As a clinician for 30 years my entire world has been managing the physician-patient relationship. On one hand, I have to be a scientist and apply all the technical knowledge about disease management, while in the other, a compassionate salesman, convincing often frightened and wary patients any families to trust my skilled hands after just a few meetings in the safe surrounds of the outpatient clinic or hospital, when they are still conscious and can process what I am saying; experiencing all of the fear and trepidation associated with this conversation.
My skills in negotiation really come from doing pediatric neurosurgery (as a necessity, not on purpose), for if there is ever a time when conversations require delicate conflict management skills, it is with parents of sick children. The quick response of anger and hostility when the clinical course is not just perfect, or even when the diagnosis is poor and the family projects their anger and disbelief on to the healthcare providers, as if we caused the disease. All of these incidence require a calm understanding of the situational extreme emotional, visceral, hind brain response that is fueled from adrenaline laced with some unknown bio-reactant that only a strong benzodiazepine (valium) can calm.
During my 30 year neurosurgery career, I witnessed every type of healthcare conflict, disclosure and participated as expert and defendant in litigation, medical board battles and business disputes. The communication system in Medicine is so broken, beyond the public adversarial disputes. The strained discourse between colleagues is worse than the Provider -patient interaction. Escalation in adversarial posturing is merely a reflection of the painful administrative oppression that healthcare providers endure from every type of regulatory agency, peers and law firms. These all are quick to accuse and constantly put providers on their highest guard. I doubt many providers are actually dispassionate but the walls to protect and preserve their emotional sanity keep expressions of compassion deeply suppressed behind the armor that required to survive the turmoil of clinical practice. What we study, the dysfunctional provider-patient discord, is just a byproduct of a larger system that fosters anxiety and fear in the very providers trusted to address the emergencies of physical and psychological disease and discord that bring patients to our clinics and emergency rooms.
As Chen points out “Not surprisingly, those patients with the strongest relationships to specific primary care physicians … had a greater influence on the kind of preventive care received” which is really about “patient’s ability to have a longstanding relationship with a doctor, to have a doctor who knows him or her as a human being.” (Chen). But if that relationship is continually threatened by outside influences that punish the provider or make the provider wary about getting close to the patients and disclosing the fragility and dilemma of humanism and the potential for error or with treatments that don’t resolve the issue, how does a provider accomplish the compassion advocated by the Schwartz Center’s theme of compassion as a cornerstone of medical care?
Providers fear for their own professional health and security. The provider is under constant attack.
The ADR input is often manifest by the medical ombudsman. This provides a clear pathway on ADR skill adaptation for the healthcare providers and to me, presents a very cogent ‘job description’ that will allow me to change hats when working on this aspect of the ADR professional offering. Houk and Amerson paper on the role of apology illustrates the Ombudsman duties quite well and I could really identify with Dr. Greene, the cardiothoracic surgeon who, as the Captain of the ship, continued to provide the family of the lost boy with the information they needed for closure. “..In light of the lengthy relationship Dr. Greene had established providing Joey’s medical care, he would be the one to disclose the facts surrounding the medical error” ( Houk). The message was clear here, the provider-doctor and surgeon, is expected to have the closest relationship with the family, have trust and compassion and therefore best suited to lead the conversation, within the ADR guidelines, to inform the distraught family.
The dichotomy is that surgeons, because of time, higher litigation exposure, personality (disorder in my case), are probably the least sensitive of all providers to the social and psychological nuances that go into having these difficult conversations. Not that they are afraid or purposely insensitive, but usually because delivering bad news is part of the job. Considering the information and context for these delicate adverse outcome conversations, I would probably concentrate on the surgeons’ approach and how they will interact with the family and less about what they are actually going to say.
Lastly, the Kaiser Model and well known medical ADR persona, Dorothy Tarrant nicely summarized the roles and responsibilities of ADR in medical organizations. Quoting her daily duties “I assist patients and providers by helping them to work together to address their needs and interests. This includes acting to fairly resolve healthcare issues, disputes and conflicts by acting as a neutral, independent and confidential resource for patients, families and providers. It is the job of the HCOM to understand the dynamics of patient-provider communication and the relational aspects of dispute resolution…”; this templates the best practices expected to facilitate the doctor-patient relationship communication necessary to heal the patient when distressed from adverse clinical outcomes.
I would only add to this from my administrative roles as prior chairman of surgery and prior member of credentialing and peer review quality assurance committees, by pointing out that the consultant or in-house ADR health care liaison should take the time to establish a relationship with the healthcare providers and have a high enough profile to seek out and establish relationships with both nurses and doctors to understand the culture and personalities of the medical “player” at an institution.
There are often physicians seen as disruptive with poor relationships to the administration of the hospital, so despite who is paying the ADR professionals salary, the role must appear and services executed as a neutral independent that will not report conversations to hospitals legal department or maintain insider information that the administrators could leverage against the doctor or nurse in future negotiations. In essence, the providers must trust the ADR facilitator/mediator/coach first, when not under duress, to improve both education and functional outcome when a specific patient-provider conflict arises.