Healthcare Perspectives 360
Healthcare Perspectives 360
Miscommunication—We Have Met the Enemy, and It Is Us
In this episode, internist Dr. Danielle Ofri, nurse Stacy Nigliazzo, and malpractice defense attorney Jake Kocienda discuss communication shortcomings and how they may fan the flames of patient anxiety and anger toward the healthcare system.
During this episode, you will:
- Hear how the complexity of the healthcare system can create patient expectations that are difficult for clinicians to meet
- Learn how miscommunication can contribute to unmanaged expectations and patient anger
- Gain knowledge of what can be done to help reduce patient and provider anxiety
Coverys companies are a leading provider of medical professional liability insurance for medical practitioners and health systems. Coverys provides a full range of healthcare liability insurance options, advanced risk analytics, and best-in-class risk mitigation and education resources to help clients anticipate, identify, and manage risk to reduce errors and improve outcomes.
Med-IQ, a Coverys company, is a leading provider of clinical and risk management education, consulting services, and quality improvement solutions, empowering individuals at every level of the healthcare delivery system with the knowledge they need to continuously improve provider performance and patient outcomes.
This information is intended to provide general information (or education). It is not intended and should not be construed as legal or medical advice. Opinions of the panelists are their own and do not reflect the opinions of Coverys or Med-IQ.
Music and lyrics: Nancy Burger and Scott Weber
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Geri Amori: Hello, everyone, and welcome to Healthcare Perspectives 360, a series dedicated to exploring contemporary healthcare issues from multiple perspectives. I’m your host, Geri Amori, and today I’m talking with internist Danielle Ofri, MD, Stacy Nigliazzo, RN, and malpractice defense attorney Jake Kocienda. Thank you for joining us in this conversation today.
Now, we have been experiencing what seems to be a heightened level of tension among patients when they come to our offices or to our facilities, and we know that some of this is because of societal concerns. We also know that we in the field of healthcare contribute to the tension when we are less than skilled at dealing with issues.
We’ve spent a lot of time teaching physicians and staff how to communicate with patients directly, but that is not our question today. Our question is are there things that we are doing today in the way we communicate internally with each other in the system that contributes to the tension that we are trying to avoid, and are there things inside of healthcare that we can do to help reduce patient anxiety and anger and perhaps even our own?
So in a very atypical way, I’m going to share two quick stories with you, two examples that are trigger examples that happened in my family just recently, and I have their permission to tell this. But more than that, afterwards I went, and I spoke with some of my colleagues in the risk management field, and we’re seeing this all over the country, people are very aware of it. So here are a couple of examples.
My spouse, who is in his eighties, spiked a fever of unknown origin. And he has several health conditions that make it shaky for him, and I took him to the emergency room. So there we are at the emergency room, and he has lots of labs and things done, and they do a chest x-ray and all kinds of things, and they say you’ll get the blood culture results in 24 to 48 hours, among other things. So I bring him home, and I’m taking care of him. And I am not a nurse, but I’m taking care of him. And 24 hours goes by, 36 hours goes by, we’re getting up there. Four days have gone by, and my nurse friend says call the lab, see what’s happening, nothing has shown up.
So I call the lab, and I say we were waiting for blood cultures, nothing is showing up. And the person at the lab very nicely said, well, it takes 5 to 6 days for those to show up. And I said, oh, okay. Well, I’m not angry, but let me just say that from a patient communication perspective, it would have been nice to have the right answer at the emergency room because my expectations were set up. And I’m sure you don’t like it when people call you and they’re upset, so maybe you could tell the people in the emergency room. I’m trying to be helpful, right? And what I get back is well they know that; it’s been that way for a long time. And I felt bad, I felt like, well, if I were a person with the proclivity to getting angry I would have, but instead I felt like oh, this poor, overworked person.
