Sunday, 26 February 2012

What's best for the patient?

Last week I wrote about the importance of ensuring that patients and relatives are listened to, and also appreciate that they have been heard.

This week I have been reflecting on what it is like when you realise that you have failed in this ambition, and despite your best efforts, the people you are dealing with are convinced that you never listened, and as a result lose faith in you as a doctor.

This will happen to most of us at some point, and when it does, it is really important to spend some time thinking about what happened, what you did well, what you could have done differently, and what, if anything,  you can learn from it. 

The problem, as I see it stems from a situation in which the expectations of the patient and their relatives differ fundamentally from mine as a physician. It is always important to take great care managing the expectations of the people you serve as a doctor, but it is also important to take into account the different styles and preferences of these people, in particular where their wishes and ambitions involve an approach that does not conform to your usual way of practising. 

If you fail as a doctor to manage expectations so that the people you are working with disagree with what you are saying and reject your information, you are faced with the choice of continuing to disagree with your patients, or moving to where they are and working with them in the manner they would like.

This can be a difficult choice, because the it raises the possibility that you surrender your best opinion and work in a way that you do not agree with, and it perhaps asks you to administer treatments that you think are futile, and perhaps will cause unnecessary distress. There are of course systems in place for resolving conflicts and disagreements with patients and their families, and second opinions should be sought where the discussion becomes intractable. However, on a human level, you have to ask yourself as a doctor what is the best way to serve a patient and their family when they have lost faith in you as a physician. This is difficult, and at the very least, it demands that you are prepared to be brutally honest with yourself, in private. 

When faced with negative feedback in the manner I describe, it is common to feel that the problem lies with them, and not you. And sometimes that is true, but it is not helpful to your personal growth to use that as your stock response, as it is a missed opportunity. Remember, being the patient or being the relative of someone very sick is a stressful experience, and often they cannot be held accountable for the way they behave. We all do strange things when we are under stress, and part of our role as doctors is to help them through the stress, and another part of our role is to take some heat when that stress manifests with the need to vent some anger and frustration. 

However, I am not suggesting that such a role comes without a personal cost for you, because being criticised by patients and relatives can be very upsetting indeed, particularly when you think that you did your best, and particularly when you think that you actually did quite well.

This is where things become very tricky, because in many ways your reputation with the patient and their family cannot be rescued once it is lost. In this situation, take yourself off quietly, and remind yourself if you can of what really matters. The key question to pose is ‘What is best for the patient?’ The answer to this question may involve a range of different responses: it may involve you standing firm, it may involve you acquiescing to requests you disagree with; it might involve you stepping back from the patient’s care, and handing them over to someone else. And that’s the really hard bit- the experience can be so emotional, and so draining, that the risk is that the care that the patient receives can become tainted by disagreement. 

So my reflection for this week, is that however hard and personal the criticism may be, it is really important to do whatever is necessary to ensure that the patient gets the best care they can. 

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