# data[].attributes.headline
A1: You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy.

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A1: You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy.

# data[].attributes.body
Year 1 exam: Feedback on professionalism, empathy and being friendly

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A2: You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

# data[].attributes.subject
A2: You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

# data[].attributes.body
Year 1 exam: Feedback on professionalism and communication

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Abstract

The objective was to evaluate a novel intervention that integrates a psychological, values-based approach with coordinated care management. This paper describes an integrated comprehensive health record system to enhance engagement with a subset of those with complex needs; those who are high-needs, high-cost (HNHC). Patients are selected after conducting data analysis on the most costly and complex patients of a payer system that works with HNHC patients. Specifically, the Patient Care Intervention Center in Houston TX, applies the values-based intervention to HNHC patients. This pilot study reports data from 18 HNHC patients over 6 months; specifically, outcomes related to daily functioning, depression, working alliance, stages of change, and overall well-being. Additionally, this paper reports preliminary findings from qualitative monitoring of provider experiences implementing the values-based approach and integrated evaluation. HNHC patients improved their daily functioning over 4 months but no other significant changes were found over time. Patients self-reported mild depression, strong working alliances with their provider, being in the contemplation phase of change, and moderate well-being. There also was variation when patients completed the assessments and data points were collected. Although this is a small sample and short time frame, preliminary results suggest that the intervention has a positive impact on HNHC patient daily functioning. Provider accounts of the implementation describe using the evaluation items to inform their interactions with patients, and also suggest that patient literacy level impacts when data can be collected. Other changes to the approach are suggested.

Keywords: care coordination; complex needs; high needs-high cost; values-based intervention.

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Values-Based Interventions in Patient Engagement for Those with Complex Needs - PubMed

# data[].attributes.attachment_link.description
The objective was to evaluate a novel intervention that integrates a psychological, values-based approach with coordinated care management. This paper describes an integrated comprehensive health record system to enhance engagement with a subset of those with complex needs; those who are high-needs, ...

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A3: You must give patients the information they want or need to know in a way they can understand.

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A3: You must give patients the information they want or need to know in a way they can understand.

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Year 1 exam: Feedback on professionalism and communication

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J Opioid Manag. Author manuscript; available in PMC 2023 Sep 1.

Published in final edited form as:

Josh Bleicher, MD, MS, Jordan Esplin, BS, Allison N. Blumling, MS, Jessica N. Cohan, MD, MAS, Mark Savarise, MD, MBA, FACS, David W. Wetter, PhD, Alex H. S. Harris, PhD, MS, Kimberly A. Kaphingst, ScD, and Lyen C. Huang, MD, MPH, FACS

Abstract

Objective:

Interventions aimed at limiting opioid use are widespread. These are most often targeted toward prescribers or health systems. Patients' perspectives are too often absent during the creation of such interventions. This qualitative study aims to understand patient experiences with education about perioperative pain control, from preoperative expectation-setting to post-operative pain control strategies and ultimately opioid disposal.

Design:

We performed semistructured interviews focused on patient experiences in the perioperative period. Content from interview transcripts was analyzed using a constant comparative method.

Setting:

All participants underwent surgery at a single, academic tertiary-care center.

Participants:

Adult patients who had a general surgery operation in the prior 60 days.

Outcome measure:

Key themes from interviews about perioperative pain management, specifically related to preoperative expectation-setting and post-operative education.

Results:

Patients identified gaps in communication and education in three main areas: preoperative expectation setting of post-operative pain; post-operative pain control strategies, including use of opioid medications; and the importance of appropriate opioid disposal. Failure to set expectations led to either significant patient anxiety preoperatively or poor preparation for home discharge. Poor education on pain control strategies led to misinformation on when and how to use opioids. Lack of education on opioid disposal led to most participants failing to properly dispose of leftover medication.

Conclusions:

Gaps in education surrounding post-operative pain and opioid use can lead to patient anxiety, inappropriate use of opioids, and poor disposal rates of leftover medications. Future interventions aimed at patient education to improve pain management and opioid stewardship should be created with an understanding of patient experiences and perceptions.

Keywords: patient expectations, patient education, opioid stewardship, pain management, qualitative methods

INTRODUCTION

In 2016, opioid overdoses accounted for over 42,000 deaths in the United States, with over 17,000 of these from prescription opioids.1 In addition to the tragic and avoidable loss of life, this national epidemic has an economic burden of $78.5 billion annually.2 Nearly 10 percent of all opioid prescriptions in the United States are written by surgeons for post-operative pain management.3 Most patients (67-90 percent) do not use their entire opioid prescription following inpatient surgery, with 42-71 percent of pills left unused.4 These large opioid prescriptions and leftover pills can place patients at risk for opioid use disorders, with 6.5 percent of patients persistently relying on opioids after major surgery.5,6 Overprescribing opioids also leads to increased access to opioids among the general public. Concern over these issues has led to significant efforts over the past decade to curb opioid prescribing, including the generation of guidelines to limit the number of opioids prescribed after common surgical procedures and provider-based educational initiatives.7-9

Patient voices have largely been left out of the conversation regarding post-operative pain management and opioid stewardship.10 Opioids are rarely prescribed in a patient-centered way and little evidence exists to inform prescribers about how patients think about pain expectations, pain management, and opioid use following surgery.11,12 Efforts to reduce opioid prescribing have generally focused on a "one-size-fits-all approach of hard thresholds" for writing opioid prescriptions.13 This approach often fails to adequately involve patient perspectives in their own pain management and lacks flexibility to allow for opioid prescribing in a patient-centered manner.13-15 Most post-operative patient opioid education studies have focused on the task of educating patients instead of eliciting the patients' own experiences and expectations regarding opioids and post-operative pain.16,17

This qualitative study explores patients' thoughts regarding their preparation for surgery, experiences of pain and pain management post-operatively, and views on opioid disposal. A better understanding of patient perspectives is needed to develop and refine patient-centered interventions aimed at improving opioid stewardship. A greater awareness of patient experiences will help providers personalize patient education and improve opioid stewardship without sacrificing individual patient preferences and satisfaction.

METHODS

This study was deemed exempt by the Institutional Review Board at the University of Utah. We performed a qualitative study evaluating patient expectations of pain following surgery and perceptions of post-operative pain control. English-speaking adult participants (age 18 or older) who had undergone an operation by a general surgeon at our institution were recruited to participate. A convenience sample of patients who had recently undergone a general surgical operation was included. Interviews were conducted in a sequential manner, and we continued to recruit patients until theoretical saturation was reached and obtaining new information from participants was unlikely. Participants were excluded if they declined to be audio recorded.

Each participant was initially invited to participate by a single member of the research team (JE) in person or by phone, who discussed the requirements of participation with patients. After obtaining informed consent from each participant, we performed semi-structured, open-ended interviews, 45 minutes to 1 hour in length, within 60 days of their operation. All interviews were conducted by a single investigator (JE), either by phone or in person at a follow-up clinic appointment, between October 2018 and September 2019. Participants did not receive any compensation for participation.

Interview guide

A semistructured interview guide was developed based on recent research on patient expectations of post-surgical pain and opioid use and misuse following surgery, as well as the investigators' personal clinical experience with the delivery of post-operative pain control ( Appendix). At our institution, at the time of this study, there was no standard education on post-operative pain management for surgical patients. Questions were designed to query patient attitudes, beliefs, and knowledge about pain and opioids with respect to their recent experience with surgery. The final guide included questions on three main topics: pain expectations prior to surgery, pain management post-operatively, and knowledge of opioid disposal methods. Participants were asked about their expectations of post-operative pain and what factors contributed to this expectation. They were then asked about what methods they used to control post-operative pain-including opioid medications, nonopioid medications, and nonpharmaceutical approaches-in addition to how successful their approach to pain control was. Questions regarding opioid disposal assessed patient knowledge of appropriate disposal methods, education by providers on disposal methods, and patients' actual practice regarding opioid disposal. This section of the interview guide aimed to identify gaps in patient education and barriers to opioid disposal.

