Patient complaints have psychological repercussions [PODCAST]

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“I believe there is an art to medicine, a psychological connection to your patients through a hands-on patient encounter. There are nuances AI may take decades to compete with. For now, in my lifetime, I hope that people examine patients and when there are questions about the quality of care, institutions perform a deeper dive into the real problem. (Was it the overall experience, a poor relationship with the doctor, financial stress that would be assumed by paying the medical bill, or actual malpractice?) Without support from our employers, physicians will continue to feel the accumulation of burnout and insecurity that leads to emotional duress, leaving medical practice or the worst outcome: physician suicide. We are not machines. The burden cost is evident, but when will the medical community, investors, and hospital administrators begin to truly support physicians and prevent these terrible outcomes?”

Gina Ambrose is an emergency physician.

She shares her story and discusses her KevinMD article, “The psychological repercussions of patient complaints.”

This episode is sponsored by Tradeoffs, available on your favorite podcast platform.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Gina Ambrose. She is an emergency physician, and she wrote the KevinMD article “The psychological repercussions of patient complaints.” Gina, welcome to the show.

Gina Ambrose: Thank you, Kevin. Thank you for having me on the podcast today.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Gina Ambrose: Yeah. So, I’m a board-certified emergency medicine physician. I did residency training at ChristianaCare in Newark, Delaware. I currently work for a private democratic group based out of Annapolis. We staff an 80-bed ED, and we see a little over 100,000 patients per year, including pediatrics.

In addition to my clinical duties, I am also partway through my MBA program at the Isenberg School of Management at UMass Amherst. I’ve also served as a performance improvement facilitator at the hospital that I work at, and I’m also the patient advocacy representative for my group.

Kevin Pho: So, we have a lot of physicians who are also pursuing their MBA degrees. In your situation, what was your reason to pursue an MBA degree?

Gina Ambrose: So, my personal reason is that I see a lot of hospital administrators who are very far removed from clinical work, some who have never even practiced medicine or don’t have medical degrees, and I find it very important to be able to relate to the people that you’re working with. And so, my goal in obtaining my MBA is to one day act as a liaison for the hospital and the clinical workers, and to try not to forget where I came from, kind of thing.

Kevin Pho: So, in the emergency department, can you give an example of an administrator with only an MBA degree, without any clinical experience, affecting physicians’ daily life?

Gina Ambrose: Yeah, well, I think that, I mean, even people who have had clinical practice, once you get out of seeing patients, I think you forget what it’s like, especially moving up the corporate ladder if you’re in a corporate staffing group, or through the C-suite in the hospital. It’s not necessarily that you don’t know what happens, but you don’t remember what it feels like to have it happen to you. And I think that being able to relate to what’s going on in real time.

So, like right now, with all the nursing shortages, people still want us to meet our metrics, right? And metrics are important, and we need to have them for various reasons. But when you kind of fall out of the realization that there is this massive nursing shortage, we don’t, we’re understaffed, people are stressed out, they’re burned out. And of course it’s going to affect our metric times. And so, hearing that there aren’t great solutions to that problem, and that we’re still held to those same standards, feels very disheartening.

Kevin Pho: All right, let’s transition now into the KevinMD article that you wrote. It’s titled “The psychological repercussions of patient complaints.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Gina Ambrose: Yeah, so it really started by listening to friends and colleagues express their frustration with the way that the hospital or the group that they worked for would handle complaints. Before I got involved in patient advocacy, I think I made a lot of assumptions. I assumed that people in the community knew the limitations of the emergency department. I assumed that patients would only make complaints about something that was serious or important. I assumed that the hospital administration would, most of the time, back up their physicians on matters of patient care.

And so, when I started out as a patient advocate representative, I found myself being really defensive for my colleagues and for myself. And it was difficult to hear patients say that their care was bad, because from where I was sitting, their care was completely appropriate.

