How do we learn from patients’ poor experiences?

by Murray Anderson-Wallace & Dr Suzanne Shale.

This article was originally published by the Health Service Journal

How do we learn from patients’ and families’ poor experiences? Download PDF

 

Far from sapping their time and energy, nurturing the healing relationship at the heart of medicine sustains clinicians’ vitality.

The word ‘complaint’ has a latin root: planctus. It means to beat the breast in grief, mourning for something lost. Through our work with patients, carers and clinicians we have come to see the difference it could make if organisations learned to treat complaints as laments for the loss of something important. This is very different from viewing them as criticism, feedback, or an administrative task.

Let’s start with an example. We have deliberately chosen to discuss a small story about a modest complaint. This is because creating and changing care cultures is what we all do in the here and now, today, tomorrow and the next day. Modest complaints – not major crises – are what most people deal with most of the time.

Michael Embleton is a consultant orthopaedic surgeon. He enjoys clinical work, his technical skills are a source of satisfaction to him, and he believes he does well by his patients.  So the letter of complaint that arrived on his desk recently made for a grating start to a busy day.

Yvonne Park’s operation had been uncomplicated. Michael had performed the surgery safely. The clinical outcomes were good.  By most measures this was a success story.   But Yvonne had written to him about her negative experience of his behaviour.

The criticism stung.

Yvonne had been admitted for what professionals describe as a ‘routine’ hip replacement. To achieve the best outcome and reduce length of stay Michael generally keeps his patients awake, with anaesthesia via spinal block. When Yvonne wrote to Michael she thanked him for the results of surgery. But she went on to say that she had found parts of the experience very distressing.

With Yvonne’s head strategically placed behind a curtain of green drapes to conceal the surgical action, Michael’s attention focused on his supporting cast, checklist, and habitual pre-operative script. Although Micheal has certainly not intended this Yvonne had felt excluded, ignored and belittled by him. Unable to see or feel what was happening, she had been reduced to a stage prop in her own intimate drama.

So was her subsequent letter an unappreciative message from an over-anxious ‘customer’? Or a glimpse of something precious being lost in the daily work of a hyper-rational health care system?

“My immediate reaction” Michael told us “was uhf goodness! Another complaint to deal with. But for some reason, I thought ‘OK’. I’m going write back and say, ‘Thank you very much’” Reflecting on Yvonne’s letter, it was clear that his habit of leaving patient reassurance to his anaesthetist had failed to quell Yvonne’s anxieties. “After the time-out she heard me say, ‘Right, we’re starting’. But clearly she needed me to say it to her directly. Even more so at the end, she wanted me as the surgeon to say to her  ‘we’ve finished, it’s all gone fine’”

Michael sensed that the loss Yvonne mourned was his attentiveness. He was the person to whom Yvonne had entrusted her well-being, the one in whom she had placed confidence.  So in his reply he explained the steps he takes at the beginning of an operation: his mental rehearsal, the ‘time-out’, the final moment of psychological separation before knife goes to skin.

The moment Yvonne received Michael’s letter she called the hospital. His secretary told him, “She says thank you very much, it has really helped her. It’s made a complete difference.  She understands fully. And she is absolutely delighted to have received a letter from you personally”.

Yvonne’s lament echoed the experience of American author Anatole Broyard, who wrote movingly about his encounters with medicine while he was dying. “I wouldn’t demand a lot of my doctor’s time” he wrote, “I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.”  (Intoxicated By My Illness)

Michael’s reply helped Yvonne because it acknowledged the human need at the core of her complaint. This made it very different from the often standard corporate response.

In a recent presentation, Robert Francis QC described the “depressingly familiar”  pattern” of complaints he had found at Stafford Hospital. “There would be a complaint, there would be a formal response and an apology, plus an action plan that would not be put into force. The same thing would happen again, the same apology would be issued and pretty much the same action plan.”

That is what happens when responding to complaints becomes a purely administrative managerial task.

When things go wrong, the prevailing consensus is that patients want transparency, an apology, and information about what will be done to ensure that no-one else suffers. But if we ignore the existential heart of the complainer’s lament, we will have completely missed the point. Talking to the Guardian following the inquest into her baby son Axel’s death, Linda Peanberg King said the Trust’s explanation “felt like a powerpoint exercise; it was shocking to hear your dead son being described in corporate speak as ‘a learning exercise’” (Guardian March 2nd 2013)

The principal objection to dealing with the human dimension of care is that it is too demanding of emotional energy and clinical time. We challenge that. Far from sapping energy, nurturing the healing relationship at the heart of medicine sustains clinicians’ vitality and takes little if any more of their time.

As Michael told us, it was not unduly burdensome to approach Yvonne’s complaint as an opportunity for caring dialogue. “No matter how trivial the issue might have initially seemed to me, the fact that it matters so much to her means that it should really matter to me too.  Having written the letter, which didn’t take very long, I felt much better. I saw her in clinic a couple of months later and the relationship was on a completely different level.”

We know that none of this is simple, and that faced with apparently belligerent patients or colleagues it may indeed feel impossible. As Michael reflected too, “It’s not some altruistic thing. It helps patients, but you also feel a whole lot better about yourself and the things that you do.”

But changing cultures in health care means everyone – along and together – revising what we think, hope, and intend to make possible.

 

Both surgeon and patient have given permission for this story to be told, but for reasons of confidentiality we have used pseudonyms.

Dr Suzanne Shale is an ethics consultant and author of Moral Leadership in Medicine (Cambridge University Press)

Murray Anderson-Wallace is an independent advisor, journalist and producer with a background in nursing, social psychology and organisational communications research.

 

Together they provide confidential advice and resources to individuals, groups and organisations to address critical dilemmas associated with patient safety and professional cultures in healthcare.