Well, fast forward. About a week later, he has been admitted to the hospital, and in 23-1/2 hours after he’s admitted, someone comes in to help with discharge planning, and he’s still running a fever. And they say just by the way, your Medicare may not pay for this because he was admitted on observational status. And my spouse, still running a fever, panics, and I’m like no, no, we would have admitted you anyway. And I just say to the person I understand you have 24 hours; I’m not saying you broke the law. I am just saying that it would have been nice if before we accepted the admission, we were told that our insurance might not pay for it, so we would have a part in helping make this decision. No, we have 24 hours, very stern.
And all I could think at that point was I’m not saying that they’re breaking the law, but the lack of willingness or ability to feel like they can break that wall down and manage the patient expectation is probably contributing to some of the anxiety and anger that we see among patients. So I did ask around to many of my colleagues in the field, and I’m hearing this story over and over again from them. What is it that we can’t fix inside of healthcare that’s leading to this problem? So are you ready to take this one on? I’m seeing heads shaking yes. Great.
Well, Stacy, I’d like to start with you. Have you ever found yourself in the middle of a communication, or lack thereof, where patient expectations were set by the system that were incorrect, and how did that affect your communication with the patient as a nurse?
Stacy Nigliazzo, RN: All the time, I would have to say. Oh, but first of all, let me say I’m so deeply sorry that you had that experience, and that your husband had that experience. When you’re already dealing with an illness, the last thing you need is added stress such as that. And whenever I hear those stories, and I hear them in my own practice, as well, it’s really disappointing.
And I’ll add that miscommunication is, unfortunately, very common in healthcare. And in the hospital setting, patients are constantly receiving information from various providers and clinicians – nurses that turn over in the shift, physicians that hand off to one another – and not all of us are speaking to one another before speaking to the patient. And as a result, our patients get conflicting or incomplete information, and that breeds a lack of trust. And when we lose that, we lose everything.
And patient care advocates tell us all the time that one of the main factors impeding wellness and recovery is when the patient feels a loss of control. Well, if we can’t even provide our patients with accurate information, they certainly will feel this loss of control in addition to that lack of trust. They will not feel heard, and people who don’t feel heard can’t listen.
Amori: Thank you, Stacy, that is true. And I want to reiterate that I wasn’t angry, I was just worried. Because while I understood, I wasn’t sure that everybody would understand, and I was wondering if that was a problem elsewhere and it seems like it was.
So, Jake, have you heard stories from patients regarding miscommunication within the system that led to a lawsuit because they felt like they had been misled?
Jake Kocienda, JD: You know, it’s interesting. To answer your question, it’s going to be yes and no. And part of the problem is this, and I hear this from plaintiffs all the time when they bring their case. What they explain and describe is miscommunication within the system from their perspective, which often is not even accurate but it’s what they perceive, and that ends up being from my world a bigger problem. It’s their interpretation of things that maybe don’t go the way they expect, and they see it as a breakdown in communication.
Sometimes it is, but even when it is, they don’t know why because they don’t know how the medical community works. They don’t understand the communication and how that happens, they just know some information didn’t get from point A to point B, and they don’t know why but they’re upset about it. They often will blame anything that doesn’t go right, or it goes bad with their illness on that lack of communication or the miscommunication, even though it has nothing to do it, so that ends up being, again, perception. And so I do hear that.
And then from the clinician’s standpoint, because I represent the hospitals and the doctors and things, I see what’s going on in the background and I do understand. And I entirely understand how someone outside looking in can misunderstand and misperceive the communication problems that arise in any organization, and the medical community is no exception to that, but that are the backbone, or at least the impetus to why something ended up going into litigation.
So I do see that. I’ve seen anything from medical records not being interfaced with other electronic records or being delivered in time; patients not seeing something in their chart or their record that they think ought to be there, and it ended up being oral communication; language use, the interpretation of the way language is being used in the medical community versus the way a layperson uses it. All those types of things from a patient’s perspective can be misunderstanding what is really going on.