And so, talking to patients and reading these cases kind of led me to define three different types of patient encounters. There’s the good encounter, where everyone’s happy and there aren’t any issues. There’s the bad encounter, where sometimes you miss a diagnosis or there’s a bad outcome. And then there’s this in-between encounter, where the care is completely appropriate, but for whatever reason, whether it’s the perception of their care or an unmet expectation, the patient complains about what happened and feels that their care wasn’t adequate, when in reality, from a medical standpoint, it does in fact seem everything went the way that it should have.

And so, there’s this big chasm between patient perception of medicine and what happens in reality, especially in the emergency department. I think people from the community come into the emergency department thinking they have unlimited resources, that their 10 years of belly pain is finally going to get diagnosed, and that it’s this magical place where everything happens. And we have a lot of constraints and limitations in the emergency department. And so, until this mismatch of perception, expectation, and reality is met, we’re always going to have people feeling as though their care was not adequate.

And so, the question is, how do you relay this to the provider? How do you tell a provider that this person said that your care was bad, and you look at the chart and you’re like, “Well, everything went the way it was supposed to. What are they complaining about?” And you really have to get into the grievances being a misunderstanding and not malpractice. And so, talking to the patient in one way and talking to the provider in another way really does have some very, very big effect on both people.

Kevin Pho: Now, can you give us an example, it would be a hypothetical example, of a typical patient complaint where the medical care was actually adequate, but the patient had a complaint for one reason or another?

Gina Ambrose: Oh, yeah, I can give you more than one, but one example that comes to mind is we had a patient who cut her lip. She fell, and she asked for a plastic surgeon. And we don’t have plastic surgeons that will come in for that type of thing. If you need to go to the OR because you need a washout or something like that, but not for something minor.

And so, she was very upset that the plastic surgeon wasn’t called in to fix her lip, and then she filed a complaint against the provider and wanted the hospital to pay for her scar revision surgery. And so, that was something where we had to, again, redefine the expectation and standard of care in the emergency department. Sometimes people get that and they’re OK with it, and sometimes they don’t.

Kevin Pho: Take us through the pathway of a patient complaint, because I think there are a lot of misconceptions surrounding this issue, both from the patient side, of course, and the clinician side. So, once a patient makes a complaint, walk us through the path that complaint takes. How does it reach administration, and what are some potential repercussions that complaint has on the physician?

Gina Ambrose: Great. So, that’s a really good question. Depending on where you work, usually every hospital has a provision. For Medicare and Medicaid, through CMS, you need to have some form of patient advocacy group or ways for patients to file complaints.

So, at the hospital where I work, we’re really, really great about it. We have people who can come into the floor, the emergency department, wherever, and deal with complaints in real time. So, if I have a patient encounter that I know is not going well, and I get the feeling that they’re probably going to want to say something to someone later, I will say, “I can call our patient advocacy group, and they can come down and talk to you.” And so, if we can get it resolved in real time, that’s obviously the best outcome and the fastest way to deal with it.

But a lot of times, one of two things will happen. Either we’ll get a complaint through a survey, and based on that information, whether it’s more of an FYI or a “this doctor or provider really needs to know that this was a bad outcome,” you can get it through a survey. And then you can also have patients who either call or send an email to the patient advocacy department, and then it goes through those folks, and then it’ll get directed to the department based on where the complaint was formed.

Kevin Pho: Now, with your experience with patient advocacy, what would you say is the biggest misconception physicians have about patient complaints?

Gina Ambrose: From what I’m hearing, I think there’s a little bit of a mismatch of expectations.

Kevin Pho: Now, what would be the most common mismatch of expectations? What category would you classify that as?

Gina Ambrose: It’s usually imaging. We have a lot of complaints that patients wanted imaging, whether it’s an X-ray or an MRI, or they thought they should have had this. And we do get a lot of patients who come in and say that their doctors told them that they were going to get this test or this study, or that they were going to be admitted.

And so, sometimes our medical community doesn’t set us up for success, because they send someone in having not seen the patient, or not really knowing what’s going on, and kind of telling them, “Oh, these things are going to happen.” But then, when you get into it, they don’t need half of the stuff that they were told they were going to need.