Data analyses

All interviews were audio recorded and transcribed verbatim. Content and thematic analysis was performed by two of the investigators (JB and JE) on a random sample of 10 percent of the interview transcripts to identify key themes and concepts from the interviews. An initial codebook was generated, then revised using an additional 10 percent of the study sample using a constant comparative method.18,19 The investigators met to discuss about addition or removal of new codes, ensuring all themes in the interviews were represented by a code and that each code was unique. This process was repeated until both coders felt the codebook was complete and concise, three times in total. The final codebook contained 23 codes, grouped into three categories corresponding to the interview guide: pain expectations (n = 7); post-operative pain management (n = 8); and opioid disposal (n = 8). Codes were not created based on an a priori framework. Rather, investigators allowed codes and themes to emerge from the interview transcripts. During this process, the investigators achieved a high rate of inter-rater reliability, defined as a Cohen's κ value of 0.7 or higher for all individual codes.20 Once the codebook was finalized, all interviews were coded by one of two coders. Codes were then analyzed by all investigators to identify key themes that best describe the overall participant experience. We do not report percentages or quantitative statistics. We used a semi-structured interview guide, which does not use standardized question wording and does not ensure that all questions are asked of every participant.

RESULTS

In total, 45 patients were approached for recruitment and 40 agreed to participate. Nine patients did not respond on follow-up and one interview was excluded from analysis because of poor audio quality. Of the 30 participants included, the majority of participants (n = 24) underwent a colorectal procedure, with most of these patients having a colon resection (n = 18). Other participants underwent operations for hernias (n = 2), gallbladder disease (n = 1), breast cancer (n = 2), or a gastrointestinal stromal tumor of the stomach (n = 1). Operations were performed by nine different surgeons. Most of the surgeries were conducted via a minimally invasive approach (laparoscopic [n = 13] or robotic [n = 13]), while the remainder had an open surgery (n = 4). Fourteen participants (46.7 percent) were female, and the median age of participants was 59.

Pain expectations

Many participants reported that they did not have realistic expectations preoperatively of the amount of post-operative pain they would experience before surgery. Participants differed on whether they expected high or low amounts of pain following surgery, but these expectations were not based on information from the surgical team. Pain expectations were founded on either their own research and reading, personal prior experiences with surgery or childbirth, or the experiences shared with them by friends or family who had undergone surgery previously. Those who did not seek such information and did not have prior experiences with surgery often reported having nothing to base their expectations on.

I had no idea what to expect. I'd never had a surgery before. I imagined it would be painful, but I had no references to how painful it might be or anything like that.-Participant 001

You know, I really didn't know what to expect, to be honest with you. I knew it would probably suck, but I wasn't sure exactly what to really go for.-Participant 019

I went into it expecting to be... for it to be pretty painful. I've had a few surgeries in the abdomen, so I kind of braced myself for... I like to expect the worst.-Participant 030

Only one participant mentioned a conversation with his/her surgeon about pain expectations preoperatively, stating "He had actually told me that my bottom would probably hurt the most and that they would use a [local anesthetic] block to help my abdomen so that it wouldn't be very painful (Participant 031)."

Some participants reported having had extreme anxiety about what their post-operative pain experience would be, while others had been relatively unconcerned. Many cited their personal pain tolerance as a reason for being either fearful or unworried about pain after surgery. Regardless of what their expectations were, very few patients felt their actual experience with post-operative pain aligned with their preoperative expectations. Those who were unworried before surgery sometimes found themselves in much more pain post-operatively, unprepared to handle this shock. Others were happily relieved by the lack of pain they experienced as compared to their expectations.

Oh, I expected to have a lot of pain, but I didn't have any.-Participant 022

Because I haven't had that much surgery, I just assumed that it would hurt a little bit more than it does.-Participant 025

Oh, it was way worse than I thought.-Participant 010

Pain control

Participants reported having a mixed experience with pain management after surgery. Most used multiple pain control modalities including opioid and nonopioid medications, ice and heat packs, cannabis, massage, mindfulness, meditation, and prayer. All but two participants used opioids as part of their pain control plan.

Regardless of individual pain plans and opioid use, a common theme was the lack of education by providers to participants on how to best manage pain and how to use opioids. Similar to participant experiences with preoperative pain expectations, many participants learned about pain management from their own prior experiences with pain or their own personal reading and research. Several participants recalled having a conversation with nursing staff or a pharmacist about how to use opioids and balance opioid use with other pain management modalities; however, almost no participants recalled a conversation with a member of the surgical team on this topic. This led to a wide diversity of understanding among participants about how to use their opioid prescriptions.

The pharmacist was really good when they came in with my bag of prescriptions and told me how to use everything, so the hospital staff was great that way.-Participant 007

Just basically reading a lot, articles on the Internet. Actually talking with doctors; not too often.-Participant 012

On receiving preoperative education: "Not a whole lot. I mean, I've just kind of, you know, just from what I already knew, really, but no formal education or anything like that." - Participant 019

Not a lot. I probably look a lot of things up on the internet if I need help with something. To understand something, I look it up. I try not to bother the doctors too much.-Participant 033

Many patients stated they used as few opioids as possible and used opioids only when absolutely necessary. Others avoided opioids secondary to side effects of the medication or a fear of opioid addiction.

I only used two of [the oxycodone]. I could've used more. I didn't like how they made me feel, so I just stuck with Tylenol and ibuprofen for the days that were a little harder.-Participant 001

It makes me really cautious. I definitely do not want to become an addict. So, I try to be careful about taking those and thinking to myself, well is the pain really that bad? Before I actually swallow one.-Participant 033

Conversely, some participants reported that they took their entire opioid prescription because they felt that is what their surgeon wanted them to do, not based on their actual need for pain relief. Other patients relied on opioids for pain control as they had incorrect information regarding other pain control methods. Some patients incorrectly thought over the counter pain medications were contraindicated following surgery. Other patients reported using tramadol, a low potency opioid, over nonopioid alternatives because they thought tramadol was not an opioid. A large number of participants reported they were not consulted about having an opioid prescription filled for them.

Well, I didn't know I had a choice. I had to have [the opioid prescription] before they'd let me out of the hospital.-Participant 014

I really didn't have a choice. The doctor filled the [opioid] prescription, and the nurse brought it to the room, and I paid for it.-Participant 022

I was told to take it all. There shouldn't be anything to dispose of.-Participant 007

Opioid disposal

Many participants had leftover opioids once their post-surgical pain had resolved. Some participants intentionally kept their leftover opioids in case they had pain in the future-either for a chronic disease with associated pain or for an unexpected episode of acute pain. Many participants stated they planned to dispose of leftover medications, either via an official disposal location or an alternative mechanism, although they had not got around to doing it yet. Others were very intentional about disposing of leftover opioids because of the fear that they would be stolen from them by friends or family who wanted to use the medication themselves or sell the leftover pills for money.

I plan on keeping [my leftover pills], so if I ever have a night where I'm in too much pain to sleep and I need to sleep. So yeah, I have it. I have it put it away. And I plan on keeping it.-Participant 003

On why the participant had not disposed of his or her leftover opioid medication: "I don't know. I don't know... I just haven't dealt with it."-Participant 015

On why the participant disposed of his or her leftover opioid medication: "Because there is people out there that steal it and use it for stuff they shouldn't be and I know that."-Participant 024

Only two participants disposed of their leftover opioids by taking them to an official disposal location. Some other participants knew that there were disposal locations for leftover medication; however, few opted to use them. One patient knew of official disposal mechanisms but did not use them because of a lack of trust that medication disposed of in this manner would be destroyed. The majority of participants with leftover opioid medications reported they did not know of any official way to dispose of them. Participants reported throwing leftover pills in the trash, flushing them down the toilet, or burning them. Almost all participants reported that they received no education on the need to dispose of leftover opioids or the correct way to do so.

