CONSIDER THIS PATIENT

Questions for reflection or group discussion

  1. This man presents to the emergency room. What is your first impression of him?

  2. He has a history of multiple visits seeking pain killers. He says he’s in 10/10 pain but vitals are normal and he appears in no acute distress. How do you proceed as the ED physician?

  3. You later find out he has a history of sickle cell disease. Would this change your approach?

CONSIDER THIS POEM BY David Budbill

I can feel myself slipping away, fading away, withdrawing

from this life, just as my father did. When the pain you're in

is so great you can’t think about or pay attention to anything

but your own pain, the rest of the world and all other life

don't matter.

I think about my friends with dementia, cancer, arthritis, and

how much more pain they are in than I am, but it does no good,

their pain is not mine, and therefore, no matter how magnanimous

I might want to be, their pain is not as important to me as my own.

Questions for reflection or group discussion

  1. How do you talk about pain with patients?

  2. Have you encountered a patient with chronic pain who has been labeled as a “drug seeker” or “difficult patient?” If so, how were they treated?

  3. What can we do to better suport patients with chronic pain?

ADDITIONAL TOPICS AFFECTING RELATIONSHIPS WITH PATIENTS

This final module is devoted to a collection of additional topics which can affect our relationships with patients.

Managing complications – How can we effectively navigate conversations with patients and families when a bad outcome occurs? How can we care for ourselves and colleagues as second victims?

VIP care – Do some patients deserve better care? How can we balance going above and beyond for one patient without jeopardizing care to others?

Conflicts of interests – How can we maintain beneficial relationships with industry and others while protecting against potential undue bias associated with these relationships?

Implicit bias – How can unconscious biases against certain groups of patients affect the care we offer them?

MANAGING COMPLICATIONS

Quality improvement and patient safety literature and programs have grown substantially over the last few decades. This work differentiates between different types of errors and behaviors, which are beyond the focus of this course. Rather this module is focused on how to navigate conversations with patients and families when a bad outcome occurs.

Ideally, the possibility of the bad outcome was discussed prior to the procedure. Investing time with the patient and/or other decision makers prior to the procedure and confirming their understanding can help prevent patients and families from feeling blindsided by a bad outcome. Investing that time also helps built rapport, making it easier to reestablish a positive relationship after the complication.

When a complication or bad bad outcome occurs, it can be tempting to avoid interacting with the patient and family. We may fear litigation and feel guilty. However, research on medical malpractice claims suggest that a leading reason why people choose to sue their clinician is to find answers, especially if they feel something is being hidden. Thus, it is best to talk to patients and families and answer their questions and concerns about what happened, what will happen next, and how can this be prevented in the future.

Beyond the medicolegal considerations, we owe it to patients to partner with them and support them when a bad outcome occurs rather than abandoning or avoiding them.

We also owe it to ourselves and colleagues to have support and learn from our mistakes and complications. When our work harms someone, it can be quite distressing and stressful commonly called the “second victim phenomenon.” It’s important to seek work environments that support giving clinicians the time and space necessary to process and recovery from these events and being gracious with one’s self and colleagues. For example, debriefing with the team involved in the patient’s care can foster this supportive culture. Ultimately, we must balance being sensitive to the emotional and mental impact of this aspect of our work while not letting it paralyze us.

VIP CARE

Placeholder for VIP Care Video

VIP care refers to the conflicting interests that occur when caring for a “very important/influential person” such as a celebrity, major donor to the healthcare system, or even a family member or colleague. We may feel compelled or pressured to provide these patients extraordinary attention or care.

All patients have human dignity and deserve a certain standard of care. Pulling strings for a friend of the family or spending extra time with a major hospital donor is not wrong as long as it does not jeopardize the care of others.

For example, asking a colleague to stay late to squeeze in a VIP patient likely does not undermine the care of other patients. However, it would be wrong to reschedule patients with more urgent issues to make room for a non-urgent procedure for a VIP.

CONFLICTS OF INTEREST

Conflicts of interest (COIs) are a natural part of professional life, and not all COIs are financial. For example, one may be biased to recommend a certain therapy because they have a research project and are looking to recruit more participants.

The potential issue with COIs is that a certain relationship may cause us to provide inferior care to a patient than if the relationship did not exist. In other words, the issue is not so much the COI itself as the potential undue bias it can create. A large portion of research and medical advances are the result of collaborations with industry, so the critical question is how can we effectively manage the potential bias associated with these beneficial relationships?

Disclosure is important because it allows others to weigh the information we are telling them in light of potential bias. This is not only true when publishing or giving talks but also talking to patients. Patients deserve and want to know if you have potential relevant bias related to their care.

However, disclosure is imperfect. Studies suggest potential COIs are often not disclosed; humans are limited in our ability to perceive our own biases; and disclosure alone can be counterproductive if we equate bias disclosure with resolution. Thus, there is ongoing need for development of better means of managing COIs. U.S. physicians can monitor reported payments from industry at OpenPaymentsData.cms.gov.

IMPLICIT BIAS IN HEALTHCARE

Implicit biases are unconscious, non-intensional biases that can contribute to discriminatory behavior and healthcare disparities. This is in contrast to explicit biases, which are overtly discriminatory conscious behaviors that one would self-report. Implicit bias against patients of certain race, age, ability, sexual identity or orientation are more insidious and difficult to perceive and manage oneself.

One potential strategy for managing implicit bias is raising awareness and discussing the potential impact of these biases with our colleagues. Project Implicit is a nonprofit organization devoted to educating the public about bias and studying implicit social cognition. They provide multiple free implicit association tests, where you can evaluate for subconscious preference for certain groups of people.

Questions for reflection or group discussion

  1. Were you surprised by the results of any of the implicit association tests you took?

  2. How have you seen implicit bias affect the care of patients in your practice?

  3. How can you manage implicit bias in your work?

REFERENCES