RAISING AWARENESS
| BUILDING TRUST BETWEEN PATIENT AND DOCTOR —Frank H. Boehm, MD, Professor of Obstetrics
and Gynecology, Vanderbilt University School of Medicine, Nashville, TN
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| Patient-physician relationship: once close and trusting relationship becoming distant and suspicious; trust
binds health care provider to patient, and patient to health care provider; trusting relationship with patient critical
in health care provider’s ability to dispense good medical care; trusting relationship also helps to minimize
malpractice claims; mistakes and shortcomings of health care providers widely publicized, affecting
public’s trust of health care system; avoidable medical errors harm 1.5 million patients annually
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| Communication between patient and health care providers: should be bidirectional rather than unidirectional;
allowing patient to know health care provider as person enhances trust and communication; patients
must feel health care provider cares about them; the more health care provider allows patient to know him
or her, more likely trust develops; time restrictions and frustrations in delivering care resulted in less bidirectional
communication
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| Hippocratic oath: 3 fundamental principles patient welfare, autonomy, and social justice; professional
responsibilities—competence, honesty, patient confidentiality, maintaining appropriate relations with patients,
improving quality of care, improving access to care, judicious distribution of finite resources, scientific
knowledge, maintaining trust by managing conflict of interest and professional responsibilities
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| Patient responsibilities that reflect on health care provider: lay press advising public to educate themselves
about their medical conditions and ask questions; suggestions seen in lay press—learn as much as you can
about your medical condition; go to libraries, Internet, or ask your doctor for articles that will help you understand
many complicated issues surrounding your health; health care provider should be willing to provide patient
with information about his condition; well-informed patient easier to care for; write down questions before arriving
at appointment—patients’ need to ask numerous questions lessens as they develop trust in health care
provider; reminding patients to write down questions can enhance trust; if possible, take close relative or friend
with you—many patients do not “hear” what health care providers tell them when being given medical information,
especially distressing or bad news; ask your health care provider to talk to you before you get undressed
for examination—patients more comfortable, attentive, and thorough when discussing their medical complaints
while fully clothed; be prepared to ask about alternative treatments that may be available—health care
provider should be willing to explain risks and benefits of any reasonable alternative treatment plan; if not
comfortable with health care provider’s advice, ask for second opinion—health care provider should be willing
to supply patients with names of competent health care providers who can provide second opinion; second
opinion that concurs with original diagnosis enhances trust and confidence and may prevent treatment for
wrong diagnosis; let your health care provider know of any problems that develop during treatment and also if
you are improving; be aware that you have right to deny particular course of action and to say no to treatment plan
(health care provider should ensure patient understands risks associated with his decisions); speak up if you
feel rushed or do not feel your doctor has answered your questions
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| Bedside manners: be respectful of patient’s hospital room (act as though you are in their home); survey of 182
families with chronically sick or disabled children found many health care providers talked to patient’s family
in insensitive or dismissive manner, even though provider felt he or she did good job; role modeling and role
playing for developing interpersonal skills needed in medical schools and resident training
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| Informed consent: more than just key to open door to surgical procedure or particular type of treatment; informed
consent ethical concept that has become integral to contemporary medical ethics and practice (ethical
requirement for medical treatment); ensure sufficient time taken to fully inform patient about risks and benefits
of treatment or procedure, and that patient understands; fully informed patient less likely to initiate lawsuit
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| Patient safety: Institute of Medicine (IOM) estimated 98,000 patients die annually from errors committed during
hospitalization (statistics indicate number may be higher); experts claim as many as 2 million patients suffer
from hospital-induced illnesses annually; Harvard School of Public Health survey—of 831 physicians
surveyed, 356 said they or members of their families had experienced medical error that created serious medical
complication (eg, death, severe pain, long-term disability); <25% believed it would be effective to use
computers to order drugs in hospitals (computerized system at Vanderbilt Hospital has reduced medication
errors to 0.02%); many doctors did not believe specially trained doctors necessary in intensive care units
(ICUs); reforming medical practices that will reduce errors can be successful only if doctors support changes
that experts recommend
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| Medical malpractice: physicians experience emotions similar to those of death and dying (ie, denial, anger,
bargaining, depression, acceptance, and hope) when being sued for medical negligence; defensive medicine
has added to annual cost of health care; incidence of medical negligence >7 times number of patients initiating
lawsuits; 3% to 4% of hospitalized patients experience injury caused by medical care (only 25% of injuries
occur because of substandard care); most patients experiencing adverse outcome never initiate legal
action; physicians attracting disproportionate share of malpractice claims likely have difficulty “connecting”
with patients; patients dissatisfied with their medical care who initiate lawsuits cite communication issues
70% of time (Beckman et al); studies show ineffective communication between patient and health care provider
most important factor in patient’s decision to file lawsuit, not medical negligence; data show physicians
with history of patient complaints about communication more likely to become involved in lawsuit; 9% of
physicians accounted for 50% of complaints
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| Barriers to trust and communication: more patients, less time, less personal interaction (unidirectional communication),
lack of objective patient feedback, and tests supplanting communication; patients’ perceptions
about health care providers—arrogant, aloof, dismissive, patronizing, judgmental, insensitive, rude, indifferent,
interrupt, and selectively dislike people
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| Gaining and maintaining trust: goal to let patients know you care what happens to them; let patient tell his
story without interruptions; be at eye level with patient; sit without obstacles in way (rearrange office furniture);
