These Patients Can Present Unique Challenges
Kendall E. Donaldson, MD, MS
I like to remind myself of two things whenever I am advising a patient who is unhappy with another provider:
No. 1: I could be that provider.
No. 2: My family member or I could be that patient.
With those two thoughts in mind, I begin these consultations by validating the concern that brought these patients to seek my care without telling them I agree or disagree with their conclusions. These patients often have an accusatory or inflammatory tone when they feel they haven’t achieved their intended goals. Their conclusions are often emotional rather than based on an objective finding or experience. I try to summarize and repeat their concerns more objectively without assigning blame or conveying an emotion. I remind them that the goals of the visit are to move forward (not look back), achieve their aim, and, ultimately, improve their level of satisfaction by helping to address the problem that brought them into my office. Some patients may be fixated on their anger, and multiple visits may be required to achieve a more productive viewpoint.
I often tell patients that I would be happy to work with their original doctor in an effort to achieve their clinical goals. I will even ask their permission to call and discuss the case with the original provider if I feel that doing so could help resolve the problem or create a better, more functional working relationship with the patient.
It is impossible to please every patient. When I have dissatisfied patients of my own, if, after spending extra time and working to resolve the issue, I cannot help them achieve their goals, we discuss the option of a consultation with another provider. I offer these patients an opportunity to seek their own consultations, or I offer to refer them to a respected colleague. This approach gives them a level of control over their situation. I actually find it much easier to manage a dissatisfied patient of one of my colleagues than someone who is dissatisfied with my care after my exhaustive efforts. This shows the value of recommending consultations when dealing with frustrated or disappointed patients. Patients truly appreciate knowing they have a team working for their best interests.
I work in a tertiary care facility, which tends to attract these challenging patients on a daily basis. I recall one patient who presented to my clinic after undergoing cataract surgery and the implantation of a multifocal IOL. She had been unhappy with her quality of vision and had undergone an IOL exchange. Subsequent corneal decompensation left her with 20/400 VA. She was the office manager for the ophthalmologist who performed her surgery, and she hadn’t returned to work since her IOL exchange. The surgeon referred her for an evaluation and treatment. Managing the medical aspect of her case with endothelial keratoplasty was much easier than managing the relationship and emotional escalation between the patient and her surgeon/employer.
Although this example is a bit extreme, the psychosocial or emotional aspect of a patient’s dissatisfaction is often more challenging to negotiate than is managing the medical issue underlying the complaint. Trying to separate the two in the patient’s mind can often be the most challenging part of managing these cases.
Dissatisfied patients require extra time and attention in order to manage their emotions as well as their medical issues. It is helpful to allot ample time for these visits when possible. Most important is establishing a partnership directed toward achieving their original goals and expectations.
Approach These Patients With Care
John A. Hovanesian, MD
No matter how hard we try for our patients, there will inevitably be some who are not happy with the care they have received, and they are going to seek a second opinion. In my view, seeking a second opinion is positive because it means the patient is engaged in finding their best outcome.
This search for a different opinion can sometimes lead the patient in the right direction and sometimes in the wrong one. Many patients seeking a second opinion are angry, suspicious, or scared. Each of the strategies I use to caring for these patients is aimed at ensuring my second opinion leads them in the right direction—toward a positive outlook, collaboratively seeking the best possible result with their doctors.
Listen to the Patient’s Story
I think first and most important is to listen to patients who are unhappy and seeking a second opinion and to let them tell their stories. In so doing, it is usually possible to discern what emotion patients are primarily feeling, which improves my ability to address the problem(s).
Validate the Patient’s Concern
Validating a patient’s concern does not mean inappropriately criticizing the care delivered by another doctor. It is possible to understand someone’s concern without suggesting or conceding that an error occurred when it probably did not. That said, it is important to let the patient know what I really think is going on, even if it differs from the opinion or treatment given by another doctor. The goal is to direct the patient to the necessary treatment, not to judge the prior doctor’s care. I wasn’t there at the time of the original treatment. I don’t know what was said or seen during that previous encounter. I only know what the patient is telling me, which is often a distorted view of the past reality.
Moderate Your Tone of Voice
Tone of voice can affect the dynamic between the doctor and the patient seeking a second opinion. We doctors often adopt a way of speaking to patients that differs from how we speak in most other circumstances. We put on our doctor voice: We tend to talk a little bit slower, to use less intonation up and down, and to use more formal language.
I think it’s really important to speak to these patients in a tone similar to what we would use with a friend because that’s what these patients need—a friend. That means using a fluid cadence of speech, more intonation, and making facial expressions that convey the appropriate emotion. Of course, what these patients truly need most is an expert opinion, but a friendly tone of voice can buy a lot of trust and credibility.
