Published in the January 2012 issue of Today’s Hospitalist
It’s the rare doctor who wants to talk about it, but being “fired” by a patient happens to nearly all hospitalists at some point in their careers.
The natural tendency may be to either blow it off as a one-time anomaly caused by a particularly challenging patient or family, or assume that it’s something that happens to only “bad” doctors and is something to be ashamed about. But hospitalists and health care experts focused on improving quality say that physicians should not suffer alone.
The good news is that physicians have resources to draw on and constructive ways to cope. And by learning some key communication skills, physicians can learn how to make it less likely that a patient will pink-slip them again.
Most importantly, they add, physicians can learn much from being fired, both about being a better doctor and about improving a health care system that patients can find so frustrating.
“People fire physicians as a last resort,” explains Roger T. Anderson, PhD, chief of health services research at Pennsylvania State College of Medicine in Hershey, Pa., and an expert on issues relating to patient satisfaction. “If patients say, ‘I’ve had it. You people don’t know what you are doing. I want a different physician,’ they are really saying, ‘I’ve had a very frustrating experience.'” The challenge for the doctor on the receiving end, he says, “is not to have a thin skin, but to try to understand what the patient is trying to plea for.”
In many ways, being fired is a red flag that something is severely wrong. The cause could be an inefficient or malfunctioning health care system, a doctor whose communication skills are below par, a patient with behavioral, psychiatric or substance problems, or a combination of all the above.
“It’s like patient safety: It’s rarely a single item that causes a system failure. It is a whole host of things that have been happening, and now it is a mess,” explains Barbara Balik, RN, EdD, senior faculty at Boston’s Institute for Healthcare Improvement and a coauthor of a recent white paper on improving patients’ and families’ hospital experience. “There have probably been some red flags that things haven’t been going well for awhile.”
This is not to imply that system snafus are always the cause of patient problems. Patients can also sometimes lash out at and fire doctors because of personality mismatches.
Dr. Balik says that it’s unrealistic to think that all patients will get along with all hospitalists. Unlike in the outpatient arena, inpatients don’t get to choose their doctors. (When patients fire their primary care doctor, they simply skip their next appointment.) It’s also true, Dr. Balik says, that doctors carry the bulk of the burden to make the relationship work.
Steven Pantilat, MD, a hospitalist, professor of medicine and director of the palliative care service at the University of California, San Francisco (UCSF), agrees. “You don’t have to have a great relationship with a patient to have a productive therapeutic relationship,” he points out. As a physician with patients who “have tried to fire me” and as a palliative care physician whose patients may be angry and “yell a lot,” Dr. Pantilat says he considers it his job to “listen, hear them out and then apologize.”
Much of the time, he says, patient-doctor disputes can be resolved “by putting in the time. So, who is going to put in the time? It might as well be you.”
Turning to mediators
But turning a bad situation around is often best accomplished with help. When they are fired, hospitalists should not have to “worry alone” because they are too embarrassed, angry or upset at “failing” to admit a problem and reach out for help, says Dr. Balik. Resources should include the hospitalist medical director, colleagues who are good with tough communication issues, or the hospital’s patient relations department, clergy or social workers, she says.
The hospitalist group at UCSF’s Mt. Zion Hospital in San Francisco recently decided to create a formal way for its members to reach out for help. Several members of the group are working to set up a special nurse-physician liaison team to work with challenging patient-provider situations.
Hospitalists will be able to call the team “like a consult “to help when they sense that relations with a patient are breaking down. The hope, explains hospitalist Stephanie Rennke, MD, is that the team will help hospitalists repair a broken doctor-patient relationship and stave off being fired.
“The team is going to act as mediators,” Dr. Rennke says. “Team members will be able to come in, assess a situation and offer some practical suggestions. Clearly you don’t want things to escalate to where a patient is firing a particular provider, particularly when there are one or two providers at most who are available.” Team members will include a nurse with a particular interest in psychology and a hospitalist interested in pain management and behavioral issues “all hot-button topics, Dr. Rennke points out, implicated in many physician firings.