You know, probably there's not a lot of awareness that you...shouldn't just throw them out. In our area I think that a lot of people probably don't know that you can take them to the hospital or I believe, I don't know if it's the city or the county, but I believe they do a drug take back every once in a while where you take your unused medications and turn them into them. But I don't think there's really good awareness of those programs or awareness that...that is the proper thing to do with extra medications that you don't need anymore.-Participant 003

No, nobody has ever told me how. Actually, now that I think of it, anytime I've ever gotten any kind of pain medicine, I've never been told how.-Participant 030

No. Not that I'm aware of, but then usually when you get instructions, you're on drugs anyway. So, I'm probably not going to remember.-Participant 035

DISCUSSION

This study assessed patients' experiences of preoperative expectations for post-operative pain, perioperative pain management, and post-operative opioid disposal. A main theme identified across all three aspects of patient care was a lack of communication and education between providers and patients. Some patients reported increased anxiety preoperatively because of unclear expectations regarding pain following surgery, while other patients reported feeling unprepared for the pain they experienced after surgery. Patients rarely reported receiving any formal education from their surgical team regarding opioid use, other pain management strategies, or opioid disposal.

Egbert et al.21 reported over 50 years ago that preoperative counseling with the goal of setting expectations regarding post-operative pain helps reduce anxiety and post-operative opioid use. Increased and improved communication between clinicians and patients can lead to many direct and indirect benefits to patient health outcomes. Education aimed at information exchange, fostering relationships, and enabling self-management can lead to increased patient understanding, satisfaction, and trust in providers, ultimately resulting in decreased suffering and improved emotional well-being for patients.22 Since this initial report, multiple studies have confirmed this finding, with preoperative education and expectation setting leading to not only decreased anxiety, pain, and opioid use but also increased use of nonopioid pain management strategies.16,17,23,24 Patients in the present study reported prior experience with surgery, experiences of friends and family, or personal research as the sources they relied on to set expectations around surgery. This represents an opportunity to develop an intervention to help better prepare patients for surgery and ultimately decrease opioid use.

Patients in this study also reported limited formal education regarding post-operative pain management techniques. Currently, many efforts to reduce opioid prescribing have focused on providers. Educating surgical providers about guidelines to reduce opioid prescribing and the use of nonopioid pharmaceuticals for pain control can significantly reduce the quantity of opioids prescribed.25-27 However, there remains room for improvement. Most medical students do not learn about opioid prescribing, and education on opioid prescribing is a part of only 20 percent of surgical residency programs.28,29 Additionally, while prescribing guidelines lead to smaller opioid prescriptions, a recent study found that patients are still prescribed three times as many opioids as needed.30 The current study demonstrates the need to create interventions that focus on patients, not providers alone. Informal education occurs frequently between providers and patients; however, this study demonstrates that this type of teaching does not accomplish the intended goal. Simple, formal educational interventions directed toward patients, such as providing them with a card describing what medications are appropriate for different pain severity, can help reduce opioid use in the immediate post-operative period.31 More research is needed to explore and validate this and other similar interventions.

One reason for a lack of patient education may be related to the time constraints of providers in our current medical system. A recent study identified physician time constraints as one of three major barriers to changing opioid prescribing patterns.32 Another study found that 81 percent of surgeons report not having enough time to educate their patients.33 The current burden of documentation and other administrative tasks for the modern surgeon does limit the time providers have to spend with their patients, with some surgical residents spending at least 30 percent of their time at work on these tasks.34,35 Patient education is one aspect of care that is too often omitted because of these time constraints. Time constraints must be considered when patient education interventions are developed.

Opioid disposal represents a third area where improved patient education is needed. Many patients in our study received no education regarding proper disposal methods and many did not know how to appropriately dispose of their leftover medication. The majority of patients have leftover opioids following surgery, and most patients (77-91 percent) store this medication in an unlocked location.4,12 Fewer than 50 percent of patients routinely dispose of leftover opioids, and most do so in non-FDA-approved ways.36 Simple interventions such as giving patients a brochure on opioid disposal or counseling patients on opioid disposal can significantly improve patient disposal rates.37-39 Other interventions, such as distribution of opioid disposal kits, can also significantly increase the rates of opioid disposal.40 Opioids maintain their potency for many years, and interventions aimed at disposal of leftover opioids can help limit the number of pills that get diverted from their initial intended use.

Opioid use and abuse presents a significant challenge to healthcare providers, and many approaches to improve opioid stewardship are needed. Interventions must be created that fulfill the objectives of maintaining adequate pain control and patient satisfaction while simultaneously minimizing opioid use. In this study, multiple educational gaps were identified. These gaps represent areas where healthcare providers can create educational interventions directed at patients-from expectation setting in preoperative clinics to improving education about the importance of safe opioid disposal after patient discharge. The findings of this study may also encourage individual providers who prescribe opioids to be more cognizant of the need for patient education. Our results can also help to encourage the creation and implementation of interventions that can improve patient education without reliance on individual providers, who are already struggling with the many demands of modern health care.

Several educational interventions have already been created, with many showing positive results in minimizing opioid use and increasing opioid disposal. One study found that providing patients with a booklet and a 20-min education session on post-operative pain intensity and effective pain control strategies helped reduce pain in the immediate post-operative period.17 Another similar study provided patients with a form and one-on-one education on how to use medications correctly, how to manage medication side effects, and how to recognize poorly controlled pain.16 This simple intervention led to decreased post-operative pain, fewer side effects from pain medications, and increased use of nonpharmacologic pain control methods. Our research suggests that these interventions should be trialed in other locations and scaled-up if proven successful in different environments. Other interventions should be developed to fill the other educational gaps identified in this study.

The generalizability of our study is limited by recruitment of participants undergoing abdominal operations (primarily colorectal surgeries) at a single academic tertiary center. Although the study was done at a single center, our participants came from seven states across the Mountain West, representing a variety of communities. Additionally, our goal, in this qualitative study, was to identify themes to guide future research and intervention development. The lack of education identified at our institution has been reported at other medical centers; however, other institutions may have different educational platforms in place for patients, leading to different experiences with post-operative pain.41 Finally, this study had the potential for recall bias, with patients failing to accurately represent events. This was minimized through the use of open-ended, nonleading questions and performing interviews within 2 months of patients' operations.

This qualitative study explored patients' experiences regarding pain and opioid use in the perioperative period. The recurrent theme identified was a lack of patient education. Patients reported inadequate education preoperatively to set accurate expectations of post-operative pain, inadequate education about pain management and opioids post-operatively, and inadequate education about safe opioid disposal. Improving patient education is critical to improve opioid stewardship and will create opportunities to deliver pain management in a more patient-centered way. Educational interventions exist, which have shown promise in not only reducing opioid use but also improving patient pain scores and satisfaction. These should be expanded, further validated, and improved, taking patient perspectives into account. Further research investigating barriers to patient education on opioids and pain management is needed to help build interventions that will be practicable and sustainable.

ACKNOWLEDGMENTS

We thank the University of Utah's Vice President's Clinical and Translational (VPCAT) Research Scholars Program for the mentorship, resources, and support afforded. Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under the award numbers UL1TR002538 and KL2TR002539. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

APPENDIX: INTERVIEW GUIDE

My name is [ interviewer]. Thank you again for agreeing to share your thoughts. As you have heard, during this interview, we will be talking about your experience with managing pain after your surgery and how where you live may affect your access to health care. We are doing this study to find out more about barriers to health care in rural areas and the different resources related to health care available in rural areas.