And then look, the facilities, the hospitals, the medical community, they struggle with communication problems just like any organization does, which is always a struggle. And often you can be the best medical clinician, but if there’s a communication problem your medical decision-making is not relevant, because you didn’t get a chance to make the right decision because you didn’t have the information or there was a miscommunication. And so it leads to malpractice suits all the time. In fact, I would venture if not all certainly in the 90s percent of medical malpractice cases have some significant element of a mis- or communication error problem within the rendering of the care that’s at issue. Even if it didn’t cause the malpractice or the claimed malpractice, it’s still in there somewhere mucking up the works.
Amori: Yup. So, Dr. Ofri, do you have any examples of internal systems communication that set wrong expectations that led to anger, possible suits?
Danielle Ofri, MD: I think really where I see the patient frustration is an expectation that clinicians will have an awareness of things that might be beyond our ability. So they’ll say oh, all my information’s in this chart, you’ll find it there. And maybe it was another hospital, and we can’t necessarily find all that or again have the hours to go through that. Or they’ll get to the pharmacy and say oh, you prescribed the wrong insulin, as if we would know exactly which ones on formulary and how that has changed week to week from 15 different insurance companies.
But they’ll take the anger out on the clinician. Or you didn’t tell me how much the CT scan would cost. And, of course, I have no idea how much the CT scan will cost. But the patient becomes angry that we as a system can’t communicate what for them is very important practicalities, but we don’t have the tools or even the possible hope of having the answers to be able to communicate that between ourselves and to them.
Amori: Okay. So as a patient family member, I’m coming in with not necessarily expectations, but hopes that you will manage my expectations. And so what are some tricks that we have, and I don’t mean tricks in a negative way. So what are some ways that we can help patients understand that the system is complex and what they believe is true may not necessarily be. What are some ways that we can communicate; any ways that we can improve the system? So here we’re not talking about the individual doctor, nurse communication, we’re talking about systems communication.
Yes, Stacy.
Nigliazzo: Well, I think we can do a better job at something you brought up, which was making sure that everyone’s on the same page with how long these tests are typically going to take, so that we set expectations from the beginning that are reasonable. And I see this in the emergency department a lot where they’ll be taken for an x-ray and told oh, we’ll have this report back to you maybe in 30 minutes. Well, maybe that is when the radiologist reads it, but that’s not when the report is dictated. It may take longer for the ER physician to see it, and then it may take him a few moments to get into the room.
So if we’ve set up the expectation you’re going to know what this x-ray says in 30 minutes, and they don’t see the doctor for an hour-and-a-half, we’ve already lied to the in one sense, or so they may perceive it that way, whereas if we’re honest about the expectation of time from the beginning, then we haven’t destroyed that trust, we’ve already communicated well, we’re giving them accurate information.
I think it all starts with what we can fix. We can’t necessarily fix what their expectation is, and sometimes patients don’t want to hear what you have to tell them. They don’t want to believe that this is their condition, or in the emergency room where your job is to rule out a life-threatening condition, not necessarily to tell them what is wrong, they’re not always happy with that. But if you have everything leading up to it where it took longer than we told you that we’re going to give you this result back, we’ve somehow set an expectation that we didn’t meet, it’s just going to make the news that much harder, whereas if we laid it all out from the beginning, maybe they’ll be in a better place to receive it.
Amori: Okay. That’s a good idea. Danielle?
Ofri: So I think we also want to distinguish for ourselves and for patients what we are responsible for and what we can’t control. There’s much about our very complicated medical system that is simply beyond nurse’s and doctor’s control, and for the patient that may often be the majority of what they’re experiencing: the bills, the delays, the prior authorizations, all these things. They think oh, my doctor gives me this so that’s it, and they don’t realize that there are 50,000 steps way beyond the control of any clinician. But again, that shouldn’t be the job of clinicians to defend what can be an indefensible medical system.
And so the idea of a navigator that helps the patient interface with the system on every level – their care, their follow-up care, the bills – all of these things that somewhere someone knows how long it takes for every test result to get back, and that it takes time for the doctor to read it and find time to get to them, that someone should be able to explain that to them.
