Providing patient-safe care begins with asking and listening... really listening!

Summary

Dan Cohen is an international consultant in patient safety and clinical risk management, and a Trustee for Patient Safety Learning. In this blog, Dan talks about how patient-safe care is all about collaborating and listening to your patients to find out what really matters to them. He illustrates this in a case study of his own personal experience whilst working as a clinician in the USA.

Content

Patients are much more likely to entrust their care to clinicians who have listened, truly listened, to their concerns. This is key to providing the highest quality of care and caring. In 1988, the Picker Institute coined the term patient-centred care,[1] calling on clinicians to focus more attention to the needs of patients and family members instead of focusing more simply on diseases—a more humanistic approach to collaboration in healthcare.

Providing patient-centred care requires thorough, clear and compassionate communication between providers, patients (and family members where appropriate) in order to secure the collaborative framework for success. Success should certainly be related to the outcomes that each patient desires.

Miscommunication between clinical staff and patients (or parents/other care providers) may lead to errors and subsequently to harm, especially when implementing treatment plans that take place primarily in patients’ homes. Thus, it is essential that clinicians communicate with patients competently, compassionately and empathically; and communication begins with listening... really listening! The concept of patient-centred care was further elaborated upon in the seminal report, Crossing the Quality Chasm in 2001.[2]

In 2012, Barry and Edgman-Levitan published a perspective paper, Shared Decision Making — The Pinnacle of Patient-Centered Care, which, for the first time, suggested that clinicians “need to relinquish their role as the single, paternalistic authority and train to become more effective coaches or partners”.[3] Clinicians shouldn't just ask “what is the matter?” but, as importantly, “what matters most to you?”.

Collaboration between patients and clinicians requires that patients be encouraged to share their views of their health and wellbeing, and their desired outcomes from clinical interventions and recommendations. This includes and extends from medical and surgical interventions, designed to improve clinical outcomes and functionality, all the way through to exercising end-of-life care options. What matters most to patients must be considered in care planning and is the quintessential element of patient-centred care and collaboration.

Listening carefully to patients goes way beyond simply talking with patients, which all too frequently translates to clinicians obtaining brief histories of symptoms without really appreciating the depth of patients’ concerns. Sometimes, especially if we are very busy, clinicians actually spend too much time talking 'to' patients, without really delving deeper to understand their concerns and/or their depths of understanding of the issues we need to consider. As far as I can recall, I was never taught in medical school or during post-graduate training to listen to patients. Instead, I was taught to gather information in a systematic way without asking questions, such as “what matters most to you” or “what is frightening you today?” or “what concerns you most?” or “is there anything else you would like to share with me today?”.

If we don’t have the answers to these questions, then we may miss opportunities to provide the best possible care and to achieve the most desirable outcomes from the patient’s perspective. What matters most to patients serves as the directional signpost for the doctor/nurse–patient relationships and we need to stay in this lane.

To achieve what matters most to patients, the process of providing care begins with each patient explaining their concerns and the clinician listening in a compassionate and empathic way. This involves more than clinicians just hearing what patients have to say, but also with clinicians observing each patient’s body language for subtle clues that can be very revealing. Listening is both an auditory and visual function in my view.

Finally, the best way to solidify collaboration is to treat patients respectfully and help them maintain their normal lifestyle, if it will be safe to do so. However, this may present challenges both for patients and clinicians. I would like to share the following case study to illustrate this.

A case study

A number of years ago, I was evaluating a young athletic woman, Karen (not her real name), for profound bruising and nose bleeds resulting from moderately severe thrombocytopenia (very low blood platelet count). It was clear after several diagnostic investigations that she had autoimmune thrombocytopenia where the body produces antibodies against its own platelets, and these are destroyed primarily in the spleen. At this time, the approach to care had been observation alone for a period of perhaps six months with oral steroid support, if necessary, to boost the platelet count to prevent bleeding, followed by splenectomy (removal of the spleen) if the thrombocytopenia persisted.

