The Rude Get Sued


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Most hospital staff and patients try to avoid rude physicians…
Lawyers look for them.

Jurors may not understand the medicine in a malpractice case, but all have been the target of rude or rushed care. This rude behavior multiplier leads to “Jackpot Justice”.

Lawyers just love a good “service lapse”- angry words, a “TUDE”, even a late return phone call, or a cranky staff person. They revel when doctors and nurses are at odds.

In fact, patients often sue not because of genuine rude behavior, but their perception of short, curt treatment, or a feeling of incomplete disclosure. How can caregivers improve their patients’ perceptions, their expectations of care, to immunize themselves against suits?

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The Rude Get Sued

  1. 1. <ul><li>Visit today for a complimentary subscription to our invigorating newsletter! </li></ul><ul><li>Medical humor </li></ul><ul><li>Practical tactics to love your healthcare career </li></ul>
  2. 2. The Rude Get Sued Patricia L. Raymond MD FACP FACG Florida Society for Healthcare Risk Management & Patient Safety 3 August 2007
  3. 3. “… if a doctor shall operate on the eye of a man with a copper lancet and that man shall lose his eye, the eye of the doctor with a copper lancet they shall put out, and if he operated on a wound and the patient die, his hand is to be cut off...” ~Code of Hammurabi, 3000 BC
  4. 6. Who’s to blame for malpractice suits? Medical Economics, July 1999
  5. 7. “ Human behavior just doesn't change unless there are significant adverse consequences for unscrupulous behavior. When justice does prevail (and often it does not) the price of righteousness has to be high to prevent continued transgression.” The Burton Report Lawyers: Defense of Righteousness?
  6. 10. Effects of malpractice on HCPs <ul><li>Injury to ‘who we are’- very personal </li></ul><ul><li>Reactive/defensive medicine </li></ul><ul><ul><li>Risk to patients </li></ul></ul><ul><ul><li>Drives up healthcare costs </li></ul></ul><ul><li>Sucks joy from medical career </li></ul><ul><li>Physician data bank </li></ul><ul><ul><li>Your ‘permanent record’ </li></ul></ul>
  7. 11. Why do MDs get sued? We’re RUDE…
  8. 13. Why do docs get sued? <ul><li>“ Lack of caring” </li></ul><ul><li>Inaccessibility of MD </li></ul><ul><li>Lack of information </li></ul><ul><li>Aloofness of caregiver </li></ul><ul><li>Reluctance to apologize or explain </li></ul>The Lancet. 1994;343:1609-1613.
  9. 14. “ It isn’t medical outcome. A patient is more willing to forgive the physician for a poor outcome if there was good communication to begin with.”
  10. 15. Is your doctor in a hurry? <ul><li>Male doctors interrupt patients after listening on average only 23 seconds </li></ul><ul><li>Female doctors, reputed to be better listeners, interrupt in 35 seconds </li></ul>
  11. 16. Association between number of patient complaints and ‘risk management events’ <ul><li>Six year study, 645 MDs (2/3 non-surgical) </li></ul><ul><li>Complaints about communication, humaneness, access, and availability </li></ul><ul><li><10% of MDs led to >50 % complaints </li></ul><ul><li>8% of MDs had >50% of 135 malpractice claims </li></ul>JAMA June 12, 2002
  12. 17. 71% of malpractice suits (are) filed based on a breakdown of the physician-patient relationship. Howard Beckman MD, 1994
  13. 19. The Medical Apology <ul><li>>30% of patients or relatives would not have sued if they had received an explanation or apology from their MD </li></ul><ul><li>Motivation for lawsuit is anger at what MD did/did not say, not negligence </li></ul><ul><ul><li>80% MDs introverts, 20% patients introverts </li></ul></ul><ul><li>< 2 % who suffer a significant injury due to negligence initiate a malpractice claim </li></ul>
  14. 21. Disclosure <ul><li>98% of patients want or expect their MDs to acknowledge errors, whether or not these caused any harm. </li></ul><ul><li>In the event of poor outcome, patients were more likely to report the error to authorities or consider legal action if their physician failed to disclose the error. </li></ul>Witman AB, Arch Int Med 1996;156:2565-2569.