Calling in an uninvolved third party is also a strategy used by hospitalists in Portland, Ore. M. Ross Tangum, MD, medical director of the hospitalist service at Legacy Good Samaritan Medical Center, says that staff from the hospital’s patient relations department are often “helpful facilitators” who sit down with the patient and family, defuse the situation, and figure out how to meet the patient’s needs.
“Often, it’s not because there was a mistake,” Dr. Tangum says. It’s more likely that each party to the conflict has his or her own expectations “and those weren’t communicated.” Common sources of conflict, he adds, are disputes over procedures or therapies and about discharge. He also points out that in his experience, sitting down and talking, even with a mediator, may not convince patients to keep their doctor. But it does help the hospital meet its non-abandonment obligations to the patient.
A designated point person
The hospitalists at St. Peter’s Hospital in Albany, N.Y., have also decided to confront the problem head-on. That’s in part because being fired reflects badly on hospitalists’ reputation and public relations within the hospital.
Although being fired happens to one of St. Peter’s large group of hospitalists only a handful of times a year, the group recently created the post of “patient-relations liaison.” Hospitalist Adam Stallmer, MD, says his role in that job is to field hospitalist-related complaints that come to the hospital’s patient relations department. He is also the go-to guy who other hospitalists in the group can call if they feel their relationship with a patient is spiraling toward termination.
Dr. Stallmer serves as a mediator and tries to head off a firing. Only once has he had to take over the care of a patient who had fired his hospitalist. He doesn’t hear about all the cases; sometimes, fired hospitalists will switch patients on their own. As long as they can find another doctor in the group to take on the patient, he says, that’s fine.
“This doesn’t happen frequently enough that we have a policy,” he notes. However, the one time he’s been fired in his two years as a hospitalist “this past summer by a patient with many psychiatric issues who had already fired two other hospitalists “helped launch a hospital-wide effort to draft a model “behavioral contract.” That contract, Dr. Stallmer says, will be used to help curb unacceptable behavior like being disrespectful to staff. When it’s completed, the document will be available to be used by all departments when dealing with particularly fraught situations.
Several years ago at a former job, recalls hospitalist Winthrop Whitcomb, MD, a patient-initiated termination of one hospitalist’s care prompted a hospital-wide, medical staff in-service educational session.
The specific issue raised was whether a doctor fired by a patient has an obligation to find that patient another doctor who will do something at variance with the original physician’s own religious or ethical beliefs. (In this instance, the first physician, on religious grounds, refused to provide medication that would relieve the patient’s end-of-life suffering because it could have hastened death. The patient’s family fired the hospitalist and asked for another to take over.)
“We didn’t come to much consensus,” recalls Dr. Whit comb, who is now director of health care quality at Baystate Medical Center in Springfield, Mass. The discussion did raise the issue of whether a physician is obligated to find another provider and, further, how to ensure that the transition and handoff take place.
Dr. Whitcomb notes that the tendency in some programs is to always hand these patients off to the one hospitalist in the group who is good at dealing with challenging patient issues or to let the situation land in the lap of the medical director. But “that’s not usually a good idea,” he points out, if the group is concerned about preventing burnout.
In addition, he says, that default strategy creates a missed learning opportunity. “Groups really should recognize that this is going to happen from time to time, and there should be a way to provide feedback to the physician who was dismissed,” says Dr. Whitcomb. “It is not fair to patients who had a legitimate message that they wanted the doctor to get, and it is not fair to physicians who could improve their practice or their communication next time.”
In Oregon, Dr. Tangum says, the subject of being fired comes up periodically at staff meetings. “The themes always tend to focus on the patient’s fault, because it’s much easier for anyone involved in a relationship breakdown to point the finger at the other party,” he says. “But I have tried to hold a mirror up to the group, and say, ‘Hold on. Let’s take some responsibility for this too.’ ” Contributing factors discussed have included less than stellar communication styles, patient frustration at being bombarded by too many doctors and not enough evidence of cohesive teamwork.
In the end, he says, the discussions helped spur changes aimed at improving patients’ experience. The group has started, for instance, using whiteboards in every room to list all members of the physician care team so patients can attach a name to a face. Hospitalists are also working to institute multidisciplinary rounds, which Dr. Tangum thinks will reduce the frustration patients feel that they are looked at as only a collection of body parts and not a whole person.
