Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Are your patients satisfied? David Scott MD To cite this article: David Scott MD (1992) Are your patients satisfied?, Postgraduate Medicine, 92:5, 169-176, DOI: 10.1080/00325481.1992.11701491 To link to this article: http://dx.doi.org/10.1080/00325481.1992.11701491
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Citing articles: 4 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [University of Technology Sydney]
Date: 24 July 2016, At: 14:59
COMMENTARY
Are your patients satisfied? Strategies that may help you avoid a formal complaint
Downloaded by [University of Technology Sydney] at 14:59 24 July 2016
David Scott, MD
Dr Scott is an internist with Park Nicollet Medical Center, Brooklyn Center, Minnesota.
Most physicians have received an angry letter from a dissatisfied patient. Many have experienced the stress, frustration, or embarrassment that accompanies a formal complaint to a hospital, HMO, professional society, or licensing authority. In the regulated world of modern medicine, however, complaints are no longer just a source of distress; they can have a real impact on a physician's practice. Complaints about physicians, even those that are unfounded, often initiate a chain of troubling events in credentialing agencies and, if unresolved, can be the first step toward a malpractice suit or formal censure. While serving as part-time associate medical director of a large HMO, I had the opportunity to review a number of patient complaints. It did not take long to see that few complaints come without warning, especially those involving primary care physicians with whom the patient has an existing relationship. In many cases, there is a progressive deterioration of the physician-patient relationship that culminates in some type of formal complaint. There are several recurring themes and various warning signs of impending problems. Observant physicians may be able to recognize a high-risk situation and take preventive measures. This article discusses a number of common complaint scenarios, warning signs of dissatisfaction, and preventive strategies. Clearly, many complaints either have no basis or involve expectations that simply cannot be met. On the other hand, the daily pace of practice allows for habits that can get any physician into hot water. Common complaints
The doctor didn't listen to me. "After 2 minutes, the doctor told me I had migraine headaches and gave me a prescription. How could he possibly know that?"
continued
VOL 92/NO 5/0CTOBER 1992/POSTGRAOUATE MEDICINE • COMPLAINTS
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Downloaded by [University of Technology Sydney] at 14:59 24 July 2016
COMMENTARY CONTINUED
In fact, this patient had classic migraine, and the physician had provided the correct treatment. Diagnosis and management were flawless. So why the problem? From medical school onward we have been bombarded with lectures, admonitions, and articles emphasizing the importance of good communication. How can such welleducated people make so many of their patients angry by not listening? I think physicians do listen, but we often make quick judgments without hearing everything patients have to say. Many patients want more than a diagnosis-they want to be heard. Patients seem to mistrust a diagnosis made too easily. They expect a very thorough history to be taken even when, to the physician, the diagnosis is obvious almost immediately. One of the most frequent complaints is that the time the physician spent with the patient was too brief. Unfortunately, in this era of time pressure, many patients still measure a doctor's interest by the clock Not surprisingly, the physician often remembers the encounter differently and has copious documentation of a complete examination. The problem seems to be the patient's perception that the examination was rushed or that some issue was not explored. How can such a perception be avoided? Conduct a relaxed, unhurried exam. This is more a matter of style than of clock time. Try to avoid phone interruptions. If time is critical, have a small dock in the room. Looking at your watch is a red flag to patients who have an inclination to dissatisfaction. Try to avoid interrupting patients. As maddening and inefficient as it may be to listen to a history that begins, "When my Uncle Ed came to visit back in 1959 ... " that is how some people organize thoughts and communicate. I have learned through experience that repeating the question
170
"When did your headaches begin?" only prolongs the story. Finish the visit with a question such as, "Have we covered everything?" or "Is there anything else?" This not only cuts down on the likelihood that you'll have to pay a second visit to the examination room because the patient has one more thing to ask, but it also gives patients a feeling of satisfaction because they think that the examination was complete. The doctor wouldn't even talk to me. "I told her nurse that my baby was really sick, but the doctor wouldn't talk to me. The nurse told me that the doctor said it was just a cold and I shouldn't worry about it." This woman was later told by an emergency department physician that her baby had pneumonia. In fact, the infiltrate on the chest film was highly questionable, but the mother was predisposed to anger after having been "put off." Few situations are riskier for a physician than communicating through a third party. First, there is the patient's reaction to being put off by the physician, and, second, there is the physician's lack of control over what is said. Often, factually correct messages are transmitted with a different tone than the physician intended. I was burned once when I communicated with a family member through a nurse about a seriously ill nursing home patient. The facts were given but in a manner so distorted I could hardly blame the family for objecting. Clearly, not every call can be handled personally, but certain steps can offer some protection. Know who is handling your messages. It is one thing for your own staff to communicate with a patient or family, but it is quite another for a hospital or nursing home staff member, over whom you have no control, to do so. Advise ill patients to call back right away if their continued
COMPLAINTS • VOL 92/NO 5/0CTOBER 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Technology Sydney] at 14:59 24 July 2016
COMMENTARY CONTINUED
condition changes or worsens; document your advice. Patients often don't feel better after reassurances alone, so an expression of concern and specific instructions can be helpful. Handle repeated calls yourself, if possible. The crush of "not-getting-any-better" calls can be daunting, but be alen to messages that suggest significant change, unusual concern, or frustration.