So honestly, I would think that imaging is the big one. People always want MRIs. Last week, I literally had someone say that they wanted an MRI of their entire body just because they wanted to get checked out. And so, having to explain what an MRI is, and why you order imaging, and the limitations of insurance, and all this stuff. But I would say imaging’s a pretty big one.

Kevin Pho: In the emergency department especially, do you feel a lot of clinicians feel pressure, whether it’s an economic pressure or pressure from administration, to perhaps acquiesce to patient requests, with satisfaction surveys or patient complaints in the back of their mind?

Gina Ambrose: I think it’s very individualized. I’m kind of starting into the middle of my career, and so I work with people who have been doing this for like 20, 25 years. And they don’t feel any pressure. They know the way they work things up. They know what they order. They’re set in their ways, kind of.

And then there are the people who have just graduated from residency, who over-order everything, because that’s what you do when you’re first out of medicine in the emergency department. You are terrified of missing something, and so it’s completely understandable to over-order. And then there’s my age group, where you’re kind of out of ordering everything, but you’re still not completely there.

And I personally do find myself ordering tests for people, because for me personally, that’s what they’re there for. So if someone comes in and they’re like, “I am terrified I have a brain tumor,” I can tell them all I want about all the reasons why they probably don’t have a brain tumor. But that person’s going to go home, and they’re not going to sleep, and they’re going to come back the next day. And until they get that MRI, they’re going to figure it out, not figure out, they’re going to want to know what their MRI shows.

And so I don’t feel an economic pressure, although I do think, with the way that reimbursement’s going, when we move to all this value-based care, as soon as the hospital stops being reimbursed for some of these, quote unquote, unnecessary studies, there is going to be a push to probably order less.

Kevin Pho: We’re talking to Gina Ambrose. She’s an emergency physician, and she wrote the KevinMD article “The psychological repercussions of patient complaints.” Gina, from, again, your work with patient advocacy, what are some things that physicians can learn from the patient feedback process?

Gina Ambrose: So, kind of looking at it from the role of the administration and the role of the physician. Administrators want patient retention. They want patient satisfaction. And indirectly, physicians want that too. You want to be proud of the place that you work at. You want your hospital or your private practice to have a good reputation. And so, in order to do that, you have to sometimes acquiesce to what patients feel they’re missing, whether it’s valid or not valid.

And I think that when we’re presented with complaints, we really have to separate ourselves and our practice from the complaint itself, because most of the time, it is not you. It is not your practice. It is not your expertise or your knowledge that is the problem. The problem is that the patient thought that something was going to happen that didn’t happen, or that they wanted something to happen. And it has very little to do with you.

But I mean, physicians, we own our patients and we own our practice, and we take it to heart so much. Being able to kind of relieve yourself of that pressure really makes you more empathetic to the patient, I think, and makes you a better doctor.

Kevin Pho: If you could give one piece of actionable advice that physicians can use to minimize their patient complaint rate, what would that one piece of advice be?

Gina Ambrose: Ask the patient what their goals of the encounter are. It’s a simple, simple statement, and I ask all my patients, “What is your goal for coming to the emergency department today?” And very concretely, they can state, “Well, I have belly pain. I want to find out what’s wrong with me,” or, “I’ve had a headache, and I think I’m having a stroke.” It succinctly allows you to focus in on what the real problem is.

And if you’re having an encounter that you don’t think is going well, or you can tell that there’s some animosity, I think that taking a moment to say, “I can see that there’s tension here and that something isn’t going the way that you would like it to. What is it that I can do to help make your experience better?”

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Gina Ambrose: I think that working as a physician nowadays can sometimes be very lonely. I think we feel very unsupported, and we don’t have the autonomy that we used to, and it can be really tough. And so, when you’re faced and presented with a patient complaint, really being able to look at it objectively and to say, “Was my medical practice good?” And if the answer to that is yes, then empathize with the patient. What is it that they didn’t get, and how can I prevent this from happening again in the future?

And if there was something wrong with your practice, then that’s good too. What can you learn from it? What feedback can you take to change your practice to make it better for the next time?

Kevin Pho: Gina, thank you so much for sharing your time and insight, and thanks again for being on the show.

Gina Ambrose: Thank you.

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