Communication Risk in Clinician–Patient Consultations

Fig. 4.1

Analysis of questions and statements in the Fahime interaction

It is reasonable to expect that in the initial history-taking stage the junior doctors might ask many questions and make few statements about the patient’s illness. However, this same pattern continued throughout Fahime’s stay in the emergency department. In addition, most of the questions asked by the doctors across the consultations were closed (yes/no) questions. There were very few open questions (e.g. ‘How often do you get dizzy like this?’), which would have given the patient more scope to expand on her information.

Our analysis of the interactions with Fahime shows that at no stage did the patient get the opportunity to tell her story. As a result, the real reason why Fahime was in the emergency department was not diagnosed until the last senior doctor came in. She was finally diagnosed with depression and advised to see her general practitioner (GP). This analysis suggests that either the patient did not feel that it was appropriate for her to ask questions or she felt too intimidated by the context to do so.

A number of key points arise from this extract, particularly the in situ complexity of managing (or even recognising) communicative risk . On the one hand, the senior doctor who came in later to yet again re-question the patient established that the patient was distressed. This doctor’s diagnosis at that point maximised risk control as she recognised what was wrong with the patient. This repetition of questions, while providing the safety net of the more senior doctor’s expert knowledge, meant submitting an emotionally distressed patient to repeated questioning and diagnostic delay—either or both of which could have led to a deterioration of the patient’s emotional state, and to increasing confusion. In a teaching hospital , junior doctors are given the opportunity to conduct exploration of condition and history-taking, hence there will be times when patients will be exposed to less than satisfactory interviews and contradictory and competing practices. However, this is a case where closer supervision of a junior doctor by a more senior, more experienced clinician in the initial stages of the interview would have been appropriate. The senior doctor on diagnosing the patient with depression advised her that she should see her GP and did recommend treatment . Fahime left anxious and stated to the researcher that she was not satisfied with her treatment.

4.3.2 Potential Risk Point: Patient Involvement—Not Listening to the Patient

Patients occasionally identify potential risk points themselves, and intervene in the interview process as a way of maintaining their own safety. This is clear from the consultation with Zahara , a middle-aged Yugoslavian-born woman but now a fluent English speaker, who presents with severe stomach pain following a surgical abdominal procedure. She had a gastric band inserted some years ago and presented with pain due to suspected slippage of gastric band.

In this consultation a potential risk point occurs during the treatment stage, when the junior doctor offers the patient some stronger pain relief (‘Do you want to try some Panadeine Forte?’). The patient had already told the doctor that she was allergic to codeine, but the doctor had forgotten this piece of information:

Doctor: Um, and any allergies to any medications?
Zahara: Um nuro—not nurofen, codeine.
Doctor: Codeine?
Later in the consultation
Doctor: Do you want to try some Panadeine Forte?
Zahara: Am I allowed to?
Doctor: Hmmm hmm.
Zahara: Panadeine Forte. Has that got codeine in it?
Doctor: Yes. Oh I’m sorry.
Zahara: ( )
Doctor: ( ) your allergies.

When the doctor offers Panadeine Forte, the patient has a choice of challenging the doctor or of trusting the doctor’s judgement. Zahara tentatively challenges the doctor’s choice (‘Am I allowed to?’). The doctor replies in the affirmative but the patient persists and questions the use of Panadeine. The doctor then suddenly remembers the allergy .

Here we see how the patient herself has avoided a potential risk of an allergic reaction by seeking clarification of the doctor’s suggestion. Her involvement is significant, given the unequal power relationship between herself and the clinician. This patient reiterates confusion about processes of the emergency department and the language used by clinicians throughout the consultation:

Doctor: Now you’ve got some tummy pain following surgery?
Zahara: Uh huh.
Doctor: On Monday is that right?
Zahara: No I didn’t have surgery.
Doctor: You had? == Yeah.
Zahara: == I got a lap band. Like, and that was a few years ago but it slipped. I’ve seen Dr Donovan.
Doctor: Yeah? Yup.
Zahara: And um—he said he wants to replace it with another one.
Doctor: Hm-mm
Zahara: And he said on Monday I had to go and get fluid taken out, all it out to make me comfortable and um, because sometimes there’s complications with that that it could have a, a prolapse and that he—’cause I rang them this morning, they’re in Melbourne and they said to come straight to St George Hospital ’cause it sounds like a prolapse.
Doctor: OK. So that—
Zahara: == And I’ve been experiencing it for the past 48 hours.
Doctor: OK and what sort of pain have you been getting?
Zahara: Very, very bad pain right there and I can feel it, you’re not supposed to feel the band and I can feel it and I’ve been vomiting every time I eat and, just extreme pain.
Doctor: Since Monday when you had it done or just == this morning?