We will start with questions about surgery and the resources available to you and then move onto questions about your geographic location and access to health care. After that will be questions about community support available to you. The last group of questions will ask you about your opinion and knowledge of pain medications.

There are no right or wrong answers to any of the questions. Different people can have different thoughts and beliefs. We are interested in hearing what you think.

This interview will last about 60 minute. My role will be to ask questions and listen to your responses. I want you to feel free to say anything that you are thinking.

Please remember that you may choose not to answer any question and you may stop participating at any time. I would like to ask you to turn off your phone or put it on vibrate mode, so that we can focus on the interview.

I would also like to remind you that this interview will be audio-taped, and that the records will be heard only by the research staff on this project, or by a professional transcriptionist. We will remove any identifying information in the interviews during the transcription process. We will keep all of the information you tell us during this interview confidential and will only use your responses for research purposes.

Any questions before we get started?

I am going to start taping now.

Let us begin.

I will first ask you questions about your surgery and the types of resources you had available to you.

1) What type of surgery did you have?

2) Where was it done?

Probes

3) What were your expectations about pain before your surgery?

Probes

How was the pain you experienced worse or less than what you expected?

4) There are many different ways to manage pain. These can include medications, ice and heat packs, meditation, massage, music, etc. Did you use any methods to manage your pain?

Probes

1. Which methods did you use?

2. How effective were they for you?

3. Which method do you prefer the most? Why?

4. Have you used these methods in the past to manage other pain?

5. What education have you received on different pain control methods?

5) How did your work situation affect your decision to have surgery?

Probes

1. What do your co-workers expect for recovery time?

2. How did your co-workers support you after your surgery?

The following questions will ask you about your opinion and knowledge of pain medication.

6) Some people argue that doctors are prescribing too many pain medications. Do you agree with this statement?

Probes

Why or why not?

7) Did you receive a prescription for pain medication after your surgery?

Probes

8) Did you have any pain medication left over after your surgery?

Probes

What would convince you to throw away your medication?

9) Have you heard the term "opioid epidemic"?

Probes

1. What thoughts do you have about that term?

2. In your opinion, is addiction prevention the responsibility of the patient or the doctor? Why?

10) What are the difficulties you face when trying to dispose of a medication?

Probes

1. Did you receive any instruction on how to dispose of your medication?

2. How far is it to the nearest drug disposal location?

11) What problems or difficulties do you see in your area related to health care?

12) What improvements would you suggest for managing pain after surgery for patients like you who live in rural areas?

13) Anything else you would like to say?

My last questions are to find out more about you.

14) How old are you?

15) Male or female?

16) What is the highest level of school that you have completed?

1. Junior high or some high school

2. High school diploma or Graduate Equivalency Diploma (GED)

3. Some college or associate degree

17) What is your zip code?

Contributor Information

Josh Bleicher, Department of Surgery, University of Utah, Salt Lake City, Utah.

Jordan Esplin, Department of Surgery, University of Utah, Salt Lake City, Utah.

Allison N. Blumling, Department of Communication, University of Utah, Salt Lake City, Utah.

Jessica N. Cohan, Department of Surgery, University of Utah; Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah.

Mark Savarise, Department of Surgery, University of Utah, Salt Lake City, Utah.

David W. Wetter, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah.

Alex H. S. Harris, Department of Surgery, Stanford University, Stanford; Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California.

Kimberly A. Kaphingst, Department of Communication, University of Utah; Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah.

Lyen C. Huang, Department of Surgery, University of Utah; Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah.

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30. Robinson KA, Thiels C, Stokes SM, et al.: Comparing patient-reported opioid use across multiple hospital systems to clinician consensus recommendations: Closing the gap between belief and reality. Ann Surg. 2020. (in press). [[ PubMed] Google Scholar]

32. Coughlin JM, Shallcross ML, Schäfer WLA, et al.: Minimizing opioid prescribing in surgery (MOPiS) initiative: An analysis of implementation barriers. J Surg Res. 2019; 239: 309-319. [[ PubMed] PMC free article] [ Google Scholar]

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40. Stokes SM, Kim RY, Jacobs A, et al.: Home disposal kits for leftover opioid medications after surgery: Do they work? J Surg Res. 2020; 245: 396-402. [[ PubMed] Google Scholar]

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Expectation-setting and patient education about pain control in the perioperative setting: A qualitative study

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Interventions aimed at limiting opioid use are widespread. These are most often targeted toward prescribers or health systems. Patients' perspectives are too often absent during the creation of such interventions. This qualitative study aims to ...

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A4: You must receive valid consent for all aspects of examination and treatment and record this as appropriate.

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A4: You must receive valid consent for all aspects of examination and treatment and record this as appropriate.

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Year 1 exam: Feedback on asking consent through the examination

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A5: You must support patients in caring for themselves to improve and maintain their own health and wellbeing.

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A5: You must support patients in caring for themselves to improve and maintain their own health and wellbeing.

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Year 3 case presentation: Using the patients own expertise in the treatmentplan

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Year 3 practical exam: I included advices in my treatment plan to support the patient.

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Dominique Wakefield, Jo Bayly, Lucy Ellen Selman, Alice M Firth, Irene J Higginson, Fliss EM Murtagh

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Patient empowerment, what does it mean for adults in the advanced stages of a life-limiting illness: A systematic review using critical interpretive synthesis - Dominique Wakefield, Jo Bayly, Lucy Ellen Selman, Alice M Firth, Irene J Higginson, Fliss EM Murtagh, 2018

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Background: Patient empowerment, defined as ‘a process through which people gain greater control over decisions and actions affecting their health’ (World Healt…

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A6: You must respect your patients’ dignity and modesty.

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A6: You must respect your patients’ dignity and modesty.

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Skip to content

The term 'dignity' has always been hard to define. A good place to start by looking at our general human rights: 'Human rights are universal - they belong to everyone. They guarantee the fundamental rights of each individual' Equalities and Human Rights Commission (EHRC 2015).

Regulation 10 under the Health and Social Care Act 2007 specifies the kinds of care and treatment that 'ensures dignity'.

Here's what the Care Quality Commission says about Regulation 10:

To meet this Regulation ... providers must make sure that they provide care and treatment in a way that ensures people's dignity and treats them with respect at all times. This includes making sure that people have privacy when they need and want it, treating them as equals and providing any support they might need to be autonomous, independent and involved in their local community.

Care Quality Commission (CQC 2017)

Where does 'dignity' fit in with other current policy priorities?

Dignity is fundamental to current social care policy. A focus for all adult social care and support was set out in the Care Act 2014. The Act begins by defining the primary responsibility of local authorities as the promotion of individual 'wellbeing'.

Wellbeing is defined as a broad concept relating to a number of factors, such as personal dignity, including treating the person with respect.

In the same way, the emphasis on choice and control through a person-centred approach underpins wellbeing. It supports the person's sense of self-respect, as well as the provider's commitment to treat the person with dignity and respect.

How can being treated with dignity help?

Care with dignity supports the self-respect of the person, recognising their capacities and ambitions, and does nothing to undermine it. It includes respect for what they can do, who they are, and the life they've lived. It's seen as a central part of quality in care work.

Surveys involving people who receive or provide social care frequently emphasise relationships above all: between the person needing care and their carer, within groups in residential care, and between the people receiving care and the wider community.

Get these right - they say - and attitudes, behaviour and high-quality care follow.