Give the Benefit of the Doubt
Occasionally, a patient will ask whether their previous doctor made a mistake or did something wrong. We should be honest in our response, but most often the only honest response is that, without having been there at the time of the evaluation and without seeing what the doctor saw at that time, there is no way to judge what decision they could or should have made.
In my experience, it’s better to encourage patients to focus on what to do next. Most patients understand that medical care is complex. This approach helps them to walk away with a better understanding of what happened.
My approach has proven effective thus far.
Jodhbir S. Mehta, BSc (Hons), MBBS, PhD, FRCOphth, FRCS(Ed), FAMS
At one point or another, all ophthalmologists encounter in their clinical practices patients who are unhappy with another provider’s care. As the head of a clinical department, I encounter these patients perhaps a little more frequently than others do. Although I haven’t read any books on the topic, my approach, outlined in this article, has proven effective thus far, but I view this as a continually evolving process.
Confront the Situation
The first thing to do is confront the situation. Someone is unhappy with their outcome or care, so take the time to understand the situation and let the person freely voice their concerns. The first appointment should be held outside of normal clinic hours, ideally in a quiet room where you can devote your attention to the person. Listening is key to understanding why they are unhappy. Investing your time in the first appointment demonstrates empathy and shows that you are serious about helping them to resolve the situation. If you can find the key to their unhappiness, your next meetings will go more smoothly. Documentation of this discussion may be helpful to make sure that both your and the patient’s thoughts are aligned, and it is something you can both circle back to.
Gather as much information as possible, the real facts about the complaint. This can be accomplished by writing to the previous provider or asking the patient to give you copies of any information they have. Getting a good grasp of the facts from both sides is helpful. It is best to remain neutral because your decisions on treatment will be based on the facts at hand. Once you examine the patient clinically and diagnostically, share your findings with them. I prefer to obtain imaging first so that I can show the patient on the scans what is happening. I think visual aids facilitate patient education and planning.
Avoid Assigning Blame
Avoid blaming any party. You were not there during the incident, so your opinion is based on hearsay. Blame can elicit feelings of anger and resentment. Your role instead is to provide hope and a solution to the matter. If the patient already blames their situation on the other provider, I think listening to the complaint without comment is the best approach.
The language and tone you use when speaking to the patient are important. They allow you to show empathy and understanding. I try to include the patient’s family members in the consultation so that they receive the same information and can discuss it afterward. Near the end of the consultation, it’s important to offer the patient an opportunity to ask more questions and the option to follow up with you if needed. I give patients my business card with my work email address so they can contact me with further questions.
Plan the Next Steps
Make a plan for the future. The next step may be to get more information, but this is still a move in the right direction. If further intervention is required, offer at least two treatment choices to the patient. Involving them in the decision allows them some control over their destiny. You may be surprised by their level of interest in further intervention. A shared plan fosters agreement about the situation and generates positive energy.
Document your discussions in a clear, easy-to-read format and include imaging. You can refer back to these materials during future discussions. Often, showing documentation of a plan that was agreed on bolsters the patient’s confidence.
Generally, these consultations will take a considerable amount of time, especially at the first appointment. Most of the unhappy patients I deal with will either require an urgent transplant or have had a complication from a cataract/refractive procedure. They appreciate the time I take with them and my ability to act quickly to resolve their issues.
Reassurance Is Key
George O. Waring IV, MD, FACS
We practitioners will all speak to patients seeking a second opinion from time to time. We must approach these patients with a caring attitude while being as supportive as possible of the operating surgeon. Although I note to patients that additional information from a second opinion can be beneficial, I am also careful to say that asking multiple doctors the same thing is likely to elicit various opinions, which is fine and healthy.
After completing a clinical evaluation, I reassure these patients that their previous doctor is competent, assuming no intraoperative complications occurred, and inform them of my clinical findings. My goals at this stage in the process are to highlight the positive aspects of their situation and explain if and how it can be improved. I remind patients several times during the encounter that a complication did not occur during surgery (if it did not) and explain that whatever spurred them to seek a second opinion is likely due to a variation in healing—which cannot be accurately predicted before surgery or accounted for during it.
I then ask if they have consulted the operating surgeon about the possibility of a postoperative enhancement and, if not, whether they would like to pursue that with the operating surgeon. If for some reason patients say no, I let them know that an enhancement can be facilitated in my practice as well. In the rare circumstance in which there may not be a solution, I am honest and direct about this fact.