Today's guest post is by Dr. Matt Poyner, a Canadian emergency physician who sold everything, quit his job, and is currently backpacking the world with his wife and four young sons. He chronicles his adventures at Big Family, Small World and shares the investment strategy that enabled his radical experiment at DividendStrategy.ca.
When a burnt out finance nerd meets a burnt out finance nerd coming through the rye, they sometimes click. A comment led to an email that in turn led to a friendship I've come to deeply enjoy. Read on to understand what the hype is about.
Crispy Doc recently wrote an great post about anger and the fact that, contrary to popular belief, it can be a powerful catalyst for conflict resolution. But when we, as physicians, are the target of our patients’ ire, anger feels anything but productive.
Coincidentally, I have an interest in both financial independence and this unpleasant aspect of our job as physicians - specifically, patient complaints. At first they might seem unrelated, but I believe that patient complaints can be a major factor in physician burnout. And, as both Crispy Doc and I know, burnout is a great motivator of financial independence. So, that’s how I landed this coveted guest-post spot!
This post is based on a presentation I have given on several occasions up here in the Great White North (aka Canada). My goal is to make physicians more comfortable handling one of the most uncomfortable parts of our job - patient complaints.
Big mistake, big learning
Like a neurotic teenager, I remember every one of my patient complaints over the last thirteen years of practice but my worst performance in handling one occurred about ten years ago when I was a relatively new ER doc working in a rural ER. One day I saw a woman in her 60’s with a headache. There were no big red flags, so I treated her and sent her home. The next day she presented to one of my colleagues with a massive ischemic stroke.
She survived, but was unable to write, so her daughter wrote the complaint letter. I was upset but also couldn’t see that I’d missed anything. We reviewed the case as a group and no one crucified me for my management. So even though I felt horrible, I also felt vindicated.
My written response was fairly typical for a physician, and went something like this: “I saw your mother on such and such a day. Given the information I had at the time I think I did everything I should have and cannot see anything I should have done differently. Unfortunately, I believe her stroke was completely unpredictable.” A few months later I arrived at the hospital for my shift and was served papers saying I was being sued.
In hindsight, I know that lawsuit could have been avoided if I had responded better.
Patient complaints are like difficult airways - only worse
Being an emergency physician, I started thinking about difficult patients like difficult airways - and they actually have a lot in common if you think about it. Most of us dread the scenario of “can’t intubate, can’t ventilate” - and we hope it will be rare - but we spend valuable time and money training for those situations because if we’re not prepared for them it will make our jobs a lot more nerve-wracking.
The truth is that most airways will go just fine and the really difficult ones might happen every few years. Complaints, on the other hand, always suck because they’re personal. And most of us will probable get a few this year alone. We invest in airway skills because we care about our patients and our jobs. We should do the same for patient complaint skills.
No training for terrible scenarios
Were you taught how to deal effectively with patient complaints? I sure wasn’t, so when I got one I really didn’t know what to do. For years it didn’t even cross my mind that I could make things better - but I sure was afraid of making things worse. It took me a decade to figure out that no one was going to educate me, so I had to figure it out for myself.
Mostly, I learned from messing up - and then trying to get better the next time. But I’m a slow learner, so it took years to learn a simple truth: dealing with complaints is actually a heck of a lot easier than dealing with difficult airways. I’m going to try to make it even easier by breaking it down into a simple four step process. But first it will help to understand where the patients are coming from.
Why do patients complain?
The four general themes that most complaints fall into are those about attitude of the physician; communication issues with the physician; not being able to access the care the patient thought was appropriate; and lastly quality of care received. The truth is, most complaint letters will touch on some or all of these categories because when human beings are upset we tend to paint the whole situation with the same brush.
When it comes to the doctor patient interaction, what people care about most is attitude. At the end of the day, they don’t care how super smart you are, that you can reduce a shoulder and perform an LP at the same time, or that you might have just come from resuscitating a baby. They need to feel that you care about them.
If you routinely stand in the doorway, don’t make eye contact, interrupt their story and generally act like their problem is not the focus of all of your attention in that moment, you are going to get a lot of complaints. In fact, there are more complaints about doctor’s negative or condescending tone than anything else.
Communication starts with the basic social norms that are so easy to forget in the chaos of the ER - introducing yourself to everyone in the room, shake hands, find a place to sit down - even if it’s only for a minute they will think it is 5 - look at them when they are talking. And respond with at least a little empathy, even if you don’t feel it, because the truth is we can’t always muster it! But they deserve a genuine attempt.
Another part of good communication is orienting patients to what is going to happen in the department during their stay - where they are going to go for what tests and that you are going to talk with them again about next steps. If you’re admitting them, tell them why. If you’re sending them home, tell them what you expect to happen over the next few days, and reasons to return. Always make them feel welcome to return.
Sometimes people want access to care that we just can’t give them. Wait times are too long, they think they need an MRI of their stubbed toe, or they want a prescription that is not appropriate. It’s not that you should always give patients what they want - you shouldn’t! We are the ones who went to medical school, and doing things that are not appropriate even if the patient wants them will also get us into trouble.
But we should talk to patients about what the reasonable options are and why. And even though it is not our fault, it is ok to apologize for the things we cannot provide like shorter wait times, same day MRIs, or another refill of a controlled substance.
Complaints about quality of care usually stem from the perception that if the doctor would have done this, I would not have suffered some bad outcome. Of course, we know that bad outcomes can happen with the best of ER care, and the worst ER care sometimes has no consequence. So, these complaints are hard to predict. But when they happen, there are definitely ways you can minimize the pain and hardship they create.
What they want vs. what we want
Before she retired, the head of our Patient Relations department said to me: “Every single phone call or email with a patient making a complaint ends the same way - ‘I just don’t want this to happen to anyone else.’” So, what the patient wants is acknowledgement of their suffering and assurance that some measure will be taken to minimize the chance of it happening again.
Contrast this to what you want when you get a complaint. You probably want to be vindicated, to defend your actions and convince the patient you did a good job regardless of their perception of events. That’s certainly what I wanted when I wrote the response about that lady with the stroke. But, if we’re really honest, don’t we really just want the problem to go away?
Well, the best way to make a complaint go away is to find a resolution. We’re getting to that.
Normal is not good enough
The “normal” response to a patient complaint makes us sound a little like Spock from Star Trek. Cold and impersonal. We will give a technical recount of events and a rationalization of care. You may think a response like that is bad - and it is - but it could be a lot worse. Here are the major mistakes doctors often make when responding to angry patients:
- Some doctors will not review the chart thoroughly before responding. I think we do this because some part of us wants to sweep the complaint under the rug. But if you get details of the case wrong, you will lose credibility and risk escalation
- Frequently doctors will fail to acknowledge the pain and suffering of the patient. Again, this is understandable because there is fear that it will be seen as admitting responsibility. This is not the case.
- Because our professional pride is always hurt by a complaint, the tone of the letter may be defensive rather than reflective
- And, finally, if we don’t really engage in the process of empathizing with the patient who is complaining and admitting that we could have done better, there may be no assurance that efforts will be made to improve
This concludes part one of a two-part guest post. Stay tuned for the next installment.
About the author: Matt is an ER doctor who has worked for thirteen years in Ontario, Canada. After a particularly gruesome public relations disaster involving his ER a few years ago, he became a local expert on how to better manage patient relations. He has given his talk as a plenary at Canada’s largest ER conference (North York Emergency Medicine Update) and at several smaller venues. Since reaching FI about a year ago, Matt is now traveling around the world with his wife and four boys while blogging at www.big-family-small-world.com. He can be reached at firstname.lastname@example.org.