Care from the heart: older minoritised women's perceptions of dignity in care (ResearchGate, 2015) describes how older people who had migrated to this country found that they distinguished between professional care and the type of generous, respectful care they received from family members. 'Care from the heart', they called it, protected their dignity.

The concept of personalisation sets out to capture these qualities of respect and compassion, and identifies care practice that supports independence, self-esteem and dignity.

This can be a good test of the degree to which social care staff really understand what life is like for the people they work with. Are microwaved frozen meals, or sandwiches on paper plates really like mealtimes? Are care homes the sort of places we think of when we think of 'home?' What makes life for people receiving adult social care services a real, satisfying life?

We all want this kind of personalised care for our families. But all families are different.

Stories for discussion

Read the following stores and reflect on the questions. It may good to discuss these with your colleagues.

These stories present very different situations, but there are also important things they have in common.

Each of the stories describes a unique individual, whose history, career, skills, interests and routines need to be recognised and respected. They have care and medical needs, but that is not who they are.

All of them have existing support networks, and relationships they value.

None of them fits easily into an institutional pattern. They can't just be 'slotted in' to whatever local services currently offer.

All of them need information about what's on offer and what it will mean for them.

Each story raises issues of equality, as well as dignity and respect.

Grace, Daniel and Don - as well as their carers - all demand a response that is thoroughly personal to them. At the same time, they are looking for what a modern social care system can offer: an approach to care that is positive, respects their strengths and experience, understands their rights and supports their independence. How can social care managers and workers develop a culture in the workplace that supports this approach?

Better life in the community

Let us have a look at a real-life example of listening to each individual to provide dignity in care.

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Skip to content The term 'dignity' has always been hard to define. A good place to start by looking at our general human rights: 'Human rights are universal - they belong to everyone. They guarantee the fundamental rights of each individual' Equalities and Human Rights Commission (EHRC 2015).

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doi: 10.3389/fpsyg.2020.01468.

Affiliations

¹ Department of Human Sciences, European University of Rome, Rome, Italy.

² Psychology Unit, LILT and Center for Oncological Rehabilitation-CERION of Florence, Florence, Italy.

³ Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada.

⁴ U.O. di Cure Palliative, Fondazione Sanità e Ricerca, Rome, Italy.

doi: 10.3389/fpsyg.2020.01468.

Affiliations

¹ Department of Human Sciences, European University of Rome, Rome, Italy.

² Psychology Unit, LILT and Center for Oncological Rehabilitation-CERION of Florence, Florence, Italy.

³ Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada.

⁴ U.O. di Cure Palliative, Fondazione Sanità e Ricerca, Rome, Italy.

Abstract

Introduction: Dignity Therapy (DT) is a brief, individualized, narrative psychotherapy developed to reduce psychosocial and existential distress, and promote dignity, meaning, and hope in end of life patients. Previous studies have shown that DT was effective in reducing anxiety and depression, and improving dignity-related distress. However, less is known about its efficacy on spiritual well-being. The aim of this study is to contribute to the existing literature by investigating the effects of DT on specific dimensions of spiritual well-being, demoralization and dignity-related distress in a sample of terminally ill patients. Methods: A randomized, controlled trial was conducted with 64 terminally ill patients who were randomly assigned to the intervention group (DT + standard palliative care) or the control group (standard palliative care alone). The primary outcome measures were Meaning, Peace, and Faith whereas the secondary outcome measures were (loss of) Meaning and purpose, Distress and coping ability, Existential distress, Psychological distress, and Physical distress. All measures were assessed at baseline (before the intervention), 7-10 and 15-20 days after the baseline assessment. The trial was registered with ClinicalTrials.gov (Protocol Record NCT04256239). Results: The MANOVA yielded a significant effect for the Group X Time interaction. ANOVA with repeated measures showed a significant effect of time on peace and a significant Group X Time interaction effect on peace. Post hoc comparisons revealed that, while there was a decrease in peace from pre-treatment to follow-up and from post-treatment to follow-up in the control group, there was no such trend in the intervention group. Discussion: This study provides initial evidence that patients in the DT intervention maintained similar levels of peace from pre-test to follow-up, whereas patients in the control group showed a decrease in peace during the same time period. We did not find significant longitudinal changes in measures of meaning, faith, loss of meaning and purpose, distress and coping ability, existential, psychological and physical distress. The findings of our study are of relevance in palliative care and suggest the potential clinical utility of DT, since they offer evidence for the importance of this intervention in maintaining peace of mind for terminally ill patients.

Keywords: demoralization; dignity therapy; dignity-related distress; end of life; palliative care; randomized controlled trial; spiritual well-being; terminal illness.

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References

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Austin P., MacLeod R. (2017). Finding peace in clinical settings: a narrative review of concept and practice. Palliat. Support. Care 15 490-498. 10.1017/S1478951516000924 - DOI - PubMed

Bandeali S., des Ordons A. R., Sinnarajah A. (2019). Comparing the physical, psychological, social, and spiritual needs of patients with non-cancer and cancer diagnoses in a tertiary palliative care setting. Palliat. Support. Care [Epub ahead of print]. 10.1017/s1478951519001020 - DOI - PubMed

Bovero A., Botto R., Adriano B., Opezzo M., Tesio V., Torta R. (2019). Exploring demoralization in end-of-life cancer patients: prevalence, latent dimensions, and associations with other psychosocial variables. Palliat. Support. Care 17 596-603. 10.1017/S1478951519000191 - DOI - PubMed

Bovero A., Sedghi N. A., Opezzo M., Botto R., Pinto M., Ieraci V., et al. (2018). Dignity-related existential distress in end-of-life cancer patients: prevalence, underlying factors, and associated coping strategies. Psychooncology 27 2631-2637. 10.1002/pon.4884 - DOI - PubMed

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national center for biotechnology information

# data[].attributes.attachment_link.title
Dignity Therapy Helps Terminally Ill Patients Maintain a Sense of Peace: Early Results of a Randomized Controlled Trial - PubMed

# data[].attributes.attachment_link.description
Introduction: Dignity Therapy (DT) is a brief, individualized, narrative psychotherapy developed to reduce psychosocial and existential distress, and promote dignity, meaning, and hope in end of life patients. Previous studies have shown that DT was effective in reducing anxiety and depressio ...

# data[].attributes.headline
A7: You must make sure your beliefs and values do not prejudice your patients’ care.

# data[].attributes.subject
A7: You must make sure your beliefs and values do not prejudice your patients’ care.

# data[].attributes.headline
B1: You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath.

# data[].attributes.subject
B1: You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath.

# data[].attributes.body
Year 3 practical exam: I demonstrated inclusion of the knowledge, skills and clinical reasoning I have obtained throughout the course.

# data[].attributes.body
My own GIT notes from a lesson in clinic

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My own womens health notes (danish) from lesson in clinic

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B2: You must recognise and work within the limits of your training and competence.

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B2: You must recognise and work within the limits of your training and competence.

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B3: You must keep your professional knowledge and skills up to date.

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B3: You must keep your professional knowledge and skills up to date.

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Neurooptometrist course (Danish)

Example of material from the weekend

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CBD course - Fascia with Paolo Tozzi

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B4: You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

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B4: You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

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C1: You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients.

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C1: You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients.

# data[].attributes.body
Year 3 practical exam: I demonstrated the ability to deliever safe and qualified treatment

# data[].attributes.headline
C2: You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

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C2: You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

# data[].attributes.attachment_link.title
BEK nr 1225 af 08/06/2021, Sundhedsministeriet

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Retsinformation.dk er indgangen til det fælles statslige retsinformationssystem, der giver adgang til alle gældende love, bekendtgørelser og cirkulærer m.v. Der er også adgang til Folketingets dokumenter og beretninger fra Folketingets Ombudsmand.

