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Berger, Sosena Kebede, Mary Catherine Beach Johns Hopkins University School of Medicine, Department of General Internal Medicine, Baltimore, MD
PATIENTS REPORTING CONFLICT OR DISAGREEMENT WITH PHYSICIAN (N=7) DISAGREEMENT WITH PLAN OF CARE (N=3) TOO LITTLE INFORMATION ABOUT DISEASE PROCESS OF PLAN OF CARE (N=4)
Patient Interview and Third Party Interview
PHYSICAL EXAM (N=1)
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 doctorpatient conflict in hospitals are lacking.
To classify types of conflict, or disagreement, through analyzing doctor-patient dialogue on a hospitalist service.
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.
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 DISCHARGE ARRANGEMENTS (N=1) CHANGE IN THE PLAN OF CARE NOT KNOWN ABOUT BY PATIENT (N=2)
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 nervewrecking, 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.
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.
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.
Demographic characteristics of patients (N=18) Mean Age 52 Female N=9 Race African American N=6 Caucasian N=11 Other N=1
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)
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
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.
In at least one case, a patient refused examination initially, only to consent later.
First study to examine inpatient plan of care discussions through audio recording >400 total minutes of recording time Single hospital on hospitalist service
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?
Greenwall Foundation for Bioethics Osler Foundation for Clinical Excellence, Johns Hopkins
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