In the extract above, Zahara’s consultation begins with the junior doctor asking, ‘Now you’ve got some tummy pain following surgery?’ using the term ‘surgery’, which the patient immediately rejects in preference for ‘No I didn’t have surgery,( ) I got a lap band.’ It had been inaccurately recorded in her medical records that she just had the surgery. The doctor’s initiating question was based on this inaccuracy, which was not corrected for some time.

These kinds of questions, which Matthiessen (in Slade et al. 2008) refers to as ‘assumptive’ questions, are prevalent in emergency department consultations where they typically function to check and double-check the doctor’s understanding of the patient’s responses. However, they can also constrain the responses available to the patient and limit the doctor’s expectations, and this can lead to misunderstanding between doctor and patient. This was the case with Zahara , where she was clearly confused about this assumption. Although she tried to correct it, this misunderstanding proceeded for most of the consultation. The way in which the wrong assumption narrowed the doctor’s own field of expected response is clearly demonstrated by the way in which he incorrectly interprets even contrary responses to his further assumptions.

Later, after being told that as she is going to be having a computed axial tomography (CAT) scan, and that the doctor would keep her informed, she turns to the researcher and says ‘Did you get all that?’ At another point after one of the nurses had left, she said ‘I heard what she said but I don’t know what she said…’—a clear indication of a potential risk point as the patient did not understand the reasons for the procedure or the doctor’s explanations.

We have now established that the alignment of clinician and patient understanding and actively listening to the patient is key to minimising patient risk and safety in the emergency department. To be able to assess patient understanding, close tracking of the patient’s story by the clinician as well as patient involvement—or agency—in the interaction are essential.

4.3.3 Potential Risk Point: Patient Involvement—Not Informing the Patient

Sometimes communication breaks down and patients are not given critical information regarding their care. Such omissions can trigger sentinel events (US Government Accountability Office GAO 2004) where serious physical risk can result. During our observations in one emergency department, we observed a nurse searching for a patient. She asked her colleagues: ‘Has anyone seen the patient from bed 16?’ Other staff members asked who the patient was. The patient, who had been involved in an accident, was described as male, with black curly hair, youngish and wearing a neck brace. One of the staff indicated that he had seen this patient walking in the direction of the toilet a short time before. The nurse who was looking for the patient exclaimed: ‘But he isn’t supposed to be walking around! He hasn’t had an X-ray yet!’ Another member of staff suggested: ‘You should have stuck a sign on him: “This patient should not walk around!”’ The patient was located and returned to his bed.

We did not record the outcome of the bed 16 patient’s stay in the emergency department, but based on the nurse’s level of anxiety about the patient’s movements, serious risk to the patient was possible and may have occurred. Through recording, interviews and observations , our study has identified that frequently patients are not informed about what they can or cannot do, or what is about to happen to them. Although this can occur in the high-pressure environment of the emergency department where emergency clinicians struggle to ensure the best possible care under duress, mistakes and omissions are frequently caused by communication breakdowns. From the perspective of patient safety, the two examples above show how listening to patients and adequately informing them at all stages are two important aspects of involving patients in their care, crucially important for minimising risk.

These examples highlight the significant challenges facing both the delivery of emergency medicine and the training of junior clinicians. In a teaching hospital , the training of junior clinicians is central to the work of emergency departments—but some exchanges are risky, as the data above have shown. Yet for clinical experience and learning to be meaningful, this training ought to take place in high pressure of the emergency department—a necessity that leaves hospital administrators and medical colleagues, not to mention patients, in potentially precarious circumstances. With the seriously extended and already under-resourced workforce in emergency departments around the world, closer supervision of novices by seniors is difficult, as is the follow-up of their work by senior clinicians, but in many cases it is crucial in terms of both the quality and safety of the patient experience.

4.3.4 Potential Risk Point: Delivery of Diagnosis

The primary tasks of an emergency department clinician are to find out what is wrong with a patient and to work out what the most effective follow-up treatment should be. Thus, diagnoses for all but very minor ailments are usually given to patients after a considerable number of emergency department activities that include several consultations between different clinicians and the patient, one or more physical examinations , tests such as blood tests and X-rays, consultations between junior and senior doctors and, often, telephone consultations with the patient’s GP.

The delivery of diagnoses is the key moment of the clinician–patient consultation and one that takes significant hospital, clinician and patient effort to reach safely, accurately and expeditiously. The point at which the diagnosis is delivered during a patient’s journey through an emergency department is clearly important. It is what the patient has been waiting for, often very anxiously, and it is what the doctor assigned to the patient has been working towards. The way in which a diagnosis is delivered therefore constitutes a key communicative event in the patient’s journey. The interaction below is one example of how a junior doctor (from a non-English speaking background) delivers the news to an elderly male, patient 4 (Clement) , who presented with left-sided pain.

Extract 4.4 Patient 4 (Clement)