Many factors contribute to the risk of complaints and claims – both before and after the event – and Medical Protection Society (MPS) will publish several articles about how healthcare professionals can minimise this risk. Managing patient expectations is vital to reducing the risk of patient disappointment; disappointment which can, in turn, lead to complaints and claims.
Following on from a recent webinar on the subject, Dr Zarina Sonday, medico-legal consultant for MPS, outlines some key advice.
Dr Sonday writes:
We are all unique, each with our own personality, insights and perspectives. As healthcare professionals, we get to see and experience these differences in action daily; patients with similar symptoms but vastly different pathologies or similar pathologies but varied presentations and everything in between.
A review of cases here at Medical Protection has made clear that expectations of outcomes between patients and practitioners are sometimes not aligned. We tend to measure successful care in terms of clinical outcomes and thus our expectations might often begin and end here. However, patients often have expectations going beyond the outcomes of the clinical care, such as waiting time, consultation duration or even interactions with staff.
There is an important distinction here between standard of care – which we as clinicians strive for – and perceived quality of care – on which patients probably judge us. Patients have perceptions about the care provided, for example they might think something went wrong when in fact it did not, or that you didn’t show enough concern. Importantly, perceptions and the emotional impact thereof can drive patient expectations. As such, it becomes increasingly important for doctors to understand some of the factors shaping patient expectations to enable better expectation management from the outset.
Patient expectations are shaped by some of the following factors:
Information overload
Just think of all the information available online. I am almost certain you have encountered patients have Googled their symptoms. No wonder they arrive with preconceived notions of the examination, special investigations, diagnosis and even treatment. It’s important to also think about our social connections and how that allows patients to make comparisons.
Peter thinks his back pain is the same as Paul’s and Polly’s, and both Paul and Polly had surgery. Naturally Peter expects he should get the same treatment as the others and so arrives at your rooms with a clear and perhaps unrealistic expectation.
Information deficit
When patients have insufficient and/or inappropriate information about what to expect they could have unrealistic expectations related to all aspects of both clinical and non-clinical care, ranging from waiting times and billing to diagnosis and medication.
Contradictory advice
Along with having ease of access to information is the risk of misinformation and information that contradicts best practice. Patients also have access to different doctors. They can ‘doctor-shop’, hoping to find what they think they want or need to hear. A huge drawback of varying clinical opinions and at times inconsistent advice, in a patient without a proper understanding of medicine, results in patient uncertainty. An uncertain patient is likelier to consider that one or more of their doctors is wrong or has erred. This is an incredibly difficult position for a doctor: there really is no way of knowing what the patients expect as they are unsure themselves.
Anxiety
It is common knowledge that anxious patients are less likely to hear even when they appear to be listening. Inevitably this will result in some misunderstanding of the information communicated and thus contributes to misalignment in expectations between doctors and patients.
Time pressures
Patients are sensitive to feeling pressured by their practitioner, whether it’s hurrying them to your room from the waiting area or cutting them off while describing their complaints. Often, what may seem like a rather simple diagnosis may cause the patient significant emotional distress. More than the diagnosis or the medication, the patient needs to be heard and to feel heard by you.
Have you given them sufficient opportunity to fully explain their concerns, do they understand all aspects of their care or the complexity of their situation?
At Medical Protection, we remain acutely aware of how busy South African doctors are and how many competing pressures they face. However, we cannot discount the number of complaints arising from when complex cases present to a practice with a packed waiting room and staff under pressure.
Understanding patient expectations is essential for better expectation management. This not only maximises patient satisfaction but can also help you minimise risk to you and your practice. When you lack insight and understanding of your patients’ expectations and fail to manage them appropriately, patients tend to have inflated, perhaps even unrealistic expectations quite far removed from the more realistic clinical outcomes you can provide. A useful way to think about this in terms of risk management is to consider the following equation: Expectation/Reality=Disappointment
The larger and more grandiose these (unmanaged) expectations, divided by a more modest realistic outcome ends up in a huge amount of disappointment. Conversely, the more managed and realistic the expectation over the actual outcomes, you can provide, the less disappointment patients experience. A disappointed patient inevitably impairs the trust on which a doctor-patient relationship is built and on a more practical level this translates into complaints (to you, your practice or the HPCSA), and more commonly these days negative reviews on social media platforms.
Practical steps for managing expectations
There are several practical measures that can be taken to maximise patient satisfaction and the risk to yourself and your practice.
Information
Start to think of information provision as a continuum: before, during and after consultation, rather than a one off event. Given time and resource constraints, consider alternative sources of information: information leaflets, reliable sources of information online, or providing access to an onsite nurse – if available – to answer questions. Clear and consistent information should be provided by all staff at the practice, particularly regarding waiting times, billing practices, follow-ups and repeat scripts. Make sure that information around your practice hours, appointment scheduling and call back times is readily available on posters in your practice, on pamphlets and on your website and social media channels if applicable.
Communication
All patients are different, with their own needs and level of understanding. This is not a one size fits all scenario. Only you know your patient, so you must decide how to frame your explanation of their condition. Try to avoid medical jargon, abbreviations or terminology that can lead to misunderstanding. If you have concerns about the patient lacking understanding and insight, consider involving a relative in the discussions – you must get the patient’s consent for this.
Cross-check
Before the patient leaves your rooms, check their understanding. Make sure they have been given them an opportunity to ask questions and voice concerns – this is an important part of feeling seen and heard. As mentioned earlier, provide resources they can take home or engage with in their own time. A consultation can feel overwhelming for many. Allowing them time and space to process information means they are less likely to call the practice or book another consultation with minor queries.
Empathy
The importance of trust in a doctor-patient relationship cannot be overstated. Having a good rapport and ensuring the patients feel seen, heard and understood can only build and reinforce trust in this professional relationship. Remember empathy in action is compassion.
Openness
You must be open to feedback. Encourage your patients to provide feedback that will be received in a non-confrontational manner. Having open constructive conversations with patients around concerns they may raise can often be the significant step in avoiding escalation to a formal complaint, provides you with a window of opportunity to address issues early and effectively. If you receive feedback in a constructive manner, it may even lead to positive changes in your practice, with long term benefit to both you and your patients.
In summary:
Different perspectives between patients and doctors are inevitable. Understanding the relationship between expectations, outcomes and potential disappointment highlights the importance of early expectation management. Hopefully this article will help you anticipate their concerns and therefore better manage their expectations and continue to build trust.
See more MPS columns from MedicalBrief archives:
MPS welcomes ‘essential’ incident and complaint guidance from DoH
How to manage frustration from working in resource-constrained institutions
The need for medico-legal reform: A welcome chance to speak up
Social media complaints and how to deal with them