The medical system tends to define medical errors, adverse events and preventable adverse events in a very narrow way; To look at ways in which care was delivered that physically harm the patients. On the other hand, when you talk to patients and you take the patient’s perspective, they really define a much broader set of breakdowns than what the medical system considers.

Kimberly Fisher, MD  A Physician & Assistant Professor of Medicine at University of Massachusetts Medical School.

About Dr. Fisher

My specialty is pulmonary, so lungs and critical care medicine which is taking care of patients in the intensive care unit. You don’t have to work very long in the intensive care unit to recognize what a difficult environment it is for patients and their families, not just because the patients are critically ill and really sick but also because of the way the care is delivered and the patient and their families experience of that care adds to the burden of the illness. Seeing that first-hand led me to want to do research to better understand and try to improve that experience.

Research: Patient Perspective of Care

A lot of the focus of my research has been on the patient perspective of care and so that’s wanting to know how patients experience care through their eyes and specifically wanting to know more about their experience of breakdowns and care. We consider a patient perceived breakdown in care to be anything that has gone wrong from the perspective of the patient. That’s not just that they were sick but something that’s gone wrong in the delivery of care.

When you talk to patients or their family members about their experience of care and whether they’ve experienced any breakdown in care, a distressingly large number and percentage of patients and their families have experienced what they would describe as a breakdown in care and those are types of problems that can span patient experience. Problems with communication or access to providers, not being able to get the information that they want, to more medical type breakdowns that may include a medical error or an adverse event or a preventable adverse event.

Our focus is really on the patient’s perspective of these, which tends to be different than the medical systems perspective. The medical system tends to define medical errors, adverse events and preventable adverse events in a very narrow way; To look at ways in which care was delivered that physically harm the patients. On the other hand, when you talk to patients and you take the patient’s perspective, they define a much broader set of breakdowns than what the medical system considers. Even though many of these don’t result in physical harm, some of them do but many of them don’t.

They often result in emotional distress, disruption of either the patient or their loved ones life because they’ve had to go to extra visits in order to try to get information. It can result in financial burden for the patient or their families above and beyond the expected cost of care and importantly it can result in a disruption of the relationship with the healthcare provider. In other words patients and their family members often lose trust in providers and the healthcare system as a result of experiencing these breakdowns in care and that may lead them to avoid seeking care at times when they should, because they’re concerned about how they’ll be treated.

Qualitative Research

I think that it’s important to both capture the story or the narrative and a lot of the research that I do is what’s called qualitative research, which means that we’re interviewing patients or their family members and then we’re finding ways to take their story and summarize it. So, we’ll look across several interviews and say what are the common themes and we might want to summarize it so that we could distil 30, 10 page interviews down to one, four-page research manuscript.

 We’ll want to summarize what are the common themes that we hear over and over again so that we can quickly summarize what those patients said to somebody else, but I find that it also loses some of its impact if you try to just turn it into a summary; a table with a few lines and some percentages. Picking out some representative quotes that capture the patient’s experience and the patient’s story can make those tables much more powerful. It makes people understand and appreciate the patient story.

Research Findings

I think learning about how patients view providers and the medical system surprised me that they had as many negative feelings about medical providers and providers who didn’t spend a lot of time with them. I was also surprised at how discerning they were and how quickly once they discerned that something wasn’t going right, they would lose trust in a provider. Recognizing how fragile the trust between a provider and a patient is was surprising to me. Also, how essential it is that the health care system really can’t function without it. It’s sort of an underpinning of everything that we do, from having the patient even come to you as sort of an act of trust.

One other interesting finding  and this isn’t surprising when you think about it, although it surprised me at the time, was how much pressure surrogate decision-makers feel. These are patient’s family or friends who are making decisions on behalf of a patient who is unable to make decisions themselves because of their illness. I had not previously appreciated the pressure that, that individual feels by being put in the position of having to make a potentially life or death decision on behalf of someone else. I think it’s sort of obvious, but it’s just not something that I had stopped to think about, so recognizing how seriously surrogate decision-makers take their role in deciding for somebody else.

Closely related to that is our finding that many patients don’t speak up about the breakdowns they experience, but one thing that we found was that if the patient has a family member or friend present at the time that you ask them if they’ve experienced a breakdown, the patient or the family member will be much more likely to speak up than if you talk to the patient alone. Putting those two pieces together both the responsibility that the surrogate decision-makers feel and the fact that they’re much more likely to speak up on a patient’s behalf made me recognize the importance of engaging the patient’s family and friends as advocates in their care.

Ideal Research Outcome/Impact

Ideally, it will help providers to recognize the patient experience, so that an individual provider who recognizes that could bring that recognition and awareness to each of their encounters with patients. Perhaps encounter patients with a fuller understanding of what they go through and that may alter those interactions and those encounters for the better. The patients are the most important part of it, but I do think that the providers can’t act to their fullest potential in a system that is difficult to work in.

Summary: Patient Experience & Breakdown of Care

In summary my research has focused on the patient experience of care and specifically breakdowns in care, we want other providers to understand this experience of patients. One thing that we didn’t talk about was some of our research is focused on the role of apology. For example, patients who do experience a break down and speak up about it, apologizing to them can be a very effective way of defusing some of their anger, restoring trust and restoring the relationship.

It’s not necessarily just as simple as saying I’m sorry. An apology has certain elements that really can make it more or less effective depending on whether all of those elements are included. But, we offer that as a simple way for providers who are equally frustrated by the healthcare system as patients. Also, a provider who maybe can’t change the system, can still really go a long way towards addressing a patient’s experience of a breakdown by rendering them a full apology that expresses empathy for what they’ve been through, i.e  regret, caring and that they’ve learned something from the patient’s experience. These studies have been published in various research journals including the patient education and counselling, the Journal of Hospital Medicine, BMJ Quality and Safety.

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