BACKGROUND

METHODS

DISCUSSION

FUNDING SOURCES

Greenwall Foundation for Bioethics Osler Foundation for Clinical Excellence, Johns Hopkins

We conducted a qualitative study of patient-doctor communication on an inpatient medicine hospitalist service. We audio-recorded 24 patient-doctor dialogues, representing 18 separate patient hospitalizations, as well as 24 corresponding interviews with hospitalists and 24 interviews with patients. The total recording time was 558 minutes. Of the 18 hospitalizations, we noted significant conflict in 7. Patient and physician dialogue and interviews were coded using a modified discourse analytic approach and then broadly categorized by two internists  to  reflect  the  patient’s  disagreement  with  the physician in given categories.

Doctor-Patient Communication on a Hospitalist Service: Types of Conflict Zackary D. Berger, Sosena Kebede, Mary Catherine Beach

Johns Hopkins University School of Medicine, Department of General Internal Medicine, Baltimore, MD

STRENGTHS/WEAKNESSES

FUTURE QUESTIONS

Barriers to doctor-patient communication are frequent and can impede care. Conflict described in the outpatient setting has often been found to be implicit, not openly expressed by the patient. Descriptions of doctor-patient conflict in hospitals are lacking.

A number of patients report disagreement with their physicians concerning various aspects of their care. Disagreement with the plan of care did occur, but was less common than disagreement with the amount of information presented or with a change in plan the patient had not been informed of. Most patients did not report or evince explicit disagreement with their physicians. In at least one case, a patient refused examination initially, only to consent later.

Which communication practices, and characteristics of doctor and patient, act as facilitators or barriers for explicit expression of disagreement on the part of the patient? To what extent does participation in the plan of care on the part of the patient influence such disagreement? When, and under what conditions, are physical exams carried  out  in  the  hospital  under  patients’  objections?

First study to examine inpatient plan of care discussions through audio recording

>400 total minutes of recording time

Single hospital on hospitalist service

AIMS

To classify types of conflict, or disagreement, through analyzing doctor-patient dialogue on a hospitalist service.

PATIENTS REPORTING CONFLICT OR DISAGREEMENT WITH PHYSICIAN (N=7)

Dialogue Patient: And what about the pain? MD: Pain pills before you eat? Patient: Uh. No. I mean, the pain, I mean you gonna uh keep the, I mean, I mean I prefer you decrease the dose of the [Dilaudid]. MD:  Yeah,  no  what  we’ll  do  is  convert  it  to  oral  (Patient:  Oh) around a similar dose. Patient:  Oh,  yeah  but  the  thing  is  that  I’m  not  comfortable with the orals. Not at the hospital and I would talk to Dr. ***(P), every time I come, I have. MD: No I did talk to her yesterday, she said today is the day you should move. I talked to her yesterday. Patient:  Yeah,  I  should  but  I’m  just  not  comfortable  with  the  oral  pills  at  the  hospital… MD: Can you try it one time for me? Patient:  I  really  don’t  want  to.  I  tried  last  time  and  I  almost got, I mean, I was just so messed up, the nurse knows  about  it.  I’m  sorry  I  wish  I  could  try. MD: Just one time. Patient:  I… MD:  …You  do  it  one  time  with  me.

TOO LITTLE INFORMATION ABOUT DISEASE PROCESS OF PLAN OF CARE (N=4)

STUDY SUBJECTS

CHANGE IN THE PLAN OF CARE NOT KNOWN ABOUT BY PATIENT (N=2)

Patient Interview Patient: Yea. Yesterday they told me I was supposed  to  get  an  MRCP,  today  they’re  telling me they want to give me a CAT scan. And then a woman doctor came in this morning  with  another  man  and  said  ‘ok,  you’re  going  to  be  drinking  a  barium  solution’  which  is  what  I’ve  done  in  the  past.   Third Party (Mom): With the CAT. Patient: Yes. And then I wake up and everyone in the world is here, and the doctors  say  ‘no  you’re  not  going  to  drink  anything  you’re  just  going  to  get  an  injection.’  (Research Assistant: Ok)