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C3: You must respond effectively and appropriately to requests for the production of written material and data.

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C3: You must respond effectively and appropriately to requests for the production of written material and data.

# data[].attributes.body
The danish law regarding journalising

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BEK nr 1225 af 08/06/2021, Sundhedsministeriet

# data[].attributes.attachment_link.description
Retsinformation.dk er indgangen til det fælles statslige retsinformationssystem, der giver adgang til alle gældende love, bekendtgørelser og cirkulærer m.v. Der er også adgang til Folketingets dokumenter og beretninger fra Folketingets Ombudsmand.

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C4: You must take action to keep patients from harm.

# data[].attributes.subject
C4: You must take action to keep patients from harm.

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Danish national guide regarding patientsafety (p. 9)

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Hippocratic Oath "First do no harm"

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Embark on a deep dive into the Hippocratic Oath and its paramount tenet, "First Do No Harm." Learn about its relevance today and how our Pre-Med Shadowing Study Abroad Program upholds these age-old ethics.

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C5: You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.

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C5: You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.

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Danish law and guideline regarding hygiene (p. 51 - law)

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C6: You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients.

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C6: You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients.

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D1: You must act with honesty and integrity in your professional practice.

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D1: You must act with honesty and integrity in your professional practice.

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Presentation from Medical Schools Council

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D2: You must establish and maintain clear professional boundaries with patients, and must not abuse your professional standing and the position of trust which you have as an osteopath.

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D2: You must establish and maintain clear professional boundaries with patients, and must not abuse your professional standing and the position of trust which you have as an osteopath.

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Boundaries - General Osteopathic Council

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Creating and maintaining effective boundaries between healthcare practitioner and patient is essential to good clinical practice and is an inherent part of professionalism in healthcare. This is also a key requirement of the Osteopathic Practice Standards.

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D3: You must be open and honest with patients, fulfilling your duty of candour.

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D3: You must be open and honest with patients, fulfilling your duty of candour.

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In January 2014, the Government proposed that there should be a professional duty of candour for health professionals. This was in response to the Mid Staffordshire NHS Foundation Trust Public Inquiry, carried out by Robert Francis QC, which published its final report in February 2013.

The Francis Inquiry found evidence that, when patients come to harm, insensitive handling and poor communication after the event can be as damaging as the original problem. It identified that clinicians and clinical staff must be properly supported when things go wrong, so they will never feel prevented from being open and honest with patients or fulfilling their duty of care.

The Government proposal, set out in the document Hard Truths: The Journey to Putting Patients First, said: 'The healthcare professional regulators will be working to agree consistent approaches to candour and reporting of errors ... and clear guidance that professionals who seek to obstruct others in raising concerns or being candid would be in breach of their professional responsibilities.'

Regulators' joint statement

In October 2014, the GOsC and other regulators made a public commitment to strengthening and harmonising professional standards in relation to candour and the reporting of errors. Their joint statement sets out the following professional duty of candour:

'Every healthcare professional must be open and honest with patients when something goes wrong with their treatment or care which causes, or has the potential to cause, harm or distress.

'This means that healthcare professionals must:

tell the patient (or, where appropriate, the patient's advocate, carer or family) when something has gone wrong;

apologise to the patient (or, where appropriate, the patient's advocate, carer or family);

offer an appropriate remedy or support to put matters right (if possible); and

explain fully to the patient (or, where appropriate, the patient's advocate, carer or family) the short and long term effects of what has happened.

'Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. Health and care professionals must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest and not stop someone from raising concerns.'

The duty of candour is common across healthcare professions, but it is recognised that different health professions and their regulators work in different ways - for example, the management and working relationships in osteopathic practice settings are very different from those in NHS hospitals. We will work with the osteopathic profession and with the other regulators to ensure that standards promoting candour are appropriate to osteopathic practice and consistent with other health practices.

Osteopathic Practice Standards

Standard D3 states 'You must be open and honest with patients, fulfilling your duty of candour.'

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In January 2014, the Government proposed that there should be a professional duty of candour for health professionals. This was in response to the Mid Staffordshire NHS Foundation Trust Public Inquiry, carried out by Robert Francis QC, which published its final report in February 2013.

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D4: You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise.

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D4: You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise.

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You need to lodge your complaint digitally from the website borger.dk by logging on with your MitID. Please note that the complaint form is in Danish.

We will reject complaints that are not received via the digital complaint form unless special circumstances apply.

Special circumstances can be that you:

are unable to obtain MitID

are exempt from receiving Digital Post

cannot understand Danish

cannot use a computer due to illness or age

are currently seeking asylum

Go to borger.dk (in Danish only)
Pregnancy

There is no digital complaint form for application for termination of pregnancy or fetal reduction. Please complete one of the forms below instead:

We prefer to correspond in Danish. It demands considerable resources and prolongs the processing of your case if all correspondence to you has to be translated in to English.

If you do not understand Danish and you are not able to get help translating our letters, please give us a reason for this.

You are welcome to write to us in English and to request getting the final decision translated into English.

When you want to complain about health care on behalf of someone else, you need a power of attorney from this person to complain to the Danish Patient Complaints Agency.

If you do not already have a power of attorney, you can use the form Power of attorney. Remember to get a signature from the person, who gives you power of attorney.

You can get advice about your appeal and patient rights by contacting a patient advisor at your regional patient office. The patient advisor can also help you to write the complaint.

The patient advisor has knowledge of healthcare services and in particular in your region and can advise you on your options, including if you want to complain.

The patient advisor can also help you apply for compensation if you are injured caused by pharmaceuticals or in connection with a treatment in the healthcare system.

Each region has a patient office, however, Capital Region of Denmark has several patient offices at different addresses in the region. You can find contact information for your local patient office on the links below.
Se contact details (in Danish)

You can contact us through:

The phones are open

Nyttige Links

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You need to lodge your complaint digitally from the website borger.dk by logging on with your MitID. Please note that the complaint form is in Danish. We will reject complaints that are not received via the digital complaint form unless special circumstances apply.

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The Competent Novice

This article explores why patients complain and outlines some strategies for reducing the rising number of complaints and for dealing appropriately with any that do occur

Key points

Try to give patients as much information as they want or need to allow them to navigate through the complexities of their illness and the healthcare system

If things go wrong, offer an explanation and a compassionate apology and explain how you will prevent similar incidents in the future

If a patient or relative expresses concerns about the patient's treatment, then listen to them and answer any questions you can. If the complainant decides to make a formal complaint ask them to contact the complaints manager as soon as possible

One in 10 patients admitted to hospital in the United Kingdom experience an adverse event,1 and around half of these events are preventable. The number of complaints from National Health Service (NHS) patients is rising in the UK: the Department of Health's Independent Complaints Advocacy Service dealt with 10 422 complaints in 2003-4 but almost 13 000 complaints in 2004-5.2

It is essential that healthcare professionals work together with patients and deal constructively with feedback to reduce adverse events. Evidence shows, however, that doctors find complaints extremely upsetting, feel unsupported in dealing with them, and are fearful of the consequences, including litigation.3 4 5 Here we describe how and why patients complain and then suggest some evidence based strategies for reducing complaints and for dealing appropriately and helpfully with any that do occur.

Why do patients complain?