  15. 23. Full vs. Partial Disclosure <ul><li>Survey to 1500 New England health plan participants </li></ul><ul><li>Medical error (PCN allergy or non-monitor Sz meds), clinical outcome (life-threatening or non serious), MD-Pt dialogue c Full or Non Disclosure </li></ul>Ann Int Med 2004;140:409-418
  16. 24. Full vs. Partial Disclosure <ul><li>Full- Accept responsibility and apology </li></ul><ul><li>Non- Expression of regret without acceptance of responsibility or apology </li></ul><ul><li>Measured likelihood of change MD, pt satisfaction, trust; legal advice </li></ul>Ann Int Med 2004;140:409-418
  17. 26. Tap dancing, anyone? <ul><li>Pt: Was this an allergic reaction? Because I know that I am allergic to penicillin. </li></ul><ul><li>MD: There is a note on your medical record that you have a history of an allergy to penicillin. I checked when you called about the rash, and it is documented. But you know, every prescription is different and every person is different. Sometimes it’s not possible to predict how a person’s body will react. </li></ul>
  18. 27. Tap dancing, anyone? II <ul><li>Pt: If you had asked if I was allergic to penicillin, I would have told you I was. </li></ul><ul><li>MD: Right. And it’s not unusual for someone to have a reaction like you did. Medications do sometimes have side effects or cause reactions that we don’t want. Sometimes it’s unavoidable- someone starts on a treatment for one thing, like the infection on your face, and unfortunately the treatment for one problem ends up causing another. It’s unfortunate, but it does happen. </li></ul>
  19. 28. Fall on your sword <ul><li>Pts adult child: So he fell because you put him on such a high dose of medicine? </li></ul><ul><li>MD: There may have been other factors involved, but it’s true that the high level of seizure medication probably contributed to the fall. I should have checked your father’s blood level a few days after I increased the dosage to see whether it was too high. I might have been able to prevent his fall if I had checked his blood. </li></ul>
  20. 29. Fall on your sword II <ul><li>MD: I was focused on keeping the seizures under control, but I didn’t follow up as I should have. I feel terrible that he fell and that I didn’t pick up on the mistake earlier. I am sorry that it happened. </li></ul><ul><li>Pts adult child: I just worry so much because he is getting older and I can’t be there to take care of him all the time. </li></ul>
  21. 30. Fall on your sword III <ul><li>MD: I understand. It’s hard to watch people age, especially when they have accidents and get hurt. I assure you that we will take good care of him. In fact, we have a committee on patient safety here that looks at exactly this type of problem. The first order of business the next meeting will be to work out a system so that this doesn’t happen again. </li></ul>
  22. 32. Full vs. Partial Disclosure <ul><li>Nondisclosure: Poor or mild outcome </li></ul><ul><ul><li>Lower patient satisfaction </li></ul></ul><ul><ul><li>Less trust in physician </li></ul></ul><ul><ul><li>Negative emotional response </li></ul></ul><ul><li>Complete disclosure did not increase likelihood of seeking legal advice </li></ul>Ann Int Med 2004;140:409-418
  23. 33. Patients Seek Legal Advice Seeking legal advise is only stat more likely for allergy/non -serious/non -disclosure
  24. 34. Juries may not understand the medicine, but all have experienced rudeness.
