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AAOS Now

Published 3/1/2010
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Jerome M. Buckley, MD; Frederic W. Platt, MD

The 7 Cs of certification

Are you competent, capable, communicative, concerned, caring, committed, and compassionate?

In the patient’s mind, being board-certified (competent and capable) is not nearly as important as being patient-certified (communicative, concerned, caring, committed, and compassionate). These are the 7 Cs. Physicians who rate highly in all these parameters may satisfy patients more fully, are likely able to deal better with unanticipated events, and rarely get sued (based on our experience).

Physicians take the Hippocratic Oath seriously, beginning with the promise to “abstain from doing harm.” Medical interventions are intended to produce the desired outcome and to reach or even exceed the patient’s expectations. Yet unanticipated events may occur even with the most competent (C1) and capable (C2) clinicians.

When unanticipated events occur, communication skills (C3) usually become more important than biomedical technical skills—particularly from the patient’s perspective. Such unanticipated events lead to not only physical, emotional, and financial needs, but, most importantly, increased informational needs of the patient and the family. At such times, poor communication is likely to result in loss of trust and rapport, as well as a potential lawsuit.

Judging competencies
Because patients cannot judge a physician’s technical competencies well, they frequently rely on how the physician relates to them in deciding whether the physician is a “good doctor.” The patient makes observations and concludes that the physician is caring or not caring, compassionate or not compassionate. The patient then extrapolates to assume a parallel development of technical skills.

This suggests that physicians need to develop and use skills that convince patients of the physician’s humanism: that we are concerned (C4); that we do care (C5); that we are committed (C6) to their welfare, and that we are compassionate (C7). The demonstration of those traits (C4–C7) may be best expressed under the umbrella of communication (C3). Often these demonstrations are nonverbal, such as shaking hands, sitting down, avoiding interrupting, good eye contact, and providing adequate time and privacy.

An unanticipated outcome becomes an opportunity. Most importantly, physicians must try to understand the patient’s viewpoint and communicate that understanding to the patient. At the Disclosing Unanticipated Outcomes and Medical Errors workshop developed by the Institute for Healthcare Communication, clinicians produce a list of behaviors that they believe will not only lead to improved rapport and trust between patient and clinician, but can also serve to repair a fractured relationship. Such a list may be lengthy but invariably includes the following recommendations:

  • Plan to take enough time to discuss the untoward and unanticipated event.
  • Know that the conversation is not over once it is done; plan for a repeat conversation in the near future.
  • Find a private place to have the conversation.
  • Allow a companion to accompany the patient to better hear and understand the explanation.
  • Discuss what happens in language the patient can understand, not highly technical biomedical terminology.
  • Sit down, rather than holding the conversation while standing over the patient.
  • Maintain good eye contact.
  • Tell the truth, unembellished and without any hint of trying to get out of responsibility.
  • Understand how it might look and feel from the patient’s standpoint and communicate that understanding to the patient; such communication may be called empathic.

If the outcome was the result of their error, clinicians recommend claiming responsibility and offering a real apology. For example, “I realize this outcome was my fault. I was the primary surgeon, and it was my responsibility to be sure we had the correct size prosthesis. The bad outcome was my fault and I am terribly sorry for it. I cannot undo what happened, but I want to try to make amends for it. And I also want to change the system we use so that this cannot happen again to you or anyone else in our hospital.”

The impact of technology
When medical science—including surgical skill sets—was far more limited, the art of medicine (communication at its best) was both necessary and highly prized by individual practitioners. Around 1700, however, “The Disease Theory” moved medical education toward making physicians experts in disease but not in the people wrapped around the disease.

For example, cardiologists study diseases of the heart; ophthalmologists study diseases of the eye; and orthopaedists study and care for diseases and injuries of the musculoskeletal system. Yet no knee, elbow, or hip ever comes to the clinics except as part of a human person. Thus, medical recommendations must be filtered through that person’s values, understandings, and goals. As physicians became experts in the causation, prevention, diagnosis, and treatment of diseases and injuries, however, they moved farther away from a patient-centered approach.

One of us (Dr. Buckley) has spent 28 of his 45 years in medicine in the medical professional liability field, focusing on patient safety and risk-management. All too frequently, he has seen lawsuits that involved highly competent (C1) and capable (C2) surgeons who lacked communication skills (C3), while clinicians with lower levels of competence and capability were seldom sued because they had superb communication skills and their patients viewed them as caring, compassionate, committed, and concerned (C4–C7).

As the emphasis in liability management shifts to addressing all unanticipated events, including near misses, the need for improved communication skills increases exponentially.

Coming full circle
Clinicians develop a level of competence and capability that depends highly on attitudes, knowledge, and skills. A physician’s caring, compassion, concern, and commitment are demonstrated to patients largely through communication behaviors, both verbal and nonverbal. The patient then makes attributions about the physician’s knowledge, skill, and compassion, based upon his or her observations of those very communication behaviors.

This does not minimize a physician’s need for biomedical and technical knowledge and skills. But a physician must take great care in communicating with patients so as to be perceived as caring and competent.

Physicians should try to be the persons we want our patients to see us as. We should try to be the physician we would want for our loved ones, with the qualities of honesty, patience, and respect. Then patients will come to see us as complete surgeons and physicians—capable and competent, who communicate concern, caring, commitment, and compassion.

Dr. Buckley has developed an algorithm of potential outcomes when providing health care, which can be viewed here.

Jerome M. Buckley, MD, is the past chief executive officer and chairman of the COPIC Companies. He can be reached at jmbdoc@comcast.net

Frederic W. Platt, MD, is a regional consultant to the Institute of Healthcare Communications. He can be reached at plattf@hotmail.com