My doctor didn't do any tests. "I've had lower abdominal pain off and on after eating for 10 years. My wife finally insisted I see a doctor because her father just found out he had colon cancer. The doctor told me I had irritable bowel syndrome, but he didn't even order any tests. How can I be sure I don't have colon cancer?" After 10 years of pain, this man, who was in his early 30s, clearly did not have colon cancer. His history was classic for irritable bowel syndrome, and the therapy recommended was stateof-the-an. It has been years since we have seen a news story about healthcare costs that did not use the terms "soaring" or "skyrocketing." Our patients, however, seem to be in agreement about who should have fewer procedures to curb costs-the other guy. We live in a society that admires machines that think but mistrusts people who tty to. Many patients expect, or demand, testing before they will accept a diagnosis. Sometimes they have a specific test in mind and are unhappy unless that test is done, even though they may not share that expectation with their physician. Often they just want "tests." Obviously, with physicians caught in an evertightening economic vise, we can't simply accede to every demand for testing. On the other hand, we have to avoid the "Lee Iacocca syndrome"-patients expecting a bumper-to-bumper warranty if things are done "our way."
There are several strategies for dealing with patients who have such expectations. For example, after the examination, discuss with the patient tests that could be done, and review the potential risks, benefits, and costs. Then give your recommendation. I find that most patients accept my judgment if the reasoning is laid out, especially when the testing involves risk. Document this discussion. Instead of ruling out a procedure, set up a plan that involves a trial of therapy and watchful waiting but that includes more testing if the condition does not improve. Patients are often more comfonable knowing their options are still open. Cenainly you may end up doing some testing you may have doubts about, but not often. Finally, read your patient. Sometimes there is only one thing that will bring satisfaction. If a patient is determined to have a CT scan for headaches, in some cases it is best to do one. You must consider the risk, likely yield, and cost of a scan versus the cost of multiple follow-up visits and calls if one is not done. In many cases in which patients complained about not having a test, the test had become a power struggle between patient and physician. The more the patient wanted the test, the more the physician was determined not to order it. If you see this situation developing, get a second opinion.
I didn't like the doctor's attitude. "I saw the doctor right after my car accident. I had a big cut on my forehead. Just because I was lighting a cigarette and driving without a seat belt after having a few beers, he acted like it was all my fault." This is obviously an exaggeration, but it makes a point. Physicians are, by nature, cautious, responsible, and hard-working, and we have a hard time identifYing with the careless or impulsive behaviors of some patients. Everyone has a "hot button." It can be difficult for an overworked physician con-
continued
VOL 92/NO 5/0CTOBER 1992/POSTGRADUATE MEDICINE • COMPLAINTS
173
Downloaded by [University of Technology Sydney] at 14:59 24 July 2016
COMMENTARY CONTINUED
fronted with a patient's self-destructive behavior not to make a judgment. But bite your tongue. Sometimes there is just no nice way to say what you are thinking. Cenainly you have a duty toeducate, but ask yourself what your motive is before you say anything. You may spare yourself some grie£ On the other hand, don't be intimidated by the threat of a complaint. Who has not encountered a drug seeker or malingerer who tries to use a physician's natural disposition toward satisfYing patients to his or her own end? If a simple "no" constitutes a bad attitude, so be it. Signs of dissatisfaction Surprisingly, few patients will come right out and tell a physician they are unhappy with the care they are receiving. Physicians are still potent authority figures, and few patients are comfortable confronting them. However, when patients are dissatisfied, they often manifest behavior that suggests unhappiness. Crescendo phone calls are one sign of such unhappiness. A patient who leaves phone messages with increasing frequency, especially to say ''I'm not getting any better" or "I forgot to ask you something," may be telling you he or she is unhappy with your care. If the calls are taken at face value and minor questions are answered and problems are addressed, the underlying issue may not surface until the patient is so frustrated that he or she takes some other action. To prevent this situation, be alert to this pattern and return the calls yourself The patient may be seeking a less threatening way to communicate the problem than in a face-to-face situation. If calls are handled by your nurse or someone else, the opportunity to address the problem is lost.
