The first in our series: Clinical Communication Concerns
What type of complaints does the College receive about physicians? How are they resolved? And are certain specialties more likely to receive a particular complaint?
Over the next several issues of Dialogue, we take a closer look at our recent data to provide you with a window into the type of issues that come before the College’s Inquiries, Complaints and Reports Committee.
You might be surprised to learn that it is not likely to be a clinical or technical concern that will prompt a patient to write a letter of a complaint to the College. The surprising truth is that about half of our complaints describe an interaction that the patient believes was unsatisfactory as a result of poor communications.
“Looking at our complaints data, it would appear that a very valuable skill in a physician’s toolkit would be an ability to communicate with empathy and understanding, and an ability to make the patient feel like he or she has been heard, ” said Dr. David Finkelstein, the College’s Complaints Director. This could include simple efforts like greeting patients, allowing them to share their stories uninterrupted and in an unhurried manner, and asking if they had any further questions at the end of an appointment, he said.
The large majority of physicians involved in College complaint cases are compassionate, dedicated and work hard on behalf of their patients, often in challenging circumstances, noted Dr Finkelstein. This, he said, makes the receipt of a complaint all the more wrenching.
Dr. Michael Szul, a College Medical Advisor and family physician agrees. “It’s difficult to have a waiting room full of patients and be worried about falling behind in your schedule,” he said “but regardless, when you have a stressed patient in your office, you need to take time with the patient, listen actively, treat him or her as an individual and share decision-making.”
The communications complaints that the College receives range from low risk to serious. Unlike many other jurisdictions both within and beyond Canada, Ontario legislation mandates that a formal investigation is at the very least initiated with the receipt of a public complaint; however, many of the low-risk complaints are eligible for early resolution. In such cases and if both physician and complainant agree, they will be able to participate in the Alternative Dispute Resolution process with a goal of achieving an early and mutually satisfactory resolution. Such complaints may include issues regarding perceptions of physician rudeness or condescension, or difficult communications with staff in a physician’s clinic.
When you have a stressed patient in your office, you need to take time with the patient, listen actively, treat him or her as an individual and share decision-making.
Those complaints not eligible for ADR, or where a patient is not willing to engage in ADR, go forward to the Inquiries, Reports and Complaints Committee (ICRC) for investigation. For the purposes of this series, we have separated communications complaints that are reviewed by ICRC into two groups – clinical and professional. A clinical communication complaint could see a patient expressing unhappiness that he or she did not receive or understand the necessary information about a treatment. A letter of complaint about unprofessional communications may cite a rude manner, a raised voice, or a dismissive comment.
A total of 1,130 unique investigations were identified which addressed either a clinical or professional communication concern. This represents 43% of files disposed of in 2018. Of the 1,130 investigations 20% (224/1130) addressed both a clinical and professional communication matter.
Clinical Communications
We begin our series by focusing on the clinical communications concerns reviewed by ICRC over a one-year period. We also highlight the most frequent type of complaints and suggest good practices for reducing the risk of receiving a clinical communication complaint.
This retrospective analysis reviewed closed investigation files related to clinical communication concerns with a decision issued between January and December 2018. The review consisted of 675 files involving 640 physicians. Ninety-six percent (N=614) of the doctors named in the files received one complaint related to their clinical communication, whereas 4% (26/640) received two or more during the period of review. Of the 675 files included, 97% (N=654) were public complaints and 3% (N=21) were Registrar’s Investigations.
Top Issues seen by ICRC
Failure to Explain/Failure to Listen
A failure to explain an aspect of care appropriately to the patient was the most frequent issue identified in the investigations. This could include failing to describe the reason for a particular assessment, or the reason for a particular treatment, or for failing to describe other treatment options.
To ensure that consent for a treatment is informed, physicians must: provide information about the nature of the treatment, its expected benefits, its material risks and material side effects, alternative courses of action and the likely consequences of not having the treatment prior to obtaining consent.
“Discuss the rationale for your clinical decisions with patients and listen to their concerns. Talk about why a treatment is necessary – or not necessary,” said Dr. Anil Chopra, the new co-chair of the Inquiries, Complaints and Reports Committee, and an emergency physician in Toronto.
Satisfy yourself that the patient understands the information by encouraging them to ask follow-up questions, he said. “It is our responsibility to foster understanding, not just transmit information,” he said.
Conversations about the need for a particular treatment or alternative treatment options don’t need to take a long time, and they can often mean the difference between a positive and negative physician-patient interaction with the patient either leaving with the sense that their voice was heard and respected or leaving with feelings of discontent, said Dr. Chopra.
Dr. Chopra said that physicians must also discuss possible side effects and complications with patients about treatments. And if there’s little chance of returning a patient to full health, you should discuss this openly so that the patient is not disappointed, he said.
Dr. Finkelstein says informed consent also applies to conversations about investigations and examinations. He notes that the recently approved Boundary Violations policy requires physicians to obtain consent before proceeding with an examination of a patient. The process can simply include a concise explanation of what the exam will entail in order to promote patient understanding and then asking for permission to proceed.
Good Practices:
- Provide information clearly and simply. Try not to use jargon.
- Ask questions to confirm a patient’s understanding of the discussion.
- Be alert to non-verbal signs that the patient may not be understanding the information.
- Make eye contact.
- Demonstrate a collaborative approach to patient decision-making.
- Wait until the patient is finished speaking to respond.
- Summarize what you think the patient has told you and ask the patient whether it is correct.
Failure to Share within Circle of Care
The “circle of care” is the group of health-care professionals treating a shared patient who need information to provide that care.
A shared understanding of patient goals, patient’s conditions and medications between distinct providers supports patient safety and high quality care, said Dr. Finkelstein Patients may be put at risk if those who provide their care do not have access to relevant, accurate and up-to-date information about them.
Failure to Communicate Test Results
The College’s Managing Tests policy states that in order to ensure appropriate follow-up on test results can occur, physicians must have an effective test results management system that enables them to record that a patient has been informed of any clinically significant test results and the details of the follow-up taken by the physician. When in receipt of a clinically significant test result, physicians must always communicate the test result to their patient and must do so in a timely manner.
For test results that are not clinically significant, physicians must use their professional judgment to determine whether to communicate a test result, and if doing so, when to communicate the test result.
Physicians must also use their professional judgment to determine how to best communicate a test result; for example, over the phone or, at the next appointment. In making this determination, physicians must consider a variety of factors, including,
- the nature of the test,
- the significance of the test result,
- the complexity and implications of the test result,
- the nature of the physician-patient relationship,
- patient preferences/needs, and
- whether the patient appears anxious or has expressed anxiety about the test.
Further Education
We believe that clear physician-patient communication is a critical aspect of effective care. When we believe a physician who has received a complaint can benefit from improvements in this regard, we will take steps to ensure that the physician is connected to the best resources. To improve clinical communications, there are a range of resources CPSO recommends to physicians:
- Self-study
- One-on-one coaching with a skilled communications coach
- The Successful Patient Interactions course assists physicians and other healthcare providers in achieving more successful encounters with their patients, for a safer health-care experience. (Saegis Solutions)
- The Clinical Communication Program (CCP) is a highly intensive interpersonal skills training program which greatly enhances doctor-patient communication. (Saegis Solutions)
- The Effective Team Interactions course will enable more effective and safer interactions between healthcare colleagues, through enhanced communications strategies and skills. (Saegis Solutions)
We urge you to read the following College policies for more helpful information: Consent to Treatment; Boundary Violations and Managing Tests.