Dialogue MD: Alright, would you mind if I listen to you? Patient: Oh my God, she just listened to me. MD: I’m  sorry. Third-party (nurse): I know, but the doctor wants to listen to you too. Patient: I thought you was my doctor? Third-party (nurse):  No,  I’m  your  nurse. (Pause for exam) MD: Alright. You look not very pleased. Patient:  I’m  not. MD: Why? Patient:  Because  it’s,  its  nerve-wrecking, everybody come in here, wanna listen to you, wanna pick and poke at you. MD: Yea, but you know that we’re  here  to  help  you  ok.  We  just want you to get better. Patient: [Now I am] I feel good, great. MD: You feel good? (Patient: Yeah).  So  you  don’t  need  to  stay  in the hospital? Patient: No. MD: Ok,  so  you  don’t  want  me  to  listen to you? Patient: You can listen. MD: Ok.

Patient Interview and Third Party Interview

Research assistant: And do you wish you have more or less information? Patient:  Well  I  think  it’s  coming  through  now, but it would have been maybe nice to have it a little earlier. I realize this is a hospital too. RA: And  when  you  say  it’s  a  hospital,  what do you mean by that? Patient: Well there are other things going on, they're not worried just about me, but I hope they're worried about me too, but they seem to be, so. RA: And then you mentioned it might have been nice to know some more things? Patient: Mainly knowing it a little bit earlier, maybe. RA: Knowing what earlier? Patient:    Well,  what’s  ahead,  and  maybe  occupational therapist would come, I did learn a few minutes ahead, somewhat maybe half hour ahead. But um, kind of knowing what to expect, but it hadn't been bad. Third-party (son): What the plan is. Last night we didn't know what the plan was and it was frustrating.

Dialogue MD: I  know  Rockville  is  a  nice  place,  it’s  a  different  county  that’s  it.  Montgomery County right? Third-party (son): Do you know anything about *** yourself? MD: I think I've never been to the place myself, but if ***(A) is saying I think she knows because all the time she refers patients. Third-party (son):  Alright.  So  that’s  a  last  option  unless  it’s  the  only  place that comes back with a private room then we will probably take it at this point. I want him to be safe, I want him to be comfortable and not have any conflicts. MD: Sure. And as I said the acute rehab may not be for long-term, its maybe 1 week or 10 days maximum. Patient: I don't want any 10 days. Third-party (son):  That’s  too  long Patient: I don't want any longer than 5 days. MD: Ok. So they will send you faster depending on how you do, and  then  they  assess  you  and  if  it’s  safe  to  go  then  they  will  just  send you home. I am just saying maximum 7 days here we have rehab here, maximum one week they keep patients and we send them home Third-party (son): He's almost safe to go now. I mean I'd actually say, swear you know if this doesn't happen today, I mean my instincts are like you know, get him out of a hospital, especially when the hospital environment in not helping him.

PHYSICAL EXAM (N=1)

Patient Interview Patient: it’s  a  shock  to  me.  I  didn’t  know this was going on but, yes they need to explain more to patients,  that’s  anywhere,  because  I was really misled from a couple, from  one,  that’s  why  I  went  to  different hospitals, because it seems  like  they  couldn’t  tell  me  what was going on with me, they was telling me everything but what was  going  on  and,  I  don’t  know.  

Demographic characteristics of patients (N=18) Mean Age 52 Female N=9 Race African American N=6 Caucasian N=11 Other N=1

DISCHARGE ARRANGEMENTS (N=1)

DISAGREEMENT WITH PLAN OF CARE (N=3)

Topics of significant disagreement with physician expressed by patient (N=7) Number of patients Too little information about disease process or plan of care 4 Change in the plan of care the patient did not know about 2 Plan of care 3 Criteria for discharge or discharge arrangements 1 Unwanted physical examination 1