And staff discussions serve as a reminder to sharpen physicians’ communication skills, including sitting down when talking with patients at the bedside, asking more open-ended questions and listening more. Those strategies have been shown to improve patients’ perception of physicians’ empathy.
“As busy as we are, sometimes we miss a beat there,” Dr. Tangum says. “The burden is on us to do this. And to the extent that we don’t, I think we set ourselves up for problems. You have to frame for patients who you are and why you are here. That lays the groundwork for them thinking that you have their best interests at heart and that you will be straight with them.”
Can it be fixed?
Even after patients reach the breaking point, there are good reasons to try to repair relations rather than just storming away in a huff. The first is concerns about lawsuits.
“The greatest predictor of getting sued is that patients are mad at you, not that you made an error,” UCSF’s Dr. Pantilat says. “That’s not the reason to do this right “so you don’t get sued “but it just so happens that if you can work these things out, you are less likely to get sued.”
Another reason to work on a fix and not just walk away when fired has to do with your relationship with your fellow hospitalists. “Are you going to ask your colleague to clean up your mess?” asks Dr. Pantilat. “You can’t think that just by bringing in some new doctor, everything will be fine without investing time to work it all out. That’s not realistic.”
“Whatever you do,” Dr. Pantilat adds, “don’t get mad back. Patients are firing you because they are mad or they are insulted. Maybe they feel you haven’t been treating them with respect. Some of them may be difficult people, but still you can establish rapport with difficult people.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Lessons learned from a near-miss
HOSPITALIST KEDAR MATE, MD, had just come on service at Manhattan’s New York-Presbyterian/Weill Cornell Medical Center. One of the many patients he was handed was a dying man with an extremely complicated history. The man was waiting for an MRI that doctors had ordered before they’d attempt a last-ditch experimental treatment.
“I’m trying to catch up on his story when his wife comes into the room, and she cannot believe the MRI hasn’t happened,” Dr. Mate recalls. “She is extremely angry and frustrated. This MRI is the last hope for saving her husband’s life and here I was, preventing it from happening in some way or slowing it down, at least, by my lack of awareness of his situation and condition. She was uncontrollable.”
To his, “I can’t talk to you in your current state of mind,” she replied, “I’m done with you.”
Once out of the room, Dr. Mate says he was able to think through what had happened. He probably hadn’t adequately prepped himself on the background and maybe hadn’t done all he could to establish a relationship with people being forced to deal with yet another doctor. And why hadn’t the MRI happened?
It seemed worthwhile to go back in and try again, rather than have the patient start all over with yet another hospitalist.
“She was still raging, but now I understood the details of the case better, and I understood her psychology better,” he says. After apologizing, Dr. Mate says he told her, ” ‘You want exactly what we want for your husband. You want him to get better, which is what we want. You are completely free to call anybody you want. If you want to call radiology, I’ll give you the phone number. I’ll give you the directions to radiology so you can go down there and bang on the door.'”
And that, in fact, is what happened. “She went down there,” he says. “All I can tell you is that the guy got his MRI that day. And after that, she and I had a great relationship. She understood that we were on the same side.”
Here are the lessons that Dr. Mate says he took away from almost being fired:
- Transition points, such as when first meeting a patient and family, require exemplary communication. Dr. Mate realized he hadn’t spent enough time figuring out a complicated history before meeting the patient and trying to develop rapport with the family.
- Patient anger is often the result of feeling vulnerable and powerless “and it’s easier to lash out at an individual than the system. When everyone agreed the problem wasn’t with Dr. Mate per se but with whatever was causing the MRI delay, he was ultimately able to work with the family.
- Don’t label a patient as “difficult.” “We tend to label patients as difficult when the circumstances are difficult,” says Dr. Mate. “And it’s not just that the circumstances are difficult, but that they are difficult for us.”
- Apologies help. No relationship breakdown is solely the fault of only one party.”Doctors should not feel offended when patients say they would prefer to have their care from another doctor,” Dr. Mate says. He also doesn’t think that being fired means that someone is a bad doctor. “It’s more often that patients are frustrated with the system and the situation they are in, and it has less to do with you the individual.”