While sensitivity and empathy are vital components of managing patient-clinician communication in a disclosure event, listening is the most important – and possibly the hardest skill – for navigating communication in these difficult circumstances. Kirsten Dyer explains.
As experienced healthcare professionals, we understand the challenges of communication and the complexities associated with communicating to patients, their families and carers after care has gone wrong.
This is particularly true in situations where patients are vulnerable, seriously ill and they and their families are experiencing a stressful time.
When an adverse patient outcome has occurred, healthcare is increasingly offering an opportunity for transparent communications. This approach to communications, or open disclosure, may be applied as best practice or required by regulations such as the GMC’s duty of candour or National Quality Standards.
By communicating openly and honestly, we knowingly enter into challenging and difficult conversations that are often highly charged for all parties.
The needs of the patient and their families are paramount, yet we must not neglect our own needs and those of colleagues.
A supported and consistent approach can enable healthcare professionals to communicate effectively, openly and reduce any inclination to avoid a confrontational conversation.
No one wants to see a patient harmed or a family in distress. All of this responsibility for communication can feel like a tall order for doctors in stressful or complex situations.
As Danielle Ofri described in the book What Patients Say, What Doctors Hear, a Swiss medical study in the early 2000s found that patients are often only given a brief space to tell their story.
The study showed patients speak for 12 seconds on average after a clinician asks: ‘What can I do for you today?’, before the clinician moves the conversation towards a diagnosis.1
This may be a result of workload pressures, yet the patient and their family may perceive they are not being heard.
What does all of this tell us about the art of listening in a busy healthcare environment?
As healthcare professionals, our natural inclination is to be fixers. Instinctively, we do listen but move on fast to inform and diagnose, sometimes before a patient has had the opportunity to finish telling us about their symptoms.
At Cognitive Institute, our many years of experience has taught us the power of listening is core to effective communications and is a learned skill. We help clinicians of all disciplines to learn about the benefits of listening.
We teach the value of ‘sitting in silence’ while still actively listening to a patient or a family member before progressing to problem-solving and solution mode.
What really matters to patients and families?
In the event of an adverse clinical outcome, a prominent concern for healthcare providers and clinicians is often blame, and the fear of blame is then a likely barrier to truly hearing patients’ views. Yet, blame is often not the top priority for patients and their families.2
In a study by Moore, Bismark and Mello, many patients demonstrated satisfaction when listened to as opposed to being told what the clinicians wanted to share with them. In the majority of cases, the most favourable outcomes for both parties were a result of transparent and compassionate patient-clinician conversations and those where patients and families were treated with empathy in a non-adversarial environment.
Importantly, patients and families both reported a strong need to hear from the person directly responsible for their care. The sample also found that, in difficult situations, offers of compensation and the presence of a division chief instead of the clinician were unwelcome with patients and families.
This underlines the importance of having the right people in the room during a disclosure event, and the positive influence this direct and personal engagement has on perceptions.
Nor is it surprising that small gestures can make a difference to families coping with medical injuries. Moore, Bismark and Mello’s work presents a range of communication-based opportunities to improve outcomes after initial disclosure conversations.
These include making sure a patient’s preferred method of communication is used for all follow-up engagement, seeking feedback from them a few months down the track and making sure that patients are aware of any actions taken to improve safety.3
Facilitating full and frank incident investigations can be used to improve safety and quality and delivers benefits to patients by fostering openness and trust as part of the experience.
Benefits of an open culture
For independent healthcare providers, the benefits of an open culture are also multi-faceted. The ongoing consequences of adverse events can be mitigated through continued dialogue and organisational learning.
Healthcare organisations are better able to manage the stress and consequences of an adverse event or complaint, while professional, ethical and moral obligations to truthfully disclose information about harmful incidents are also fulfilled.
Additionally, open disclosure may contribute to a safer health system and enhance public trust in healthcare organisations.
These outcomes emerge from embedding better transparency and openness into healthcare, using the knowledge gained to help prevent recurrence of errors. It is supported by the role that listening and effective communication play in strengthening relationships between a healthcare organisation and an individual in their care.4
Are we still scared of being sued?
While the case for authentic, open and transparent communication has continued to gain traction over the past 20 years and the sector’s approach has improved significantly, we still have some way to go before the best-practice principles become a consistent, thoughtful and systemic part of our training and skills.
Ultimately, the fear of medico-legal litigation in the event of an error or failure of care remains a significant barrier to improving open and transparent communication with patients and their families.
The risk of legal action has many implications for both individual practitioners and employers when something goes wrong; potential reputational damage, the loss of employment and erosion of trust from patients, families and colleagues are just a few. Sometimes the implied threat is enough to stymie even the best open disclosure intentions or policies.
The benefits of prompt communication and resolution and shifting management of claims from defence to a patient-safety focus are highlighted in a recent article by Sage, Boothman and Gallagher, in the context of addressing growing concerns about medical liability.
The article concludes that rather than waiting for complaints and lawsuits, a health system’s risk management approach must have a quick-response system for addressing unfavourable patient outcomes.
The seizing of control over timing deals with persistent concerns about delayed claims from both risk managers and clinicians – and presumably patients. It also reduces financial uncertainty by promptly resolving most well-founded claims without legal action and shifting claims management from a ‘legal defensibility’ basis to a ‘patient-safety’ focus.
According to Wu, Huang, Stokes and Pronovost, when reporting the results of disclosing adverse events to patients and families, ‘it’s not what you say, it’s what they hear’.
There is broad consensus that physicians and healthcare organisations should disclose adverse events, but it is largely understood that most practitioners need support to do so successfully.5
The clarion call is that while there remains genuine trepidation about open disclosure and legal implications, there is a huge opportunity for healthcare providers to focus investment and resources on improving outcomes and skills, with potential substantial pay-off for culture, reputation and risk mitigation.
For information about MPS Partnerships’ transformational risk prevention programmes, including navigating adverse outcomes and duty of candour courses see www.mpspartnerships.org.
1. Ofri, D. (2017). What patients say, what doctors hear: what doctors say, what patients hear. Boston, Massachusetts: Beacon Press
2. Leape, LL (2006). Full Disclosure and Apology – An Idea Whose Time has Come. Physician Executive, 32(2).
3. Moore, J, Bismark, M and Mello, MM.(2017). Patients’ Experiences with Communication-and-Resolution Programs After Medical Injury. JAMA Internal Medicine, 177(11), p.1595.
4. Review: Implementation of the Australian Open Disclosure Framework. (2020). The Australian Commission on Safety and Quality in Health Care (safetyandquality.gov.au).
5. Wu, AW, Huang, I-Chan, Stokes, S. and Pronovost, PJ (2009). Disclosing Medical Errors to Patients: It’s Not What You Say, It’s What They Hear. Journal of General Internal Medicine, 24(9), pp.1012-17. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2726881/.
Kirsten Dyer (right) is senior clinical educator at Cognitive Institute and Medical Protection Society Partnerships