Complaints often follow adverse clinical events, but they can occur even when nothing has "gone wrong." Similarly, not all adverse events result in complaints. Focus group studies show that patients want to be told about events occurring in hospital that have caused them harm. Patients want to receive an apology, a description of what has happened, any consequences, and the medical steps needed to reverse these and/or to prevent further harm.4 A survey of 1007 complainants found that their primary motivation was to prevent other patients experiencing the same adverse event in the future.6 Only 7% of patients who complain do so because they want financial compensation.7

About two thirds of complaints concern clinical judgment or decisions,6 7 but it is rare for complaints to occur because of a clinical incident in isolation (11% in one study8). Often a series of adverse experiences will eventually motivate a patient to make a formal complaint. Most complaints (72%) involve an element of staff insensitivity or communication breakdown.6 7 Complaints related to communication are usually found to be valid. In a cross sectional study of complaints referred for peer review, the proportions upheld were as follows: complaints about breakdown in communication, 78%; complaints about failure to investigate or treat, 25%; complaints about misapplication of clinical skills, 20%.8

How can patients complain?

Patients or relatives in the UK can complain to any member of NHS staff (figure ​(figure). ). Only the patient or complainant can decide whether they wish the complaint to be formal, in which case it will be referred to the complaints manager according to the local complaints policy. The complaints manager will try to resolve formal complaints through correspondence and/or face to face meetings. An internal inquiry may also be held.

Ultimately, dissatisfied patients can resort to litigation, although this is rare (fewer than 50 cases a year in the UK); 38% of potential litigation cases are abandoned each year, 43% are settled out of court, and only 4% proceed to court (see the "key points" on the home page of the NHS Litigation Agency, www.nhsla.com/home).

Anyone with a concern about a specific doctor can also complain direct to the General Medical Council. The council will deal with cases where it considers that a doctor has made serious or repeated mistakes; has not examined patients properly or has failed to respond to reasonable requests for treatment; has misused information about patients; has treated patients without consent; has behaved dishonestly; has made sexual advances towards patients; or has misused alcohol or drugs.9

How can you prevent complaints from occurring?

To reduce complaints doctors must not only work to reduce adverse events but also strive to improve communication. Complaints about doctors' attitudes fall after doctors attend communication skills workshops,10 so you should attend all available training courses in communication skills and consider attending commercial courses-for example, in preparation for clinical exams. You can also ask for feedback from colleagues. The Patient Advisory and Liaison Service officer at one local trust had the following advice for medical staff: "If you say you'll get back to someone by the end of the week, then do. Even if you still don't have the information they wanted, contact them and explain this. Try to give timescales and stick to them." Improved written communication may also help: the number of complaints at that trust has not risen since clinic letters have been copied to all patients, contrary to some expectations (personal communication to JC).

When something goes wrong

Patients who have been involved in an adverse incident experience not only the physical effects of the incident but also fear and loss of trust. Doctors should do all they can to reduce this emotional trauma, by apologising for the distress caused (and where appropriate for the error as well), and by being open about exactly what happened.11 If necessary, patients will lodge a formal complaint to obtain information, but patients may forgive medical errors if they are explained promptly, fully, and compassionately. The box gives guidance on effective apologies and on how to act with honesty and sensitivity in a non-confrontational manner12; an apology does not represent an admission of liability.13

The National Patient Safety Agency (an NHS body set up to identify problems relating to the safety of patients and to find appropriate solutions) has published a policy for adverse healthcare events or outcomes.14 The agency suggests that if you become aware that a potential incident has been averted-so no harm was caused-there is no requirement to inform the patient (although there may be advantages of doing so). If you become aware of an incident that has led to severe harm or death, you should notify the senior responsible clinician immediately and apologise as soon as possible to the patient and/or the carers. The senior clinician will probably set up a meeting with the patient or the patient's representative. The National Patient Safety Agency guidelines cover the running of these meetings and the follow-up of such incidents.

What to do when a patient complains

If a patient raises concerns about his or her treatment or care, the correct thing to do is to listen to them, take their concerns seriously, and answer any questions you can. This may provide sufficient reassurance, in which case you should inform the senior responsible clinician and document the discussion in the clinical notes.

If the patient wishes to make a formal complaint, you should advise them to complain to the complaints manager in the relevant NHS trust at the earliest opportunity. You can make the referral to the complaints manager on the patient's behalf, although most complaints managers will wish to avoid any intermediaries, as this can introduce delays. In fact, you may only become aware of a complaint via the complaints manager, who will usually feed back to the relevant team.

Complainants will often be extremely angry as well as experiencing fear and lack of trust. Their anger may focus on individual healthcare practitioners, including you and/or your colleagues. It may help to acknowledge the complainant's anger and to try to understand the underlying causes, but do not become distracted from treating the complaint seriously. It may also help to be aware of the effect that the complainant's anger will be having on you. Many doctors take this anger very personally, when often the cause of the anger is the adverse outcome. There may be significant inaccuracies in the complainant's perception of the situation. Try to be supportive of colleagues if you can.

If you become aware that a patient has made a complaint about you specifically, then the first thing to do is to discuss the situation with a senior colleague or your educational supervisor. You will probably be feeling upset and guilty, and you may become angry or feel disappointed in yourself even if you haven't done anything wrong: after all, most of us go into medicine to help people, not to make things worse. Other doctors have reported uncertainty about where to go for support in these situations,4 and there is no easy answer. Probably your colleagues, including allied health professionals, will be the most helpful. If necessary, staff counselling will almost certainly be available via your occupational health department. An incident such as this may make you question your choice of career.

The table ​table may be a useful aid if you are deciding how to proceed with respect to a complainant. The data are from an account of a survey (by questionnaire) of 424 patients who had initiated complaints in the Netherlands. These data suggest that the most important thing doctors can do is to admit a mistake when it has occurred.

Expectation of what the professional should do

Degree of importance accorded by patients

Very important

Important

Not important

Admit a mistake when it has occurred

84

7

2

Explain how the incident could have happened

65

14

9

Offer an apology

41

22

24

Show sympathy for what I went through

38

21

29

Make an effort to recover our relationship

15

17

53

Challenges for the future

Barriers exist to the adoption of the advice in this article about openness and explanation after adverse incidents and complaints. The advice will probably be familiar to most readers but be difficult to follow as a culture of acceptance of criticism is missing among medical professionals.15 If we are to foster openness and encourage reporting of adverse events, then support and training for doctors must be increased.

This problem may be tackled by exorcising the myth that doctors should be perfect and by emphasising the importance of teamwork. One example is the administration of intrathecal chemotherapy, which now cannot take place unless a qualified pharmacist, nurse, and physician all complete a formal checking process. Important lessons can also be learnt from the airline industry, where deaths fell by 80% when teamwork training became mandatory and safety procedures were ritualised.16

The government is working towards streamlining the complaints process both for patients and for doctors.17 Reducing the blame culture, training doctors in teamwork, and improving the flow of information is the best way to ensure safety for patients and sanity for doctors.

Notes

This series aims to help junior doctors in their daily tasks and is based on selected topics from the UK core curriculum for foundation years 1 and 2, the first two years after graduation from medical school.

Notes

We thank the general manager of the oncology department at University College London Hospital, the Patient Advice and Liaison Service at University College London Hospital, and the complaints office at that hospital for its advice.

Contributors: Both authors contributed to the conception and writing of this article. JD is the guarantor.

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

References

1. Department of Health Expert Group. An organisation with a memory London: DoH, 2000

2. Independent Complaints Advocacy Service. The first year of ICAS: 1 September 2003-31 August 2004 London: Department of Health, 2004

3. Bark P. Impact of litigation on senior clinicians: implications for risk management. Qual Health Care 1997;6(1). [ PMC free article] [ PubMed]

9. General Medical Council. Referring a doctor to the GMC: a guide for individual doctors, medical directors and clinical governance managers. London: GMC, 2007.

16. Johnson D. How the Atlantic barons learnt teamwork. BMJ 2001;322:563 [ Google Scholar]

17. Department of Health. NHS complaints reform: making things right London: DoH, 2003

Articles from The BMJ are provided here courtesy of BMJ Publishing Group

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The Competent Novice: Dealing with complaints

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This article explores why patients complain and outlines some strategies for reducing the rising number of complaints and for dealing appropriately with any that do occur

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D5: You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively.

