The case for a more proactive approach

Consider asking patients if they have any concerns about their care.

Although nearly half of inpatients indicated they had experienced a problem during hospitalization, about 30% of them said they did not always feel comfortable speaking up about their concerns, according to results of a study published in the March 2019 The BMJ Quality & Safety.

There are many reasons why patients may be reluctant to call attention to such problems. “The No. 1 reason why they don't say anything is that they worry about being identified as a complainer and somehow this adversely affecting their relationship with the care team, and they're just not willing to take that chance,” said Thomas H. Gallagher, MD, MACP, coauthor of the study and associate chair of patient care quality, safety, and value in the department of medicine at the University of Washington (UW) in Seattle.

To ease the burden on the patient, hospitalists should do their best to make it easier for them to share their concerns about problems in care, he said. When asked directly, almost 40% of nearly 1,000 hospitalized patients reported a breakdown in their care in one study, according to results published in the August 2017 Journal of Hospital Medicine.

In his practice, Dr. Gallagher lets his patients know upfront that the health care team wants to hear about any concerns. “I try to really be proactive and tell them the first time we meet that health care is complicated, and sometimes things don't go as we want them to, and, if they ever have any concerns about something that might have gone wrong in their care, to please let me know so that we can talk about it and figure out what happened and fix the problem for them,” he said.

More often than not, what the patient is worried about turns out not to be an error, “But there are a fair number of times when patients actually are identifying errors in care. And not only do you want to fix those for that patient, but fix the system flaw that led to that error so that other patients don't experience it,” said Dr. Gallagher, who is also professor of medicine and of bioethics and humanities at UW and director of the UW Medicine Center for Scholarship in Patient Care Quality and Safety.

In a study published in the May 2012 Journal of Clinical Oncology, his research team interviewed patients with breast or colorectal cancer who thought something had gone wrong with their care. “The problems that they were describing were not the food was cold or the parking was inconvenient,” Dr. Gallagher said. “When you read the transcripts of those, they really are upsetting as a doctor to read: talking about thinking they're on the wrong medication, having side effects that nobody's paying attention to, worrying about a significant delay in their diagnosis, feeling like there was a real communication breakdown with the doctor.”

Even if you can't swiftly solve the problem, it's important to identify patients' concerns and empathize with them, he said. “It's not that patients who don't bring these concerns up to their providers aren't talking with anyone about them. They're more than happy to talk about what happened with their friends and neighbors, the person next to them in the hospital room, all sorts of people, and trying to make sense of it,” said Dr. Gallagher.

But hospitalists' ability to uncover these concerns depends on how they ask the question. “If you pop your head in the door and say, ‘How's it going? Any concerns?’” he said, “The polite response from the patient is, ‘Oh, everything is fine. No problems.’”

To get a more accurate response, Dr. Gallagher recommended entering the room, sitting down if possible, and asking a couple of different ways about how things are going. “I like words like ‘problems,’ ‘concerns' . . . [and] asking things like, ‘Do you have any concerns about your care? Has there been anything that hasn't gone as intended?’” he said. “Once patients get to know you and realize that you really want to hear about problems in care, you don't need to ask the question so many times at once because the patient will just tell you whatever is on their mind.”

One concern hospitalists may have is the can-of-worms concept: What if it takes a long time to address the patient's concerns, and what if the problem is outside their control? But many times, patients are simply looking for a listening ear, not necessarily a solution, said Dr. Gallagher.

Compared to not asking about the problem at all, “It's much better to surface these concerns and discuss them directly so that patients can really have an accurate understanding of what happened and feel like, ‘My doctor cares about what happened to me and acknowledges and apologizes for things that didn't go well,’” he said. “You can do that quickly, and the patients end up feeling heard and understood and aren't spending a lot of time sort of processing these negative experiences with others outside the hospital.”