174
Ask repeated callers an open-ended question such as, "Is there anything else?" or ''Are you comfortable with this plan?" This may get them talking. Your staff should be trained not to cut patients off if they sound unhappy and to convey this information to you. The emergency department as second opinion The emergency department is, for many patients, the ultimate recourse. They don't need a referral or an appointment. It may be the only part of the healthcare system over which they have some control. A patient who goes to an emergency department with a viral illness, back or joint pain, dermatologic problem, or similar minor ailment that you have been treating without success is probably looking for a second opinion without asking for one. A typical scenario follows. Monday-Patient sees you with a backache. Everything points to a simple musculoskeletal problem. You prescribe conservative treatment and recommend over-the-counter ibuprofen. Wednesday-Patient calls and is no better. You recommend patience and continuation of current therapy. Friday-At a follow-up visit, the patient is still in pain. On examination, you find nothing, carefully explain the problem, review the appropriate back exercises with the patient, and prescribe a mild muscle relaxant. Friday night-The patient is seen at the emergency depanment for "terrible" back pain. He says, "My doctor is not doing anything about it." The emergency department doctor notes that the patient appears to be in a lot of pain. Results of examination are normal. A small amount of acetaminophen with codeine is given with instructions to follow up with you on Monday. continued
COMPLAINTS • VOL 92/NO 5/0CTOBER 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Technology Sydney] at 14:59 24 July 2016
COMMENTARY CONTINUED
Monday-Patient calls to say the pain is worse and to let you know he was seen in the emergency department. He says, "The emergency department doctor couldn't believe you haven't done a CT scan yet." You suggest another appointment at the end of the week and offer physical therapy in the meantime. Patient agrees to another appointment but fails to show up for physical therapy. Wednesday-Patient sends angry letters to hospital medical staff and medical association depicting you as grossly incompetent. To help diffuse a situation like this, read the emergency department notes sent to you. The doctor often picks up a hint of the patient's true agenda. Look at the records of the emergency department examination to see how the patient is described. Call patients who go to the emergency department, unless the problem was obvious and not serious (eg, a minor laceration). Ask them what happened and how they are doing, and ask for their input on how to proceed.
Third-party calls Any telephone call that opens with ''I'm calling on behalf of ... " can be trouble. Assuming the patient is not a child or a debilitated elderly person, you should ask yourself why the patient is not calling. Often the call is symptomatic of a disagreement between spouses over the medical care of one of them, but it can also come from a spouse (or parent of an adult child) who wishes to relate the frustration that the patient will not express. It may be helpful to listen carefully to the information presented by the caller, because this often can tip you off to problems. But don't discuss the problem with another person without the patient's
176
documented permission. To do so may violate patient rights laws in some states and may make the patient very unhappy. Always talk to the patient. Even if you have permission to discuss his or her care with another person, speak direcdy to the patient as well. The problems of third-party communication are as great, if not greater, when the third party represents the patient rather than you. Be sure to find out what led to the call and make sure that both the caller and the patient received the same message.
Dealing with a dissatisfied patient Once you have identified dissatisfaction or frustration, communicate with the patient as soon as possible. A call to say "I saw you were at the emergency department yesterday and wondered how you are doing" can work miracles. A few minutes of your time and attention are valuable to your patients. Your contact gives the patient an opportunity to express his or her concerns. If the patient seems uncomfortable with your suggestions, recommend a consultation. If a patient threatens a complaint or other formal action, that is his or her right. Any attempt to dissuade the patient can only inflame the situation. The best response to such a threat probably is, "That is your right, of course, but I'm still concerned about your problem. How would you like to proceed?" As long as you continue to care about the patient even after he or she has stopped caring about you, you have done your best. Rill
Address for correspondence: David Scott, MD, Park Nicollet Medical Center, 6000 Earle Brown Dr, Brooklyn Center, MN 55430.
