Wednesday, October 23, 2013

Patient Advocacy: Managing Conflict of Interest

Patient advocates need to learn how to resolve conflicts

A patient advocate once was concerned that giving chemotherapy to his client was causing him more harm than good. During the course of the treatment, the patient would often complain that he was in agony, telling his advocate, “I can’t take it any more” and the advocate would faithfully relay his misgivings to the doctor team. The head of the team didn’t see any merit in the advocate’s objections and ruled them out. Over the next few months, the advocate watched the patient suffer in silence, through treatments that the advocate believed he would not have chosen had he been informed in advance about the pain they might cause him. The patient finally died, but only after the chemo had left him with unstoppable and painful bleeding in his bladder, robbing him of a more peaceful and comfortable end.
Patient advocates have to perform a difficult balancing act. Their primary role is to help their patient, but they don’t want to escalate an issue and alienate the hospital staff either. How do they keep both parties happy?
The biggest challenge in medical practice is the growing conflict between doctors and patients – especially over costs. Disagreements can arise over many issues – ranging from continuing aggressive treatment for a critically-ill patient to refusing a patient’s request for antibiotics to treat a viral infection. End-of-life issues are especially highly emotionally charged, requiring active involvement of a patient-advocate. When conflict arises, communication channels break down and it’s left to the patient-advocate to sort things out. A mature advocate understands that at the heart of such conflicts is usually a clash of values, and because these are hardest to resolve when everyone is emotionally labile, his first priority is to defuse the emotions and change the climate of mistrust to one of common ground.
A useful mnemonic which experienced patient advocates use to deal with upset patients is called RAPSAND.
                R = Re-establish rapport (Empathy)
                A = Agreement (Get the patient to say Yes)
                P = Problem (Define this)
                S = Solution
                A = Ask Permission (Is the patient happy with the solution you have offered?)
                N = Next step (Follow up)
                D = Document

The most worrisome conflicts are those which arise over treatment choices. If they are not promptly resolved, they can mar the doctor-patient relationship and have an adverse impact on the patient’s outcome. Resolving such conflict is therefore the first priority of a patient-advocate. If he has been employed by the hospital, he has to make sure that he puts the patient’s interests first, and is not seen to be acting in a manner which suggests that he is an agent appointed by the hospital to protect their interests. The moment a patient feels that an advocate is representing the hospital, he is likely to lose faith in him. Instead what he needs to do is:
                Drive maximum patient participation in care decisions
                Develop mutual trust and respect between the doctor and the patient and his family
                Help improve a patient’s experience of a hospital by explaining the hospital system to them, and emphasizing care, compassion and connections
                Be seen as impartial ombudsman, to whom patients, as well as the hospital staff can provide feedback in confidence
                Provide a mechanism for patients and families to cut through the red tape and avoid delays in emergency care
                Let’s not forget that patient advocacy is a new discipline in India. A patient advocate has been introduced as a new component in the care delivery chain, and can help to provide legitimacy to the patient’s voice when the healthcare system ceases to listen. If an advocate is appointed by a government agency (as in the West), he is expected to establish formal programmes for safeguarding patients’ rights, and assist hospital staff in understanding their duties and the patient’s rights. As a third party, he is expected to balance the interests of both parties and provide medical and non-medical support in both inpatient and outpatient care. They are also a trusted source of information, referrals, and navigation.
                Once an 80-year-old poor, illiterate woman with breast cancer was being treated like a senile senior citizen by a resident doctor in a stuffed-to-the-seams government hospital. A concerned citizen watching this interaction decided to act as her advocate and came to her aid. To his surprise, he discovered that the woman was very perceptive. However, because she was illiterate and new to the city (having just arrived from a village) she felt intimidated by her surroundings; and because of her illness, she was not mentally alert enough to be able to make her own medical or financial decisions.
                The busy surgeon was treating her like an imbecile, but the advocate invested his time in talking with her, listening patiently, and asking her the right questions, so she could understand her treatment options. Later he took upon himself the job of meeting with her physician. The physician’s approach to this patient also changed, once he found someone was taking an active interest in her case and documenting his discussions with the patient. He quickly became more respectful and thoughtful.
                Because patient advocates collaborate closely with hospital staff on patient safety and quality-related issues, they can help hospitals identify opportunities to improve patient satisfaction, and bring about much-needed improvement, especially for poor, uneducated patients. Whether through position or persuasion, patient advocates can make good use of medical data, and offer sensible recommendations so the government hospital can improve its track record.
A doctor once had a serious difference of opinion with the father of a little boy, who had met with a road accident. The father felt that his son would benefit from a particular type of physiotherapy. The doctor didn’t. The father brought him loads of health literature but the doctor was not impressed. They argued over the matter. Finally, they both agreed to get a third – independent – opinion. The doctor called in another doctor-friend to act as a patient-advocate. This second doctor read the patient’s report and medical file. Ultimately he agreed with the father’s point of view and said there was no harm in trying out the therapy for a short span of time and if it didn’t work, they could always change it later on. When they heard him, both men laughed. An ego-conflict was amicably resolved. Later, this second doctor also helped the patient’s father get the therapy reimbursed by his insurance company. To this day, the patient remains grateful to the advocate and speaks very highly of the first doctor, who put him in touch with this advocate. For every health problem – big or small, he always goes back to the same hospital.

The moral of this story is - whatever you do; don’t let a patient walk out of your facility disillusioned, angry or dissatisfied. When you can’t reach an agreement, get an advocate on board. He will resolve the issue in the most humane way.

The above is an extract from Dr.Aniruddha Malpani's book : Patient Advocacy - Giving Voice to Patients
The book launch will take place on Saturday, 16 November 2013 at Hall of Harmony, Nehru Center, Worl, Mumbai - 400018 during the 4th Annual Putting Patients First Conference.

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