Patient advocates need to learn how to resolve conflicts
A patient advocate once
was concerned that giving chemotherapy to his client was causing him more harm
than good. During the course of the treatment, the patient would often complain
that he was in agony, telling his advocate, “I can’t take it any more” and the
advocate would faithfully relay his misgivings to the doctor team. The head of
the team didn’t see any merit in the advocate’s objections and ruled them out.
Over the next few months, the advocate watched the patient suffer in silence,
through treatments that the advocate believed he would not have chosen had he
been informed in advance about the pain they might cause him. The patient
finally died, but only after the chemo had left him with unstoppable and
painful bleeding in his bladder, robbing him of a more peaceful and comfortable
end.
Patient advocates have to
perform a difficult balancing act. Their primary role is to help their patient,
but they don’t want to escalate an issue and alienate the hospital staff
either. How do they keep both parties happy?
The
biggest challenge in medical practice is the growing conflict between doctors
and patients – especially over costs. Disagreements can arise over many issues
– ranging from continuing aggressive treatment for a critically-ill patient to
refusing a patient’s request for antibiotics to treat a viral infection.
End-of-life issues are especially highly emotionally charged, requiring active
involvement of a patient-advocate. When conflict arises, communication channels
break down and it’s left to the patient-advocate to sort things out. A mature
advocate understands that at the heart of such conflicts is usually a clash of
values, and because these are hardest to resolve when everyone is emotionally
labile, his first priority is to defuse the emotions and change the climate of
mistrust to one of common ground.
A useful
mnemonic which experienced patient advocates use to deal with upset patients is
called RAPSAND.
R
= Re-establish rapport (Empathy)
A
= Agreement (Get the patient to say Yes)
P
= Problem (Define this)
S
= Solution
A
= Ask Permission (Is the patient happy with the solution you have offered?)
N
= Next step (Follow up)
D
= Document
The most
worrisome conflicts are those which arise over treatment choices. If they are
not promptly resolved, they can mar the doctor-patient relationship and have an
adverse impact on the patient’s outcome. Resolving such conflict is therefore
the first priority of a patient-advocate. If he has been employed by the
hospital, he has to make sure that he puts the patient’s interests first, and
is not seen to be acting in a manner which suggests that he is an agent
appointed by the hospital to protect their interests. The moment a patient
feels that an advocate is representing the hospital, he is likely to lose faith
in him. Instead what he needs to do is:
Drive
maximum patient participation in care decisions
Develop
mutual trust and respect between the doctor and the patient and his family
Help
improve a patient’s experience of a hospital by explaining the hospital system
to them, and emphasizing care, compassion and connections
Be
seen as impartial ombudsman, to whom patients, as well as the hospital staff
can provide feedback in confidence
Provide
a mechanism for patients and families to cut through the red tape and avoid
delays in emergency care
Let’s not forget that patient advocacy is a new discipline in
India. A patient advocate has been introduced as a new component in the care
delivery chain, and can help to provide legitimacy to the patient’s voice when
the healthcare system ceases to listen. If an advocate is appointed by a
government agency (as in the West), he is expected to establish formal
programmes for safeguarding patients’ rights, and assist hospital staff in
understanding their duties and the patient’s rights. As a third party, he is
expected to balance the interests of both parties and provide medical and
non-medical support in both inpatient and outpatient care. They are also a
trusted source of information, referrals, and navigation.
Once an 80-year-old poor, illiterate woman with breast cancer was
being treated like a senile senior citizen by a resident doctor in a
stuffed-to-the-seams government hospital. A concerned citizen watching this
interaction decided to act as her advocate and came to her aid. To his
surprise, he discovered that the woman was very perceptive. However, because
she was illiterate and new to the city (having just arrived from a village) she
felt intimidated by her surroundings; and because of her illness, she was not
mentally alert enough to be able to make her own medical or financial
decisions.
The busy surgeon was treating her like an imbecile, but the
advocate invested his time in talking with her, listening patiently, and asking
her the right questions, so she could understand her treatment options. Later
he took upon himself the job of meeting with her physician. The physician’s
approach to this patient also changed, once he found someone was taking an
active interest in her case and documenting his discussions with the patient.
He quickly became more respectful and thoughtful.
Because patient advocates collaborate closely with hospital staff
on patient safety and quality-related issues, they can help hospitals identify
opportunities to improve patient satisfaction, and bring about much-needed
improvement, especially for poor, uneducated patients. Whether through position
or persuasion, patient advocates can make good use of medical data, and offer
sensible recommendations so the government hospital can improve its track
record.
A doctor
once had a serious difference of opinion with the father of a little boy, who
had met with a road accident. The father felt that his son would benefit from a
particular type of physiotherapy. The doctor didn’t. The father brought him
loads of health literature but the doctor was not impressed. They argued over
the matter. Finally, they both agreed to get a third – independent – opinion.
The doctor called in another doctor-friend to act as a patient-advocate. This
second doctor read the patient’s report and medical file. Ultimately he agreed
with the father’s point of view and said there was no harm in trying out the
therapy for a short span of time and if it didn’t work, they could always
change it later on. When they heard him, both men laughed. An ego-conflict was
amicably resolved. Later, this second doctor also helped the patient’s father
get the therapy reimbursed by his insurance company. To this day, the patient
remains grateful to the advocate and speaks very highly of the first doctor,
who put him in touch with this advocate. For every health problem – big or
small, he always goes back to the same hospital.
The moral of this story is - whatever you do;
don’t let a patient walk out of your facility disillusioned, angry or
dissatisfied. When you can’t reach an agreement, get an advocate on board. He
will resolve the issue in the most humane way.
The above is an extract from Dr.Aniruddha Malpani's book : Patient Advocacy - Giving Voice to Patients
The book launch will take place on Saturday, 16 November 2013 at Hall of Harmony, Nehru Center, Worl, Mumbai - 400018 during the 4th Annual Putting Patients First Conference.
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