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D5: You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively.

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Guide to GDPR

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What is the LGPD? Brazil's version of the GDPR

Brazil passed the General Data Protection Law in 2018, and it will come into effect February 2020. This article examines the GDPR vs. the LGPD, how it differs, and...

Do consumers know their GDPR data privacy rights?

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We asked 716 small business leaders in Europe about their GDPR compliance. Their answers suggest widespread ignorance about data security tools and loose adherence to the law's key privacy...

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General Data Protection Regulation (GDPR) Compliance Guidelines

# data[].attributes.attachment_link.description
What is the LGPD? Brazil's version of the GDPR Brazil passed the General Data Protection Law in 2018, and it will come into effect February 2020. This article examines the GDPR vs. the LGPD, how it differs, and... Do consumers know their GDPR data privacy rights?

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D6: You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law.

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D6: You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law.

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When we're making decisions, the Equality Act 2010 gives us a duty to take into account the need to:

eliminate discrimination, harassment and victimisation

advance equality of opportunity

foster good relations between different parts of the community

The Equality Act protects people against discrimination on the grounds of protected characteristics, of which there are 9:

age

disability

gender reassignment

marriage and civil partnership

pregnancy and maternity

race

religion or belief

sex

sexual orientation

We are required to consider all individuals in their day to day work, in shaping policy and in providing services. This is in line with the Public Sector Equality Duty ( PSED) introduced by the Equality Act 2010.

Specific duties

We are transparent about how we respond to the PSED, as required by the Equality Act 2010 (Specific Duties) Regulations 2011. We set clear equality objectives and publish information on our efforts to achieve them.

Diversity and inclusion strategy

The diversity and inclusion strategy sets out our ambitions for equality and diversity between 2018 and 2025, both in relation to staff and in providing services to the public.

This strategy ensures that, as a department, we continue to champion equality and diversity in all that we do, whether it concerns our staff or the wider public.

A refreshed diversity and inclusion strategy will be published in 2021.

Equality objectives

To support the Home Office business plan to cut crime, control immigration and stop terrorism, and to meet the requirements of the PSED the department has devised specific equality objectives.

The objectives have addressed equality issues across our functions and the services we provide. We work with stakeholders to deal with the issues that are most pressing for the department.

External benchmarking

Participating in external benchmarks helps us to understand and assess our performance against our aims, and to establish how we could use the experience of others to increase the diversity of our workforce and the inclusion in our workplaces and the services we provide.

We have previously been awarded a place in the Stonewall Top 100 Employer's Index (2020) and in 2021 we were recognised as a Disability Confident Leader, a prestigious accreditation which will last for 3 years.

Staff support networks

While external benchmarks are important opportunities to evaluate our progress towards our aspirations of being a model employer, we also recognise the immense value that staff support networks can add to our workplace and our public policy. These networks provide direct support to their members through ongoing engagement, they provide insight on the lived experience of our people and run events to keep staff and line management aware of how to respond to differing needs.

As an internal resource our networks have been instrumental in understanding how we can better engage with our stakeholders and the communities we serve.

Our internal networks take on a critical role, keeping us focused on creating an inclusive and engaged department. Some of our staff support networks are:

The NETWORK - the Home Office race equality network

ABLE - the Home Office's disability network

Spectrum - for lesbian, gay, bi and transgender staff

a:gender - the cross-government network for transgender, transsexual and intersex staff

GEN - Gender Equality Network (formerly Home Office Women)

Christian Network

Hindu Connection

Home Office Islamic Network (HOIN)

Jewish Network (J-Net)

Sikh Association

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We incorporate equality into our core objectives, making every effort to eliminate discrimination, create equal opportunities and develop good working relationships between different people.

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D7: You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace.

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D7: You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace.

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P.22 Maintaining public trust and confidence in the osteopathic profession

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D8: You must be honest and trustworthy in your professional and personal financial dealings.

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D8: You must be honest and trustworthy in your professional and personal financial dealings.

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Average fee and reasons for variations

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How much does treatment cost? - General Osteopathic Council

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This site makes use of cookies. If you continue we'll assume you are happy to receive them. However, if you prefer, you can change your cookie settings at any time.

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Cost-Effectiveness of Manual Therapy for the Management of Musculoskeletal Conditions- A Systematic Review and Narrative Synthesis of Evidence From Randomized Controlled Trials

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D9: You must support colleagues and cooperate with them to enhance patient care.

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D9: You must support colleagues and cooperate with them to enhance patient care.

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Psychology notes from a session in clinic (danish)

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Presentation I hosted in the clinic (Danish)

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D10: You must consider the contributions of other health and care professionals, to optimise patient care.

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D10: You must consider the contributions of other health and care professionals, to optimise patient care.

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P. 23 Working in partnership with healthcare providers

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D11: You must ensure that any problems with your own health do not affect your patients. You must not rely on your own assessment of the risk to patients.

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D11: You must ensure that any problems with your own health do not affect your patients. You must not rely on your own assessment of the risk to patients.

# data[].attributes.attachment_link.title
The Importance of Health Values Among Health Care Providers

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D12: You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.

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D12: You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.

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Kolbs reflection

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My case presentation from year 3

Lots of analysing and reflection

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Example of advices given to a patient of mine (danish)

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The danish board of health - Health factors (lifestyle)

Diet, Smoking, Alcohol, Activity, Sleep, Stress, Sexuality

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Indhold og afgrænsning af domænet

Selv om helbredsfaktorer om borgere og patienter indsamles ofte, har det hidtil været vanskeligt at sammenligne og dele data. Spørgsmål og svar om helbredsfaktorerne har været ustrukturerede og forskelligartede, og i forbindelse med deling af data er helbredsfaktorerne ofte nævnt som eksempel på et område med behov for standardisering, så dokumentation og efterfølgende anvendelse af data bliver optimeret.

Med begrebsarbejdet ønsker vi at opnå fælles forståelse af begreber, der anvendes til at udtrykke helbredsfaktorerne på tværs af faggrupper, organisationer, fagspecialer og sektorgrænser.

For hver enkel helbredsfaktor får centrale begreber og termer afdækket deres betydning, udarbejdet entydige definitioner og der gives anbefalinger til foretrukken sprogbrug. Arbejdet er afgrænset fra og relaterer sig ikke til helbredstilstande som eksempelvis graviditet, KOL, diabetes. Relation til disse tilstande kan etableres i fagsystemerne.

Der arbejdes med én helbredsfaktor ad gangen, og standardiseringerne offentliggøres derfor løbende, efterhånden som arbejdet bliver færdiggjort og godkendt.

Overordnet referenceramme

Målgruppen for arbejdet er alle, som udvikler spørgeskemaer, databaser og systemer til at opsamle information om helbredsfaktorer hos borgere og patienter samt dem, der vil anvende de indsamlede informationer til behandling, statistik, kvalitetsarbejde, helbredsmonitorering mv.
Søg i Begrebsbasen

Senest opdateret 30.11.2023

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Indhold og afgrænsning af domænet Selv om helbredsfaktorer om borgere og patienter indsamles ofte, har det hidtil været vanskeligt at sammenligne og dele data. Spørgsmål og svar om helbredsfaktorerne har været ustrukturerede og forskelligartede, og i forbindelse med deling af data er helbredsfaktorerne ofte nævnt som eksempel på et område med behov for standardisering, så dokumentation og efterfølgende anvendelse af data bliver optimeret.

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Year 2 assesment OCC

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Standards of practice - General Osteopathic Council

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We set and monitor practice standards and provide guidance to osteopaths to ensure that patients receive quality care.