COMPLAINTS • VOL 92/NO 5/0CTOBER 1992/POSTGRADUATE MEDICINE
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Are your patients satisfied? David Scott MD To cite this article: David Scott MD (1992) Are your patients satisfied?, Postgraduate Medicine, 92:5, 169-176, DOI: 10.1080/00325481.1992.11701491 To link to this article: http://dx.doi.org/10.1080/00325481.1992.11701491
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Citing articles: 4 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [University of Technology Sydney]
Date: 24 July 2016, At: 14:59
COMMENTARY
Are your patients satisfied? Strategies that may help you avoid a formal complaint
Downloaded by [University of Technology Sydney] at 14:59 24 July 2016
David Scott, MD
Dr Scott is an internist with Park Nicollet Medical Center, Brooklyn Center, Minnesota.
Most physicians have received an angry letter from a dissatisfied patient. Many have experienced the stress, frustration, or embarrassment that accompanies a formal complaint to a hospital, HMO, professional society, or licensing authority. In the regulated world of modern medicine, however, complaints are no longer just a source of distress; they can have a real impact on a physician's practice. Complaints about physicians, even those that are unfounded, often initiate a chain of troubling events in credentialing agencies and, if unresolved, can be the first step toward a malpractice suit or formal censure. While serving as part-time associate medical director of a large HMO, I had the opportunity to review a number of patient complaints. It did not take long to see that few complaints come without warning, especially those involving primary care physicians with whom the patient has an existing relationship. In many cases, there is a progressive deterioration of the physician-patient relationship that culminates in some type of formal complaint. There are several recurring themes and various warning signs of impending problems. Observant physicians may be able to recognize a high-risk situation and take preventive measures. This article discusses a number of common complaint scenarios, warning signs of dissatisfaction, and preventive strategies. Clearly, many complaints either have no basis or involve expectations that simply cannot be met. On the other hand, the daily pace of practice allows for habits that can get any physician into hot water. Common complaints
The doctor didn't listen to me. "After 2 minutes, the doctor told me I had migraine headaches and gave me a prescription. How could he possibly know that?"
continued
VOL 92/NO 5/0CTOBER 1992/POSTGRAOUATE MEDICINE • COMPLAINTS
169
Downloaded by [University of Technology Sydney] at 14:59 24 July 2016
COMMENTARY CONTINUED
In fact, this patient had classic migraine, and the physician had provided the correct treatment. Diagnosis and management were flawless. So why the problem? From medical school onward we have been bombarded with lectures, admonitions, and articles emphasizing the importance of good communication. How can such welleducated people make so many of their patients angry by not listening? I think physicians do listen, but we often make quick judgments without hearing everything patients have to say. Many patients want more than a diagnosis-they want to be heard. Patients seem to mistrust a diagnosis made too easily. They expect a very thorough history to be taken even when, to the physician, the diagnosis is obvious almost immediately. One of the most frequent complaints is that the time the physician spent with the patient was too brief. Unfortunately, in this era of time pressure, many patients still measure a doctor's interest by the clock Not surprisingly, the physician often remembers the encounter differently and has copious documentation of a complete examination. The problem seems to be the patient's perception that the examination was rushed or that some issue was not explored. How can such a perception be avoided? Conduct a relaxed, unhurried exam. This is more a matter of style than of clock time. Try to avoid phone interruptions. If time is critical, have a small dock in the room. Looking at your watch is a red flag to patients who have an inclination to dissatisfaction. Try to avoid interrupting patients. As maddening and inefficient as it may be to listen to a history that begins, "When my Uncle Ed came to visit back in 1959 ... " that is how some people organize thoughts and communicate. I have learned through experience that repeating the question
170
"When did your headaches begin?" only prolongs the story. Finish the visit with a question such as, "Have we covered everything?" or "Is there anything else?" This not only cuts down on the likelihood that you'll have to pay a second visit to the examination room because the patient has one more thing to ask, but it also gives patients a feeling of satisfaction because they think that the examination was complete. The doctor wouldn't even talk to me. "I told her nurse that my baby was really sick, but the doctor wouldn't talk to me. The nurse told me that the doctor said it was just a cold and I shouldn't worry about it." This woman was later told by an emergency department physician that her baby had pneumonia. In fact, the infiltrate on the chest film was highly questionable, but the mother was predisposed to anger after having been "put off." Few situations are riskier for a physician than communicating through a third party. First, there is the patient's reaction to being put off by the physician, and, second, there is the physician's lack of control over what is said. Often, factually correct messages are transmitted with a different tone than the physician intended. I was burned once when I communicated with a family member through a nurse about a seriously ill nursing home patient. The facts were given but in a manner so distorted I could hardly blame the family for objecting. Clearly, not every call can be handled personally, but certain steps can offer some protection. Know who is handling your messages. It is one thing for your own staff to communicate with a patient or family, but it is quite another for a hospital or nursing home staff member, over whom you have no control, to do so. Advise ill patients to call back right away if their continued
COMPLAINTS • VOL 92/NO 5/0CTOBER 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Technology Sydney] at 14:59 24 July 2016
COMMENTARY CONTINUED
condition changes or worsens; document your advice. Patients often don't feel better after reassurances alone, so an expression of concern and specific instructions can be helpful. Handle repeated calls yourself, if possible. The crush of "not-getting-any-better" calls can be daunting, but be alen to messages that suggest significant change, unusual concern, or frustration.