And there’s a role for a job, a full-time person to be that interface for all of these confusions would, I think, go a long way. And again, that’s expensive to hire an extra nurse to do education like that, but, of course, we need that if we’re looking for good outcomes. I think as Stacy pointed out, someone who is frightened and frustrated isn’t going to be able to hear the diagnosis and the treatment. And so we will get better medical outcomes I strongly believe if we invest a little more in communication and education with our patients, I think it would go a long way toward helping their medical care and their peace of mind.
Amori: Okay, thank you. Stacy, you want to comment on that?
Nigliazzo: I just want to add that the job description and the job title for that navigator should be angel, because that is what those people are.
Amori: That’s wonderful. Yes, Jake.
Kocienda: So I agree with all those solutions that have been raised so far, I think that they’d be very helpful. But part of the problem, and this is not being directly in the medical community, is I see this as a societal problem. I see it as our entire country – I can’t say world because the medical community is very different in other countries – but at least in our country the understanding and expectations of our medical community I think are not only unrealistic but very inaccurate. And they expect things as a whole, as a general population they expect things maybe from a lack of understanding, but they expect things that really they shouldn’t be expecting.
And I think that it’s a societal education that has to take place so that they have a better understanding. Instead, what I think society generally hears is criticisms of the system, the fact that we spend too much money and we’re not a socialist medicine society versus we don’t want socialized medicine. And they get wrapped up in these things, and as a result there’s just a general lack of understanding when they enter into the system. And in many cases because they’re dealing with an illness, they’re dealing with stresses and anxieties in that system, it’s going to be in some part a little too late.
It’s not a quick fix at all, but I think we have to start somewhere and that’s with society getting a better understanding of what the medical community does, because the generalized expectations are really not only unfair but they’re really inaccurate and they’re not appropriate. They just don’t know because of how complex our medical community has become, and our medical delivery system has become, it’s way outpaced general society’s understanding.
Amori: Fabulous. All right, well that’s all very, very helpful. So here’s our classic question. If you have one thing you’d like our listeners, both those who work in healthcare and those who use healthcare, to know from today’s discussion, what would that be? Stacy, let’s start with you this time.
Nigliazzo: We owe it to our patients to be effective communicators and good listeners. We have to do better in making sure they feel heard and are receiving timely, accurate information as a fundamental tenant of caregiving.
Amori: Thank you so much. Jake, you want to speak up on this one next?
Kocienda: I think the main takeaway from this topic is that there needs to be an understanding that patients just generally do not have a clear understanding of what to expect in the system, and I think the only thing I can suggest of a more immediate solution might be really have to spend the time, whether it be clinicians – you get an extra caregiver who’s involved, or an angel as Stacy mentioned – is that there has to be a moment, a timeout where you focus on the patient and ask them and try to figure out do you really understand, do you have questions. It seems so simple and basic, but a lot of times because of the pressing of all the time commitments and limitations, sometimes there just isn’t that time and that question asked, and that could sometimes at least help in some situations.
Amori: Thank you. And Dr. Ofri.
Ofri: And I think going off what Jake was saying in terms of societal education, to recognize that between the clinician and the patient exists many, many, many nonclinical entities – insurance companies, device companies, pharmaceutical companies, pharmacy benefit managers – that are in between the recommendation of care and the receipt of care that are beyond clinician’s control and respond more to market forces and things beyond medicine, for which much of the dissatisfaction arises. And, of course, that’s a societal reckoning that we have to decide, when we have our healthcare system driven by a market economy there are going to be other forces beyond your nurse and doctor that affect the care that you get.
Amori: Excellent. So you all have helped me. And I just wanted to thank you so much for joining us today, this has been a really lively conversation and an enlightening conversation. And special thanks to our audience for joining us here today.
So until next time, this is Healthcare Perspectives 360.
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