The UMHS medical error disclosure program managed to decrease the number of lawsuits and liability
costs and significantly shortened the time required for
resolution of a claim. 15
In 2014, Atul Gawande, MD, MPH, FACS, delivered
four British Broadcasting Corporation Reith Lectures
on The Future of Medicine. 21 In one lecture, Dr. Gawande noted that there are two primary reasons why
surgeons fail. The first one is ignorance—the limited
understanding of the conditions that apply to any given
problem. The second reason is ineptitude—having
the knowledge but failing to apply it correctly. 21 A
blended mix of formal education for surgical residents
to improve their communication skills and implementation of surgical checklists is the recipe for a
brighter future of surgery in which optimal communication and reduced errors are the norm in the
surgical patient care.
Communicating with the difficult patient
The difficult patient may pose a challenge even for
the most experienced and composed physician. In the
adult primary care setting, 15 percent to 30 percent
of patient encounters are labeled as difficult, according to the physician. 22, 23 (It should be noted that most
of the literature on difficult patients comes from the
primary care sector.) Although the day-to-day practices of surgical and primary care differ, the principles
of patient communication apply to all specialties.
The patient encounter is shaped by the behavior of
the patient, the response of the physician, and the
situational factors. Each of these factors must be recognized and addressed to optimize communication.
Earlier studies have tried to characterize difficult
patients and suggested these individuals are more likely
to have multiple poorly defined symptoms, personality
or psychiatric disorders, and subclinical behavior traits,
and they are often older, recently widowed or divorced,
and of lower socioeconomic status. The difficult patient
also is likely to be non-adherent to the treatment plan.
In a 1978 New England Journal of Medicine article, James
E. Groves MD, further classified difficult patients as
belonging to one or more of four subgroups: ( 1) dependent clingers, ( 2) entitled demanders, ( 3) manipulative
help-rejecters, and ( 4) self-destructive deniers. 24 The
article recommends screening for psychiatric diagnoses or a history of physical or substance abuse and then
approaching the difficult patient with motivational
interviewing and patient-centered communication
through which symptoms are validated and boundaries are set.
Perhaps most importantly, the physician should
identify the subtype of difficult patient and tailor the
encounter accordingly. Dependent clingers exhibit
neediness and evoke aversion from the physician.
The physician must be firm but tactful and set limits
on the patient’s expectations. The entitled demanders often threaten the physician with punishment,
mainly lawsuits, and evoke a counterattack response.
The physician should acknowledge the patient’s right
to receive excellent care and redirect the entitlement
into a partnership. Manipulative help-rejecters are
often smugly satisfied when the prescribed treatment
is ineffective and have a pathologic dependency on
the patient-physician relationship, evoking feelings of
depression, guilt, or inadequacy in the physician. The
best approach here is to commiserate with the patient
TABLE 2. THE BREATHE OUT TECHNIQUE
B List at least one Bias you have about the patient.
Re Reflect on why you identify the patient as difficult.
A List one thing you would like to Accomplish today.
Th Think about one question you would like to ask to further explore your assumptions.
E Stop before Entering the exam room, and take three deep breaths in through your nose and out through your mouth.
O Reflect on the Outcome of the encounter.
U Did you learn anything Unexpected?
T List one thing you look forward to addressing if you run into this patient Tomorrow.