As a clinician for 25 years plus training, my entire world has been managing the physician-patient relationship. On one hand, I have to be a scientist and apply all the technical knowledge about disease management, while in the other, a compassionate salesman, convincing often frightened and wary patients any families to trust my skilled hands after just a few meetings in the safe surrounds of the outpatient clinic or hospital, when they are still conscious and can process what I am saying; experiencing all of the fear and trepidation associated with this conversation. My skills in negotiation really come from doing pediatric neurosurgery (as a necessity, not on purpose), for if there is ever a time when conversations require delicate conflict management skills, it is with parents of sick children. The quick response of anger and hostility when the clinical course is not just perfect, or even when the diagnosis is poor and the family projects their anger and disbelief on to the healthcare providers, as if we caused the disease. All of these incidence require a calm understanding of the situational extreme emotional, visceral, hind brain response that is fueled from adrenaline laced with some unknown bio-reactant that only a strong benzodiazepine (Valium) can calm. 
As a neurosurgeon, I have been involved with every type of conflict, disclosure and the process of litigation and medical board battles. The system is so broken, beyond what we have studied, and the compromised communication between provider and patient is merely a reflection of the painful administrative oppression that healthcare providers endure from every type of regulatory agency, peers and law firms. These all are quick to accuse and constantly put providers on their highest guard. I doubt many providers are actually dispassionate but the walls to protect and preserve their emotional sanity keep expressions of compassion deeply suppressed behind the armor that required to survive the turmoil of clinical practice. What we study, the dysfunctional provider-patient discord, is just a byproduct of a larger system that fosters anxiety and fear in the very providers trusted to address the emergencies of physical and psychological disease and discord that bring patients to our clinics and emergency rooms.
As Chen points out “Not surprisingly, those patients with the strongest relationships to specific primary care physicians … had a greater influence on the kind of preventive care received” which is really about “patient’s ability to have a longstanding relationship with a doctor, to have a doctor who knows him or her as a human being.” (Chen). But if that relationship is continually threatened by outside influences that punish the provider or make the provider wary about getting close to the patients and disclosing the fragility and dilemma of humanism and the potential for error or with treatments that don’t resolve the issue, how does a provider accomplish the compassion advocated by the Schwartz Center’s theme of compassion as a cornerstone of medical care? Providers fear for their own professional health and security. The provider is under constant attack.
Nevertheless, understanding the potential exquisite role of the ADR medical ombudsman will facilitate healthy relationships between medical staff, a critical need for the health and safety of both patients and the staff themselves. There is a clear pathway on ADR skill utilization and potential adaptation for the healthcare providers themselves who seek to master the role of healthcare ADR specialist. Houk and Amerson paper on the role of apology illustrates the Ombudsman duties quite well and one could really identify with Dr. Greene, the cardio-thoracic surgeon who, as the Captain of the ship, continued to provide the family of the lost boy with the information they needed for closure. “..In light of the lengthy relationship Dr. Greene had established providing Joey’s medical care, he would be the one to disclose the facts surrounding the medical error” ( Houk). The message was clear here, the provider-doctor and surgeon, is expected to have the closest relationship with the family, have trust and compassion and therefore best suited to lead the conversation, within the ADR guidelines, to inform the distraught family.
The dichotomy is that surgeons, because of time, higher litigation exposure, personality (disorder in my case), are probably the least sensitive of all providers to the social and psychological nuances that go into having these difficult conversations. Not that they are afraid or purposely insensitive, but usually because delivering bad news is part of the job. Considering the information and context for these delicate adverse outcome conversations, an ADR specialist should probably concentrate on the surgeons’ approach and how they will interact with the family and less about what they are actually going to say.