  25. 35. Exacerbated by <ul><li>Lack of EQ </li></ul><ul><li>The 2APC </li></ul><ul><li>Patient Illiteracy </li></ul><ul><li>Documentation (& poor penmanship) </li></ul><ul><li>Adversarial relationship with our own attorneys </li></ul>
  26. 37. <ul><li>IQ does not correlate well with success </li></ul><ul><ul><li>Correlation of IQ with career success 4-25% </li></ul></ul><ul><li>Women are not ‘smarter’ than men re EQ </li></ul><ul><ul><li>Men and women do have a shared, gender-specific profile of strong and weak points </li></ul></ul><ul><li>Frequently as IQ rises, EQ falls </li></ul><ul><li>EQ is a learned behavior, not fixed or genetically predisposed. Growth of EQ= maturity </li></ul>Explain IQ verses EQ Daniel Goleman, Working with Emotional Intelligence, 1998
  27. 39. Poor collegial relationship between physicians and nurses <ul><li>2/3 of nurses are abused by physicians at least once every two to three months </li></ul><ul><li>92.5% have witnessed disruptive MD behavior </li></ul><ul><li>2-5% of medical staff exhibit disruptive behavior </li></ul><ul><li>Disruptive behavior was important contributing factor to erosion of nurse satisfaction and morale </li></ul>Rosenstein, AJN 2002
  28. 41. Why should we care? <ul><li>Nursing shortage </li></ul><ul><ul><li>“ I’m just working here until </li></ul></ul><ul><ul><li>a good fast-food job opens up.” </li></ul></ul><ul><ul><li>Percentage of dissatisfied nurses considering leaving according to Nursing Executive Center Advisory Group </li></ul></ul><ul><ul><ul><li>94% of very dissatisfied </li></ul></ul></ul><ul><ul><ul><li>89% of somewhat dissatisfied </li></ul></ul></ul><ul><ul><ul><li>63% of somewhat satisfied </li></ul></ul></ul><ul><ul><ul><li>Only 33% of very satisfied </li></ul></ul></ul>
  29. 42. Why should we care? <ul><li>Nursing shortage </li></ul><ul><li>Bad interaction with docs leads to bad patient outcomes </li></ul>
  30. 43. Incivility and morbidity/mortality <ul><li>Knaus 1986 Ann Int Medicine </li></ul><ul><ul><li>5030 patients in 13 ICUs </li></ul></ul><ul><ul><ul><li>Differences in death rates related to interaction and communication between nurses and MDs </li></ul></ul></ul><ul><li>Shortell 1994 Medical Care </li></ul><ul><ul><li>17,440 patients in 42 ICUs </li></ul></ul><ul><ul><ul><li>Group culture, leadership, communication, coordination, conflict management abilities </li></ul></ul></ul><ul><ul><ul><ul><li>Lower risk-adjusted length of hospital stay & nurse turnover </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Higher technical quality of care </li></ul></ul></ul></ul>
  31. 44. Why should we care? <ul><li>Nursing shortage </li></ul><ul><li>Bad interaction with docs leads to bad patient outcomes </li></ul><ul><li>Pull fannies from the fire </li></ul>
  32. 46. Health literacy issues <ul><li>48% of patients wouldn’t know when to take a pill for instructions: </li></ul><ul><ul><li>“take the medicine on an empty stomach- one hour prior to eating or two hours after eating.” </li></ul></ul><ul><li>22% do not understand “take every six hours.” </li></ul><ul><li>Higher health illiteracy with age (60% greater than 85 y/o) </li></ul>1998 AMA study on low health literacy
  33. 48. “ Patients want their physician to help them restore balance and control over their lives, not to treat them with an impersonal or condescending attitude. Lawsuits are launched by patients who blame poor outcome on a perceived lack of professionalism on the part of the physician.” ~Richard Bernard, SCPIE/American Healthcare Indemnity
  34. 49. Rx: Teach your docs bedside manners
  35. 54. EQ 101 for the physician <ul><li>Be on time, Be courteous, Explain yourself </li></ul><ul><li>Encourage participation </li></ul><ul><ul><li>Patients </li></ul></ul><ul><ul><li>Nurses </li></ul></ul><ul><li>Disclose errors and poor outcomes </li></ul>
  36. 55. 1. “Be gracious” <ul><li>Time management </li></ul><ul><ul><li>Schedule realistically & respect your patients’ time </li></ul></ul><ul><li>Use your patients proper names </li></ul><ul><ul><li>At least three times per visit </li></ul></ul><ul><ul><li>Appropriate touch prior to exam </li></ul></ul><ul><ul><li>‘Seem’ to take time </li></ul></ul>gracious
  37. 56. 2a. Ask patients to assist with their own care <ul><li>Pre Appointment Tasks: </li></ul><ul><ul><li>List </li></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><ul><ul><li>PMedHx, PSxHx </li></ul></ul></ul><ul><ul><li>Questions and concerns </li></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>
  38. 57. Physicians with no history of malpractice claims <ul><li>More information re what to expect from care </li></ul><ul><li>Verified level of understanding </li></ul><ul><li>Encouraged patients to talk during consultation </li></ul>Levinson W, JAMA 1997;277:553-559.
