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![Page 1: Communication with Patients, Colleagues and the Public with Specific Reference to Medical Litigation WMA – SEYCHELLES BASIC CONCEPTS IN ETHICS SEMINAR,](https://reader035.fdocuments.us/reader035/viewer/2022062805/5697bfbc1a28abf838ca12be/html5/thumbnails/1.jpg)
Communication with Patients, Colleagues and the Public with Specific Reference to Medical Litigation
WMA – SEYCHELLES BASIC CONCEPTS IN ETHICS SEMINAR, 10TH & 11TH JULY 2015 (July 2015)
Professor A Dhai Immediate Past-President SAMA
Director: Steve Biko Centre for BioethicsHoD Bioethics Discipline
Faculty of Health Sciences University of the Witwatersrand, Johannesburg
South African Unit of the UNESCO International Network in Bioethics
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• Changing practitioner-patient relationship• Core values in medical ethics • Communication• Competence• Stress as a factor in litigation risk• Implications of Increasing Litigation• Medical Malpractice & Professional
Negligence• Recommendations
INTRODUCTION
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• purpose of health care practice : – always to care for the sick and promote their health interests and well being. – health care practice - moral contract between the public and the profession – health care practitioners important agents through which scientific knowledge applied
to human health.
• attitudes and expectations of both public and practitioners undergone change: – traditional practitioner-centred approach to patient care transformed into the present
day patient-centred approach, – legal influences having bearing on relationship - gradual transition of practice towards
that of defensive medicine - ? the humanistically responsive practitioner may soon become a concept belonging to the past?
– political, social and economic factors have introduced demands, anxieties and stresses in health care practice.
• practitioners whose jobs in the past were clear and unequivocally well understood now face uncertainties and doubts as to their roles
The changing practitioner-patient relationship
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• WMA Core values of Medical Ethics:– Compassion
• Understanding and concern for another person’s distress• Patients perception that concerns are appreciated and
being treated rather than just the illness– Competence
• High degree expected and required• Technical and ethical
– Autonomy• Self-determination• Both practitioner and patient
Core values of Medical Ethics
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• *70% litigation due to poor communication – Moore et al : dissatisfaction with communication largest
factor leading to complaint (Chile)– Hamasaki et al : increasing trend of doctor’s explanations
forming a pivotal point of medical malpractice litigation (Japan)
• At heart of most dissatisfaction – failure to communicate caring– Ambady et al : surgeons audio-taped voices assessed by
patients – high dominance over and low concern for patient correlated with surgeons who had previous claims
– Beckman et al : association between perceived lack of caring and decision to litigate
– Chiu et al : driving motivation for litigation – emotional desire to achieve comfort ,i.e., sense of being cared for
References available on request
Communication
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• Moore et al :– Patient perception of doctor competence increased– Patient intention to sue decreased
• Hagihara et al :– Explanatory behaviour + explaining and listening to families
– markedly lower probability of court decisions of negligent care
Impact of Good Communication and Demonstrating Caring
References available on request
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• Negative attitudes towards communication
• Lack of inclination to communicate
• Personality differences with patients
• Undervaluing importance of communication
• Lack of understanding of communication process
• Lack of knowledge or training in communication skills
• Fear of litigation!
Key Barriers to Effective Communication
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TYPE OF OFFENCE
GUILTY VERDICTS - HPCSA
2009/2010 2010/2011
Incompetence 26 18
Insufficient Care/Treatment & Mismanagement of Patients
31 20
Negligence 15 23
Misdiagnosis 4 6
Practicing Outside Scope of competence 10 4
Overcharging / charging for Services not Rendered 43 34
Other 70 67
TOTAL 199 172
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• Higher levels of occupational stress (public sector) cf average working population:
• Understaffing • Lack of resources• Lack of control• Difficult work schedules• Inadequate security• Poor career advancements• Poor salaries
Thomas LS, Valli A. Levels of occupational stress in doctors working in a South African public sector hospital. SAMJ(2006); 96:1162-1168
Stress
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• Increase in Frequency
• Increase in Magnitude
Claims Inflation
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• Serious concerns on sustainability of the current claims trajectory on practitioners, patients, wider healthcare economy. – snowballing cost of professional indemnity insurance, resulting in
higher medical costs in the private sector. – public health institutions - affects the State’s ability to finance
healthcare in the medium to long term, has a negative effect on service delivery • inevitably reduce quality of care in already resource-strapped setting.