Lastly, the Kaiser Model and well known medical ADR persona, Dorothy Tarrant nicely summarized the roles and responsibilities of ADR in medical organizations. Quoting her daily duties “I assist patients and providers by helping them to work together to address their needs and interests. This includes acting to fairly resolve healthcare issues, disputes and conflicts by acting as a neutral, independent and confidential resource for patients, families and providers. It is the job of the HCOM to understand the dynamics of patient-provider communication and the relational aspects of dispute resolution…”; this templates the best practices expected to facilitate the doctor-patient relationship assisting in communication necessary to heal the patient when distressed following adverse clinical outcomes. In addition to these jobs however, we should add to this ( based upon my experiences and 
administrative roles as prior chairman of surgery and prior member of credentialing and peer review quality assurance committees), that the consultant or in- house ADR health care liaison should take the time to establish a relationship with the healthcare providers and have a high enough profile to seek out and establish relationships with both nurses and doctors to understand the culture and personalities of the medical “player” at an institution. There are often physicians seen as disruptive with poor relationships to the administration of the hospital, so despite who is paying the ADR professionals salary, the role must appear, and services executed, as a neutral independent that will not report conversations to hospitals legal department or maintain insider information that the administrators could leverage against the doctor or nurse in future negotiations. In essence, the providers must trust the ADR facilitator/mediator/coach first, when not under duress, to improve both education and functional outcome when a specific patient-provider conflict arises.
Ref:
PAULINE W. CHEN, M.D.; DOCTOR AND PATIENT How Connected Are You to Your Doctor? March 26, 2009
Harvard Center for ADR – The Schwartz Center at http://www.theschwartzcenter.org/
Carole S. Houk, JD, LLM; Leigh Ana Amerson, BA; and Lauren M. Edelstein; Apology and Disclosure How a Medical Ombudsmen Can Help. Bring a Policy to Life By http://www.psqh.com/mayjun08/apology.html
Interview in Modern Medicine with Dorothy Tarrant. http://managedhealthcareexecutive.modernmedicine.com/mhe/Visionaries/Advocacy-with-compassion- Dorothy-Tarrants-role-as-/ArticleStandard/Article/detail/329925
Let us scientifically investigate the impact the effects of this hostile work environment. Referencing Maxfield et al work with the AORN and AACN on “The silent treatment.” we see the discussion on this 2010 study of 6500 nurses and nurse managers discussed the impact of compromised communication for any reason in the healthcare work environment. Hostility between personnel creates this miscommunication and prevents sharing critical patient data. As this study points out, “creating a culture where healthcare workers speak up…the study shows that healthcare professionals’ failure to raise the following three concerns when risks are known undermines the effectiveness of current safety tools: 1. Dangerous shortcuts 2. Incompetence 3. Disrespect.” So what we see in our personnel hostility is profound disrespect for each other and our system, when a failure to communicate puts patient safety directly in harm’s way.
In 2004, Gerardi addressed this as a critical need in any work place and we must consider similar solutions within our hospital environment. He described the use of mediation techniques to identify conflict early and develop a plan to resolve it by “listening, re-framing the concerns raised, identifying commonalities and clearly defining decisions”. We have at our disposal several well tested dispute resolution techniques and several people within our organization trained or expressing a desire to be trained in this professional management role that our organization desperately needs. As Maxfield solutions suggest “… when it comes to creating healthy work environments that ensure optimal quality of care, individual skills and personal motivation won’t be enough to reduce harm and save lives unless speaking up is also supported by the social and structural elements within the organization. Changing entrenched behavior in healthcare organizations will require a multifaceted approach and, to this end, the authors provide a series of recommendations leaders can follow to improve people’s ability to hold crucial conversations.” We must adopt guidelines which are memorialized by employee contractual procedure and an institutional commitment at every level, from senior management to hospital personnel and provider-nursing communication. The doctrine we create and offer for ratification includes a methodology to identify and address access to our system of conflict management for the employees. Here, we outline for reporting abuse; a safe method to report this abuse and not suffer discrimination, retaliation, or termination; the methods our hospital will take to address this report and remedy the issue; the method of investigation of accusations and corrective education when abuse has occurred; and lastly, the follow up communication methods for the person reporting the initial issue. Indicate how the reporting person will receive information about the outcome of the abuse report.
Renaissance Reflections of a Physician and Surgeon 
You must be logged in to post a comment.