We have the stats, but where is the action?
The IOM’s now infamous 1999 Report, To Err is Human, estimates the number of patients that die each year from preventable harm is around 98,000; however, a recent literature review by Patient Safety America estimates the number to be closer to 210,000 and possibly as high as 440,000 patients.
The past decade saw the advent of Patient Safety Organizations and a focus on risk, quality, and safety management unlike anything we have seen in healthcare, and yet, it does not appear this newly acquired awareness has been practically applied in healthcare settings. As Steven Convoy writes in his international bestseller, The 7 Habits of Highly Effective People, “to know and not to do is really not to know.”
So what do we know? It is believed that a significant proportion of preventable deaths are the result of communication failures. CRICO reviewed 23,658 malpractice cases from 2009 to 2013 and identified over 7,000 cases with communication failures as one of the leading causes of patient harm.
What’s more, anecdotal evidence and self-reported findings from patients reveal an unfortunate trend: patients do not think healthcare practitioners listen to them.
So what can medical personnel do to improve patient communication skills and prevent patient harm?
- Verify Their History – A paper by R. Hampton et al in The British Medical Journal suggests that over 80% of diagnoses can be solely or almost entirely based on a patient’s history through a discussion, with laboratory investigations and physical examinations only yielding useful information in 8-9% of cases. Focusing on a “chief complaint” may cause you to skim over tell-tale comorbidities. It is important, then, to look at the whole picture, and in the words of Dr. William Osler, “Listen to the patient. He is telling you the diagnoses.”
- Ask for Help – When conducting a physical exam or talking through a differential diagnosis, consider telling your patient what signs and symptoms you are looking for, because they might be able to help you. Patients live in their own bodies 24/7 and experience their symptoms firsthand. If they know what sorts of indicators you are looking for, they can bring them to your attention early on in the process. Two pairs of eyes are better than one.
- Avoid “Cookbook Medicine” – Clinical practice guidelines are just that: guidelines. As Dr. Doug Campos-Outcalt, Clinical Sciences Analyst for the American Academy of Family Physicians (AAFP) notes for Medscape, guidelines are written for "average" patients, but how many people fit that description? Whatever approach you decide to take, don’t forget to tailor it to the patient in front of you. Chances are your professional judgement and observed facts form a more comprehensive picture than a rigid and prescriptive textbook based on randomized clinical studies.
- Keep an Open Mind – Your first impression may be wrong, so allow subsequent information to inform your decision making, and don’t ignore any test result because it does not fit with your original opinion. Here is an extreme example of this cognitive bias known as anchoring heuristic: A patient with multiple underlying medical problems that predispose to infection had repeated positive blood cultures with Corynebacterium. These were dismissed as contaminants and the patient was diagnosed with a nonspecific viral syndrome. After two months of pain and suffering, numerous blood cultures, and several hospital visits, the patient was finally diagnosed with acute Corynebacterium endocarditis.
- Have Faith in Yourself – In a study conducted in Flanders, Belgium on the intuition of healthcare practitioners, out of 3,369 children found to have a non-severe illness, only 6 of the children were mis-diagnosed and had a more serious illness.
With the long hours, stress, red tape and mounting paperwork, it is understandable that medical personnel feel disconnected from their patients. But by being aware of yourself and employing the above strategies, you can help ensure that when you use your ears to listen to a patient, you also use your mind.
Blog Authors: Heather Annolino, RN, MBA, CPHRM & Naomh Gibson
Ellen J. Belzer, MPA, Improving Patient Communication in No Time, AAFP
Jeffrey Chi, MD & Abraham Verghese, MD, Improving Communication With Patients: Learning by Doing, JAMA