Karen did not want to take steroids, even though these might have elevated her platelet count to a safer range. Steroids are associated with weight gain and acne and she did not want to experience these side effects. Her platelet count was sufficient enough to prevent really serious bleeding, so I agreed to avoid this as long as she promised not to engage in rigorous physical activities. I had a long discussion of the risks and benefits with Karen, and she agreed with this plan. After a period of two months, Karen’s platelet count remained stable although still quite low, and her bruising had subsided a bit as had her nose bleeds.

One day Karen came to see me because she wanted to play in a tennis tournament, at which point I said clearly, and with great sensitivity, that I felt that was very risky and that if she fell or was hit by the ball she could be seriously injured and possibly even die. I needed to be very firm about this, though I did so in an empathic way as I could relate to her frustration.

I had an uncomfortable feeling that Karen might play in the tennis tournament regardless of what we had discussed. So, I told Karen that if she were to agree to take prednisolone every day, and if her platelet count rose substantially on this regimen, then I would—though with some cautionary reluctance—endorse this approach, but that she was to seek emergency medical care for any injury, immediately!

What mattered most to Karen, playing in the tennis tournament, was potentially dangerous, but I was concerned that she might simply go ahead and participate anyway, with her platelet count dangerously low, even though I had advised her against it. This was a tough situation to be in... for Karen but also for me.

Karen started the prednisolone and her platelet count rose nicely to a safe range over a one-week period. All bruising resolved completely and she had no nosebleeds. Karen participated in the tournament. However, about a week after the tournament, and while slowly tapering off the prednisolone, Karen was involved in a car accident and banged her forehead hard against the steering wheel and the front window. She had not been wearing a seatbelt.  

Karen was rushed to A&E, fully conscious and feeling ok. Her platelet count was below normal but not dangerously so. She was miraculously not seriously harmed, though of course she was quite frightened.

I kept Karen on prednisolone, began tapering again after one week, and we had a long heart to heart talk about her risky behaviour. Her car did not have functioning seat belts and I had forgotten to ask about that. She promised me she would not perform any risky behaviour after another very empathic and firm conversation.

As Karen’s thrombocytopenia did not resolve by the end of the six-month observation period, I referred her for surgical removal of her spleen, which went smoothly. Two months after splenectomy her platelet count was just below normal, and in a very safe zone, where it remained for the next two years before I lost touch with her.

Conclusion

Providing patient-safe care is all about collaboration, about partnering with patients for best outcomes while incorporating what “matters most to the patients” if at all possible and with safety assured. This collaboration begins with listening to patients, really listening to them. Patient-safe care must be patient-centred care.

References

1. Gerteis M, Edgman-Levitan S, Daley J, Delbanco T. Through the Patient’s Eyes. San Francisco: Jossey-Bass, 1993.                        
2. National Research Council. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press, 2001.
3. Barry J, Edgman-Levitan S. Shared decision making — the pinnacle of patient-centered care. N Eng J Med 2012;366:781-782.

Related reading on the hub:

• “Listening to a patient’s history for longer can help doctors make the right diagnosis”

Further reading on the hub from Dan:

• Clarity and the Art of Communication for Patient Safety
• Late night reflections on patient safety: commentaries from the frontline (2014)
• Patient safe care as a moral imperative: The mandate of medical ethics
• Diagnostic errors and delays: why quality investigations are key
• Patient Safety Spotlight Interview with Dr Dan Cohen, Patient Safety Learning Trustee
• Structures, processes and outcomes for better or worse: Personal responsibility in patient safe care
• What does all this safety stuff have to do with me? How one professional’s arrogance led to new insights
• Interview with Dr Dan Cohen on human performance

About the Author

International consultant in patient safety and clinical risk management, senior healthcare executive with extensive leadership experience, former US Department of Defense (DoD) physician executive with career culminating as Chief Medical Officer/Executive Medical Director for the DoD TRICARE health plan currently providing healthcare to over 9 million beneficiaries worldwide. Most recently served as Chief Medical Officer for Datix where he championed the company’s comprehensive patient safety thought leader efforts internationally through innumerable conference presentations, publications and commentaries.