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

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

Department of General Internal Medicine, Baltimore, MD PATIENTS REPORTING CONFLICT OR DISAGREEMENT WITH PHYSICIAN

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

PATIENTS REPORTING CONFLICT OR DISAGREEMENT WITH PHYSICIAN (N=7) DISAGREEMENT WITH PLAN OF CARE (N=3)
PATIENTS REPORTING CONFLICT OR DISAGREEMENT WITH PHYSICIAN (N=7) DISAGREEMENT WITH PLAN OF CARE (N=3)

DISAGREEMENT WITH PLAN OF CARE (N=3)

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

PHYSICAL EXAM (N=1)

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.

BACKGROUND

Barriers to doctor-patient communication are frequent and can impede care. Conflict described in the outpatient
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.

AIMS

To classify types of conflict, or disagreement, through analyzing doctor-patient dialogue on a hospitalist service.
To classify types of conflict, or disagreement,
through analyzing doctor-patient dialogue on a
hospitalist service.
Dialogue Patient: And what about the pain? MD: Pain pills before you eat? Patient: Uh.
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.
Patient Interview and Third Party Interview Patient Interview Research assistant: And do you wish you
Patient Interview and Third Party
Interview
Patient 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.
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.
me everything but what was going on and, I don’t know. DISCUSSION A number of patients

DISCUSSION

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.

STRENGTHS/WEAKNESSES

METHODS

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.

STUDY SUBJECTS

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)

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,
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)
just going to get an injection.’ (Research Assistant: Ok) Dialogue MD: I know Rockville is a
Dialogue MD: I know Rockville is a nice place, it’s a different county that’s it.
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.

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

>400 total minutes of recording time

Single hospital on hospitalist service

FUTURE QUESTIONS

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?

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

 

1

Unwanted physical examination

FUNDING SOURCES

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