By S. Jay Jayasankar, MD
Unrealistic expectations are preventable triggers for claims
A patient’s disappointment with an unexpected turn of events or outcome is a key driver for medical liability claims, even though only a small fraction of claims involve a compensable injury or are decided in the plaintiff’s favor. Integral to quality care and among the risk prevention efforts under our control is appropriate patient education to ensure that patients have realistic expectations about the risks, rehabilitation, and outcome of an orthopaedic procedure.
How does a patient develop expectations? In this information era, patients ‘learn’ from a growing number of sources with varying validity. In addition to hearing from family, friends, and others who have experienced the surgery or treatment, patients can be influenced by conventional news sources and Internet sites with information of variable quality and potential bias or sensationalism.
The patient’s own past experience is a powerful contributor to future expectations. I once treated a 20-year-old man with bilateral club foot. He was delighted with the results of surgery on the first foot. But he was dissatisfied with the immediate result of the surgery on the second foot, even though it was a “successful” correction. His past recovery experience set an expectation standard.
A patient’s understanding depends not only on the material he or she receives but also on the way the patient assimilates that information and translates into actionable beliefs, based upon cultural and individual values and beliefs as well as past experiences.
Patient education efforts work in this background. Their expectation, not ours, is the yardstick by which our patients measure the course of recovery, occurrence of complications, and the outcome.
Patient education: Responsibility and opportunity
Informed consent requires us to inform the patient about the condition and its likely course, treatment options, and expected benefits and risks. Patient understanding and involvement are central to optimal treatment selection and active patient role in treatment and recovery. This maximizes patient benefit and safety. We should carefully communicate realistic expectations for the course and outcome.
Richard Boothman, JD, chief risk officer for the University of Michigan Health System, has pointed out that physicians often create expectations that cannot be met through thoughtlessness, simple-minded marketing, gimmicks, arrogance, misguided compassion, and a number of other ways and then wonder why patients are upset at unanticipated outcomes.
Orthopaedic surgeons and their patients would be better served by using the “expectation model” in patient education to ensure that the patient’s expectation of the course of recovery, their role in it, and the potential outcome matches the surgeon’s. Such a model would maximize patient participation and minimize disappointments and risk. It provides orthopaedic surgeons the opportunity to optimize the treatment program for that patient, develop rapport, and earn the patient’s trust. The result is to maximize patient satisfaction, potentially reducing liability risk.
This trust and rapport will be important facilitators in secondary prevention, in the event of an adverse event down the line, when empathic communication and explanation are essential for good care and for risk reduction. Studies indicate that for patients who sustain an injury, the perceptions of being ignored, lack of empathy, and inadequate explanation are major drivers of medical liability claims.
Educating patients effectively
Communication is more than a simple transfer of information. Understanding, emotion, satisfaction, rapport, and empathy are among the factors involved. Patients read the unspoken language of physicians: Does the doctor look them in the eye or stare at the computer screen? Is he or she standing up or sitting down when addressing the patient? Does he or she frequently look to the door? Studies show poor communication is a key factor in liability risk.
Knowledge of relevant cultural beliefs and the specific patient’s modeling systems (Fig. 1) can help a physician in individualizing efforts to improve patient understanding, participation, and empowerment. Although some physicians may be inherently better at this, all physicians can improve communication skills by learning to focus on mindfulness, thoughtfulness, and empathy.
If patients are asking the receptionist questions that they should be asking the physician, the doctor needs to find out why. Perhaps a change in body language or improved communication with the patient is needed. The Accreditation Council for Graduate Medical Education includes interpersonal communication skills as a required core competency as does the American Board of Medical Specialties for its Maintenance of Certification process.
No learning is effective or complete without evaluating what is learned. To ensure that communication goals are achieved, the physician must also pay attention to the patient’s nonverbal cues. Listening to the patient must be active—acknowledging and encouraging while sharing agreement and disagreement in an empathic manner.
Ongoing assessment during communication
In talking with a patient, a physician should attempt to learn what the patient expects and help shape those expectations to match the physician’s intention. If the patient forms different expectations than those the physician is attempting to communicate, the physician needs to direct the dialogue to eliminate this ‘expectation gap.’
A patient’s hopes and wishful thinking introduce an unconscious dissonance between the patient’s understanding of what the physician says and the patient’s expectation of the outcome. For example, if the physician explains that the procedure has a 50 percent chance of success, the patient’s innate optimism may be so powerful that he or she assumes that the outcome will be among the successful 50 percent.
Although it may appear that efforts to communicate more effectively may demand more time—and they may, in some instances—mindful communication that picks up on cues from the patient could result in less time spent reviewing information. It is not so much a matter of more time as it is of using and tailoring the time for each patient’s need. Having patients verbalize their expectations and guiding them should be a part of this communication; a conscious effort will improve effectiveness.
Using educational aids and assistants
Printed material, well-designed patient education modules such as those being developed by the AAOS, visual and audio aids, and staff trained to interact and educate patients are all helpful. But the physician should also directly review information with patients to confirm the effectiveness of the communication and appropriateness of patient expectations. Such a review also enhances rapport and communicates a sense of caring that fosters trust.
With these efforts, a patient is less likely to feel abandoned if a mishap or perceived failure of outcome occurs. Open communication in the event of an adverse event is a key factor in preventing/mitigating a claim.
It’s all about expectations!
As professionals, orthopaedic surgeons strive to positively influence the development of instruments being used to measure physician performance. The patient uses his or her expectation of the course of recovery and outcome as a tool to measure the physician’s performance daily.
Physicians have the opportunity and the duty to provide patients with realistic expectations in this era of informatics and glamorization that tends to create unrealistic expectations. Studies estimate that half of the patients leave the physician’s office not understanding what the physician told them, and recall rates are generally low. Studies demonstrate the need for surgeons to enhance their patient education and counseling skills.
The ‘expectation model’ of patient education, with its focus on developing realistic expectations, is good medical practice and a risk management tool because it focuses on patient understanding. As a result, the patient experiences the expected course of recovery and outcome, leading to increased trust and an enhanced patient-physician relationship. The latter, in turn, improves quality and risk management. It is all about expectations!
S. Jay Jayasankar, MD, is a member of the AAOS Medical Liability Committee. He can be reached at email@example.com
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