appear relaxed; act as if you have no other patient but that patient; let patients know you more personally (ie,
show family pictures, tell stories); understand you may dislike some patients, and attempt to work through that;
do not yell at angry patients (try to understand their frustrations); offer apology—some states have passed legislation
prohibiting use of physician’s apology or expression of sympathy as evidence of liability in medical malpractice
lawsuit; patients often initiate lawsuit because they don’t know what happened and they feel health care
provider not open and honest; insurance companies have begun teaching physicians how to discuss medical errors
with patients; spirituality and health—be open to discuss patient’s spiritual beliefs; become patient’s
advocate—do not consider tort reform only issue affecting medical malpractice; patients want to know that you
care about whether they are insured; address problem of uninsured by advocating for universal health care coverage
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| MEDICAL RECORDS AND LIABILITY: WHAT YOU NEED TO KNOW —Marlene Schwebel, JD, CNS,
Director, High Risk Obstetric Ambulatory Services, Division Maternal/Fetal Medicine, University of Medicine
and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ
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| Medical records: legal and ethical principles same whether medical records paper or computerized; must be
protected from unauthorized use and access (most abuse of computerized records involves authorized users);
concerns with computerized records—need to know which computers networking with other agencies and
who has access; need to know about computers shared with other parties not bound by confidentiality; other
issues include storage (back-up system) and destruction of records; for records to be admissible as evidence in
court, must have safeguards in place, must be accurate, and protected; computer password must be protected;
loaning computer password to another person not defense in lawsuit; accessing medical records of others considered
breach of confidentiality and can present ethical dilemma
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| Entries in medical record: must be clear, legible, and meaningful; sloppy and illegible entries equated with
substandard care; entries should be objective and nonjudgmental; do not criticize colleagues or other disciplines
in medical record; include names of persons accompanying patient or interpreters used; subjective
part of entry can include patient’s account of reason for being there (can quote patient and highlight patient’s
attitude)
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| Altering medical record: makes defensible case indefensible; legal term spoliation; spoliation defined as intentional
destruction, mutilation, alteration, or concealment of evidence, usually document; if proven, may be
used to establish that evidence unfavorable to party responsible; possible penalties include cancellation of insurance,
exclusion of coverage, possible loss of professional license, criminal charges, and loss of case; how
alterations detected—different ink; squeezed notations in margins or ends of paper; change in penmanship;
correction fluid “white-outs”; erasures; impression or lack thereof on subsequent pages of record; paper used
not available at time of entry (too old or too new); entries into record on different dates in same ink or different
ink used on same day; cut and paste (line can be detected on paper); completely legible note on day of incident;
different records at different locations; forensic analysis; do not write over mistake; instead, draw line
through mistake, follow by writing “error” with initials and rewrite note; lost records—difficult to explain;
chart of active patient not involved in lawsuit can be recreated through records of appointments, billing, and
laboratories; have policy that no charts leave office or implement sign out/sign in policy
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| Recommendations for documentation: illegible, sketchy, and incomplete records imply to jury that patient
care also “sloppy”; provides “gift” to plaintiff; avoid ambiguous entries; good documentation helps other providers
treating same patient and helps stimulate memory in event of lawsuit; use black ink (reproduces best);
good documentation helps defend lawsuit, explains rationale and patient decision-making (patient included in
decision-making about treatment less likely to initiate lawsuit); entries should be nonjudgmental and objective;
entries should include dates, times, and signature; include risks and benefits of treatment and alternatives to
treatment; when writing, eg, “patient counseled extensively,” include length of time; phrase “including but not
limited to” recommended (does not hold you to only those issues named in documentation); avoid subjective
descriptions and quantify statements; documentation can provide educational topics for updates; if you did not
chart it, do not alter medical record (saying how you did it provides better defense than why you altered medical
record); document as if reading entry to jury; think of medical record as witness that never dies
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Suggested Reading
Beckman HB et al: The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern
Med 154(12), 1994; Hickson GB et al: Patient complaints and malpractice risk. JAMA 287(22):2951, 2002;
Knight EM: The case for accurate and complete physician documentation. J S C Med Assoc 101(9):322, 2005;
Leape LL: Full disclosure and apology—an idea whose time has come. Physician Exec 32(2):16, 2006; Luft HS:
Clinical performance measures and medical malpractice. JAMA 296(13):1589, 2006; No authors listed: Principles
of medical record documentation. J AHIMA 63(9):67, 1992; Teutsch C: Patient-doctor communication. Med Clin
North Am 87(5):1115, 2003; Weinbaum B: What I learned while on trial, Alvarado case shows that documentation
is key to avoiding a costly legal ordeal. Mod Healthc 36(48):23, 2006.
Educational Objectives
| The goal of this program is reduce malpractice claims by building trust between the patient and health care provider
and to prevent or reduce liability through good documentation in the medical record. After hearing and assimilating
this program, the clinician will be better able to:
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 | 1. Discuss issues contributing to the waning trust the public has in the medical profession.
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| 2. Identify ways in which trust can be enhanced between patients and their health care providers.
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| 3. Cite the barriers to the development of trust and communication between patient and health care provider.
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| 4. State 3 elements necessary for good documentation in the medical record.
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| 5. Follow the guidelines on how to correct an entry in the medical record.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Boehm was recorded at the 32nd Annual High-Risk Obstetrics Seminar sponsored by Vanderbilt University
School of Medicine, held December 8-9, 2006, in Nashville, TN. Ms. Schwebel was recorded at the 21st Annual Issues
and Controversies in Ob/Gyn, sponsored by the University of Medicine and Dentistry of New Jersey, Robert
Wood Johnson Medical School, held November 9-11, 2006, in Lake Buena Vista, FL. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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