Risk Management and Medical Liability
A Manual for Indian Health Service and Tribal Health Care Professionals
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Section Three: The Patient-provider Relationship
A. Building the Relationship
The technical quality of the care we provide is, of course, very important. However, the quality of the patient-provider relationship, as perceived by the patient, may have equal or even greater effects on the outcome of the encounter. Compliance has been shown to correlate with the quality of the patient-provider relationship, and the establishment of trust is essential if the patient is going to have faith in the physician’s diagnostic and healing abilities. Finally, a solid patient-provider relationship can potentially help reduce the incidence of tort claims. Studies have shown that most cases of iatrogenic complications and adverse outcomes never enter the tort system.1 Why is this? Perhaps one reason is that patients will be much less likely to sue when they have feelings of well-being, goodwill, satisfaction, and respect. Accessory motives for litigation are unhappiness and anger and, probably much less commonly, vengeance and greed.
While theoretical behavioral models abound, providers tend to develop their own style of practice influenced by many factors including their training, personal backgrounds, and life experiences. No one approach to patient relationships is appropriate for every provider. The following checklist and explanations provide a fairly simple and basic foundation for initiating a durable patient-provider relationship.
Patient Care Checklist 2
Setting the Stage for a Durable Patient-Provider Relationship
¶ Greet and Acknowledge the Patient by Name
- Patients should be respectfully greeted with expressions such as hello, good morning, or a similar expression in the native language using the patient’s name.
- Local norms should determine if the first name is used, or Mr., Mrs., or some other culturally appropriate expression.
¶ Introduce Yourself
- Providers should introduce themselves by name at the first visit or if it has been a while since the patient has been seen.
- Provider name badges are a good idea because they help patients remember names, but should not take the place of self-introductions.
¶ Provide Support and Reassurance
- Try to assess the patient’s level of physical and/or psychological distress (e.g., fear) through nonverbal cues or the way they respond to questions.
- Attempt to put patients at ease through attentiveness, nonverbal expressiveness, and reassurance, but following culturally acceptable norms of touch, eye contact, etc.
¶ Facilitate Dialogue
- Develop a “negotiated relationship” between provider and patient. Clearly not everything is subject to negotiation (e.g., many technical aspects of care, or emergency care), but issues that relate to patient choices of care (the goal being informed choice), or willingness to comply with recommendations, are important to negotiate with the patient.
- Critical to this process are carefully thought out non-judgmental questions, and attentive listening. Specific kinds of questions to consider include:
- What are they presenting themselves (or their child) for (i.e., their request or problem)? Ask and listen, rather than assume.
- What do they think is wrong, or what do they think is needed? Do they have alternative or traditional beliefs about their condition or need? Is the patient seeking assistance from available traditional healing methods, and how is this likely to influence the effects of medical care?
- What do they expect from treatment (i.e., their expectations)? What level of responsibility are they assuming for their or their child’s condition and/or follow-up to care?
¶ Respond and Teach
- Attempt to clarify to the patient (or family) what the options for care are.
- Do not talk down to patients, but also do not use jargon or concepts that are not familiar to them. The intent is to respectfully respond to their perspective and:
- acknowledge and clarify the similarities and differences in their perspective; what is clinically evident, and what we are able to do for them, considering alternatives of traditional medicine if available and desired.
- actively teach the patient, with the intent of informing and empowering them to assume appropriate responsibility for their health (or their child’s).
- negotiate with the patient and/or family to involve them in decisions that are appropriate and important in their care.
- tailor treatment and follow-up, as much as possible, to the individual or family’s existing routines, providing all important instructions in writing.
¶ Express a Warm Goodbye
- Reach clear closure with patients with a gesture of goodbye, following an opportunity for them to ask any final questions. Simply moving on to the next patient, without an opportunity of closure, can leave patients with an important, unanswered question and/or emotionally upset or troubled.
B. Ending the Patient-Provider Relationship
The proper termination of the patient–provider relationship is also very important. Ending the relationship in an adversarial manner can at times cause serious risk management concerns, and may even be illegal. Termination of the patient-provider relationship can occur in any one of the following acceptable manners:
- Provider services no longer needed. This, of course, is the most common means of termination. Patients without chronic disease who have no need for regular follow-up account for most of these situations. Another reason might be the need for a higher level of expertise than the current practitioner can offer. In both cases, the termination is amicable and understood by the patient. There are no risk management issues to consider.
- Mutual consent of parties. There are times when, for whatever reason, both the provider and patient agree that another provider should be identified to continue the patient’s medical care. No individual provider can satisfy every patient, and personality conflicts are occasionally unavoidable. If a patient requests another provider and the physician agrees, it is appropriate to make such a mutually agreeable transfer of care. The transfer of responsibility should be noted in the medical record.
- Withdrawal of provider from the case after reasonable notice to the patient and completion of current treatment. Sometimes, the provider alone determines that he/she can no longer care for a particular patient; the patient on the other hand, may or may not understand the need for change. With just cause, it is acceptable for the provider to withdraw him/herself from the case, provided the following conditions are met:
- The patient is notified of the desire to terminate the relationship;
- The current treatment plan is completed or the patient’s condition is stable;
- An alternative provider is identified and made available to the patient;
- The termination process is documented in the medical record, including the reasons for ending the relationship.
Abandonment of patients is never acceptable, and would constitute substandard care even if the previous care had been flawless. This includes leaving patients without options for care both in the inpatient as well as the outpatient setting. Providers must be cautious to prevent the perception that abandonment has occurred. It is essential to always indicate follow-up plans on all patients with undiagnosed ailments or those in need of ongoing treatment. Termination of care, when it occurs, must always be formally documented.
1 Hiatt HH; Barnes BA; et al. Special Report, A Study of Medical Injury and Medical Malpractice [Harvard Medical Practice Study] NEJM: Vol.321, No. 7:pp480-484, 1989.
2 Adapted from Promoting Health and Preventing Disease, Oral Health Program Guide, Section II, Indian Health Service Dental Program, and work done by Eric Bothwell, DDS, Dental Services Branch, IHS Headquarters.
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