My doctor didn't do any tests. "I've had lower abdominal pain off and on after eating for 10 years. My wife finally insisted I see a doctor because her father just found out he had colon cancer. The doctor told me I had irritable bowel syndrome, but he didn't even order any tests. How can I be sure I don't have colon cancer?" After 10 years of pain, this man, who was in his early 30s, clearly did not have colon cancer. His history was classic for irritable bowel syndrome, and the therapy recommended was stateof-the-an. It has been years since we have seen a news story about healthcare costs that did not use the terms "soaring" or "skyrocketing." Our patients, however, seem to be in agreement about who should have fewer procedures to curb costs-the other guy. We live in a society that admires machines that think but mistrusts people who tty to. Many patients expect, or demand, testing before they will accept a diagnosis. Sometimes they have a specific test in mind and are unhappy unless that test is done, even though they may not share that expectation with their physician. Often they just want "tests." Obviously, with physicians caught in an evertightening economic vise, we can't simply accede to every demand for testing. On the other hand, we have to avoid the "Lee Iacocca syndrome"-patients expecting a bumper-to-bumper warranty if things are done "our way."
There are several strategies for dealing with patients who have such expectations. For example, after the examination, discuss with the patient tests that could be done, and review the potential risks, benefits, and costs. Then give your recommendation. I find that most patients accept my judgment if the reasoning is laid out, especially when the testing involves risk. Document this discussion. Instead of ruling out a procedure, set up a plan that involves a trial of therapy and watchful waiting but that includes more testing if the condition does not improve. Patients are often more comfonable knowing their options are still open. Cenainly you may end up doing some testing you may have doubts about, but not often. Finally, read your patient. Sometimes there is only one thing that will bring satisfaction. If a patient is determined to have a CT scan for headaches, in some cases it is best to do one. You must consider the risk, likely yield, and cost of a scan versus the cost of multiple follow-up visits and calls if one is not done. In many cases in which patients complained about not having a test, the test had become a power struggle between patient and physician. The more the patient wanted the test, the more the physician was determined not to order it. If you see this situation developing, get a second opinion.
I didn't like the doctor's attitude. "I saw the doctor right after my car accident. I had a big cut on my forehead. Just because I was lighting a cigarette and driving without a seat belt after having a few beers, he acted like it was all my fault." This is obviously an exaggeration, but it makes a point. Physicians are, by nature, cautious, responsible, and hard-working, and we have a hard time identifYing with the careless or impulsive behaviors of some patients. Everyone has a "hot button." It can be difficult for an overworked physician con-
continued
VOL 92/NO 5/0CTOBER 1992/POSTGRADUATE MEDICINE • COMPLAINTS
173
Downloaded by [University of Technology Sydney] at 14:59 24 July 2016
COMMENTARY CONTINUED
fronted with a patient's self-destructive behavior not to make a judgment. But bite your tongue. Sometimes there is just no nice way to say what you are thinking. Cenainly you have a duty toeducate, but ask yourself what your motive is before you say anything. You may spare yourself some grie£ On the other hand, don't be intimidated by the threat of a complaint. Who has not encountered a drug seeker or malingerer who tries to use a physician's natural disposition toward satisfYing patients to his or her own end? If a simple "no" constitutes a bad attitude, so be it. Signs of dissatisfaction Surprisingly, few patients will come right out and tell a physician they are unhappy with the care they are receiving. Physicians are still potent authority figures, and few patients are comfortable confronting them. However, when patients are dissatisfied, they often manifest behavior that suggests unhappiness. Crescendo phone calls are one sign of such unhappiness. A patient who leaves phone messages with increasing frequency, especially to say ''I'm not getting any better" or "I forgot to ask you something," may be telling you he or she is unhappy with your care. If the calls are taken at face value and minor questions are answered and problems are addressed, the underlying issue may not surface until the patient is so frustrated that he or she takes some other action. To prevent this situation, be alert to this pattern and return the calls yourself The patient may be seeking a less threatening way to communicate the problem than in a face-to-face situation. If calls are handled by your nurse or someone else, the opportunity to address the problem is lost.