– healthcare practitioners, on a personal level - struggling to reconcile ethical duties towards patients : growing aversion to liability risk and the related fear of being sued.
– anecdotal evidence – decreasing specialists in high risk disciplines overburdening public facilities
Implications of Increasing Medical Litigation
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Perfecting communication, listening and empathy skills
Essential components to avoiding risk of litigation
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• Some patients are difficult to deal with and could wear down practitioner endurance:– angry, abusive, self-destructive and noncompliant.
• Ethical challenges encountered when caring for such patients include:– questions around mutual respect, compassion and justice – whether or not limits to these values should be permissible
The difficult patient
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• Emotionally stressful – may have to develop defense mechanisms to cope with tensions.
• Feeling useful and being useful - integral to achieving satisfaction at work – noncompliant, uncooperative patient denies those that provide care the chance to feel
that usefulness and satisfaction
• Frustrated & dissatisfied– understandable as really work hard to improve patient’s condition and efforts are met
with noncompliance
• Emotional reactions and responses adverse towards the patient – trigger rift from the practitioner’s ethical and moral ideals.
Impact on the practitioner
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• Listen to rejection of management
• Empathy and compassion are not only the ability to feel a patient’s pain and suffering, but also to have an awareness of the whole person, the person’s ideas, feelings, attributes, and prejudices.
• Important to remember that we can learn from our patients.
• Learn to adjust to specific patients and their behaviour
Responding to the noncompliant patient
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• start off by asking what patient understood about the proposed management.
• was patients given sufficient information in a way that could be understood?
• effective communication is key to enabling patients to make informed decisions.
• take appropriate steps to find out what patients want to know and ought to know about their condition and its treatment.
• patients are more likely to co-operate fully with the agreed management of their conditions if they make properly informed decisions about their health care.
• If a patient has not truly understood would it be fair of the practitioner to label her/him as noncompliant?
Responding to the noncompliant patient
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• Despite strict adherence to core ethical values in health care practice by the empathic, altruistic and compassionate practitioner, the angry, abusive, self-destructive, noncompliant and vindictive patient is a reality.
• SMDC
• Legal sanction
Reality
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• Be aware of and discuss challenges imposed by the difficult patient with peers, other colleagues
• Seek advice from insurers
• Practice of empathy and compassion could be understood by discussing why one loses empathy and how the situation could be adjusted
• Good note keeping – assists with patient management during follow up, – could be used in the practitioner’s defense
RECOMMENDATIONS
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• Medical malpractice – negligent or intentional unlawful conduct on the part of health care
practitioners that causes injury or damage to their patient or their patient’s property.
• At common law - where professional persons intentionally or negligently unlawfully cause harm to another person.
• Malpractice goes further than professional negligence– because it includes negligent or intentional acts.
• for example where a health care practitioner intentionally breaches the confidence of his or her patient.
MEDICAL MALPRACTICE
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• When health practitioners negligently fail to exercise degree of skill and care of reasonably skilled practitioner in their field of practice.
– Specialists expected to exercise greater degree of skill and care than general practitioners.
– Greater skill and care also required where more complicated medical procedures used.
• Therefore general practitioners would be negligent if they undertake work for which they do not have the required specialist skills – unless it is an emergency situation and no specialist is available.
• Negligence also when fail to take informed consent
PROFESSIONAL NEGLIGENCE
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• ELEMENTS:• Disclosure• Understanding and appreciation• Capacity• Voluntariness
INFORMED CONSENT
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• A risk is material if:– A reasonable person in the patient’s position, if
warned of the risk, would attach significance to it; and
– The health practitioner should reasonably be aware that the patient, if warned of the risk, would attach significance to it.
Material Information
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Avoiding Trouble – Gillespie’s “Six Cs”
• Communication• Consent• Confidentiality• Competency • Clinical Records• Careful Prescribing
• MPS Junior Doctor Issue 1/2009
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• Abiding by the WMA Core Values goes a long way in avoiding risk
• Continuously perfecting communication, ethics and technical skills are essential
• Good note keeping assists with patient management during follow up, and could be used in the practitioner’s defense
• The practice of empathy and compassion could be understood by discussing why one loses empathy
• PRACTITIONERS ARE VULNERABLE TOO
Key Points