation’ over what the provider is noting in the medical record. Some concerns include that a provider may state facts that the patient doesn’t like (such as patient is overweight or obese as measured by BMI) or suspicions the provider has (such as patient has had a history of alcohol abuse, patient seemed like they may have been under the influence of alcohol during today’s visit). There are additional concerns voiced by some providers such as a patient’s ability to understand medical terms, abbreviations, etc. Mental health providers also share many of the above concerns along with others.
Providers also seem to recognize the potential advantages of giving patients open and ready access to this information. They anticipate that, for some patients, improvements in self-management or treatment adherence might be gained from the increased access to the notes made during treatment planning.
One other interesting similarity that these two stories share is the concerns (of both providers and patients) over privacy and trust. The patient-provider relationship is built on these two concepts, and introducing the concepts of recording visits and providing increased access to provider notes through programs like Open Notes introduces new “rules of the road” to that relationship. I think it is understandable that there may be an adjustment period during this “growth point” in that relationship, I anticipate that privacy and trust will be stronger than ever between patient-provider relationship.