174
Ask repeated callers an open-ended question such as, "Is there anything else?" or ''Are you comfortable with this plan?" This may get them talking. Your staff should be trained not to cut patients off if they sound unhappy and to convey this information to you. The emergency department as second opinion The emergency department is, for many patients, the ultimate recourse. They don't need a referral or an appointment. It may be the only part of the healthcare system over which they have some control. A patient who goes to an emergency department with a viral illness, back or joint pain, dermatologic problem, or similar minor ailment that you have been treating without success is probably looking for a second opinion without asking for one. A typical scenario follows. Monday-Patient sees you with a backache. Everything points to a simple musculoskeletal problem. You prescribe conservative treatment and recommend over-the-counter ibuprofen. Wednesday-Patient calls and is no better. You recommend patience and continuation of current therapy. Friday-At a follow-up visit, the patient is still in pain. On examination, you find nothing, carefully explain the problem, review the appropriate back exercises with the patient, and prescribe a mild muscle relaxant. Friday night-The patient is seen at the emergency depanment for "terrible" back pain. He says, "My doctor is not doing anything about it." The emergency department doctor notes that the patient appears to be in a lot of pain. Results of examination are normal. A small amount of acetaminophen with codeine is given with instructions to follow up with you on Monday. continued
COMPLAINTS • VOL 92/NO 5/0CTOBER 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Technology Sydney] at 14:59 24 July 2016
COMMENTARY CONTINUED
Monday-Patient calls to say the pain is worse and to let you know he was seen in the emergency department. He says, "The emergency department doctor couldn't believe you haven't done a CT scan yet." You suggest another appointment at the end of the week and offer physical therapy in the meantime. Patient agrees to another appointment but fails to show up for physical therapy. Wednesday-Patient sends angry letters to hospital medical staff and medical association depicting you as grossly incompetent. To help diffuse a situation like this, read the emergency department notes sent to you. The doctor often picks up a hint of the patient's true agenda. Look at the records of the emergency department examination to see how the patient is described. Call patients who go to the emergency department, unless the problem was obvious and not serious (eg, a minor laceration). Ask them what happened and how they are doing, and ask for their input on how to proceed.
Third-party calls Any telephone call that opens with ''I'm calling on behalf of ... " can be trouble. Assuming the patient is not a child or a debilitated elderly person, you should ask yourself why the patient is not calling. Often the call is symptomatic of a disagreement between spouses over the medical care of one of them, but it can also come from a spouse (or parent of an adult child) who wishes to relate the frustration that the patient will not express. It may be helpful to listen carefully to the information presented by the caller, because this often can tip you off to problems. But don't discuss the problem with another person without the patient's
176
documented permission. To do so may violate patient rights laws in some states and may make the patient very unhappy. Always talk to the patient. Even if you have permission to discuss his or her care with another person, speak direcdy to the patient as well. The problems of third-party communication are as great, if not greater, when the third party represents the patient rather than you. Be sure to find out what led to the call and make sure that both the caller and the patient received the same message.
Dealing with a dissatisfied patient Once you have identified dissatisfaction or frustration, communicate with the patient as soon as possible. A call to say "I saw you were at the emergency department yesterday and wondered how you are doing" can work miracles. A few minutes of your time and attention are valuable to your patients. Your contact gives the patient an opportunity to express his or her concerns. If the patient seems uncomfortable with your suggestions, recommend a consultation. If a patient threatens a complaint or other formal action, that is his or her right. Any attempt to dissuade the patient can only inflame the situation. The best response to such a threat probably is, "That is your right, of course, but I'm still concerned about your problem. How would you like to proceed?" As long as you continue to care about the patient even after he or she has stopped caring about you, you have done your best. Rill
Address for correspondence: David Scott, MD, Park Nicollet Medical Center, 6000 Earle Brown Dr, Brooklyn Center, MN 55430.
COMPLAINTS • VOL 92/NO 5/0CTOBER 1992/POSTGRADUATE MEDICINE