  39. 58. Can you hear me? <ul><li>Tape recorder </li></ul><ul><li>Family member </li></ul><ul><li>Teach back </li></ul><ul><li>Printed educational material (6 th grade level) </li></ul><ul><li>Your own website with appropriate links </li></ul>
  40. 60. Patients on the Net <ul><li>85% MDs had a patient bring Internet information to their appointment </li></ul><ul><li>Physicians believe that patients bringing in accurate, relevant online information is beneficial and welcome it. </li></ul><ul><li>Conversely, physicians believe that inaccurate or irrelevant information harms the quality of care, health outcomes, time efficiency, and the physician-patient relationship. </li></ul>Journal of Medical Internet Research (2003;5(3):e17)
  41. 61. 2b. Help your docs partner with medical colleagues <ul><li>Bring nurses on as partners in care management </li></ul><ul><ul><li>Shared responsibility </li></ul></ul><ul><ul><li>Personalization </li></ul></ul><ul><ul><li>A bit of thanks </li></ul></ul>
  42. 63. Nobody wants constructive criticism. It's all we can do to put up with constructive praise.  -- Mignon McLaughlin Fish Compl
  43. 65. Help your docs learn to express gratitude/ positive reinforcement <ul><li>Thorndyke’s law 1911 </li></ul><ul><ul><li>Performance that is rewarded is likely to be repeated ( Positive reinforcement>negative reinforcement) </li></ul></ul>
  44. 66. <ul><li>“ Make a Change” </li></ul>
  45. 67. Rude by proxy: Our office staff “ Sarcasm is just one more service that we offer.”
  46. 68. Customer service <ul><li>Managing Patient Expectations. The Art of Finding and Keeping Loyal Patients. Susan Keane Baker  1998 Josey-Bass. </li></ul><ul><li>The ominous second call </li></ul><ul><li>Autonomy: “Consider it done” </li></ul><ul><li>Ritz Carlton: “My pleasure”, “Certainly”, “No problem” </li></ul>
  47. 71. 3.Help your docs learn to apologize <ul><li>Patients want: </li></ul><ul><ul><li>Detailed explanations </li></ul></ul><ul><ul><li>Sincere apology </li></ul></ul><ul><ul><li>Assurances that steps will be taken to prevent recurrences </li></ul></ul><ul><ul><li>Medical fees associated with an error to be waived </li></ul></ul>Ann Int Med 2004;140:409-418
  48. 73. How??? <ul><li>Formal workshop on medical apologies </li></ul><ul><li>Collect and distribute studies on disclosure </li></ul><ul><li>Create a culture that values timely, heartfelt apologies, not defensiveness. </li></ul>
  49. 74. 4. Expect your docs to be nice to their/your lawyer <ul><ul><ul><li>Give up control in court </li></ul></ul></ul><ul><ul><ul><ul><li>Not your turf </li></ul></ul></ul></ul><ul><ul><ul><li>Assist in discovery and trial </li></ul></ul></ul><ul><ul><ul><ul><li>Find and forward medical literature </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Educate your attorney about the medicine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Be educable about the legal issues and proper defense behavior </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Be available to your attorney for questions </li></ul></ul></ul></ul>
  50. 76. If your docs choose to be rude… The Doctors Wealth Protection Guide, Mandell DB, Goldstein AS, Jarvis CR.  1999 Guardian Publishing
  51. 77. Few things are harder to put up with than a good example. -Mark Twain 1835-1910
  52. 78. Teach your docs to play nice. I 3 Implement it immediately!
  53. 80. <ul><li>Visit today for a complimentary subscription to our invigorating newsletter! </li></ul><ul><li>Medical humor </li></ul><ul><li>Practical tactics to love your healthcare career </li></ul>