Rapport with patients gets hard look


Actors trained to fake an illness test West Virginia Universitymedical students on their bedside manner and ability to diagnose patientproblems.Two years ago, Rebecca Burbridge took the test and learned a
lesson: Stop using complicated medical terms.
“I walked into the room, asked the patient something, and shehad to ask me what I meant,” said Burbridge, now a fourth-year medicalstudent. “It’s something stupid that you wouldn’t think about. Now, it’s alwaysin the back of my head.”Nationally, more medical schools are using a test similar tothe one used at WVU, according to the Federation of State Medical Boards. By2004, all medical students may have to pass a communication and clinical testwith standardized patients before they get their license.One of the reasons behind the test cuts to the heart of themedical malpractice debate: A doctor’s ability to form a rapport with a patient
can be the defining line between a person filing a lawsuit or not suing adoctor when something goes wrong.
“A lawyer once told me about the No. 1 defense to gettingsued,” said Dr. Michelle Nuss, assistant professor of medicine and psychiatryat WVU. “If the patient likes you and you screw up, they’ll be less likely tosue you.”
Medical students are book smart, but can they communicate withtheir patients? That was one of WVU’s goals when it first made students takethe Objective Structured Clinical Examination four years ago, said Nuss, one oftwo WVU professors teaching the yearlong class.“It can be a disaster,” Nuss said. “Some students just don’thave the social and communication skills to do effective medicine.”Marshall University uses a similar evaluation on its students.The West Virginia School of Osteopathic Medicine hopes to start the test in thenext several months, said Dr. Howard Hunt, the osteopathic school’s associatedean for clinical education.‘A desire to seek retribution’Not all victims of medical negligence sue. And not allmalpractice lawsuits result from doctor negligence. So what makes some patients sue when something goes wrong whenothers may not?Four University of Rochester doctors tackled this question,wading through 45 plaintiffs’ depositions from settled malpractice suits from1985-87.Here are some of the findings of their June 1994 Archives ofInternal Medicine article:
  • Plaintiffs had a bad relationship with their health-careprovider in 71 percent of the cases.
  • Patients who were deserted by their doctors accounted for 31.5percent of the suits. Patients may have had trouble contacting their doctor, orthe physician sent a surrogate — usually a medical resident — to deal with thepatient. This is the most common relationship complaint, the study said.
  • In 29 percent of cases, the doctor did not take seriously thepatient’s symptom or the opinion of the family or patient. “When the observations and opinions of patients or theirfamilies are summarily rejected ... and then their opinions subsequently turnsout to be correct, their initial anger can evolve into a desire to seekretribution,” the report said. But a year later, an Archives of Internal Medicine commentarychallenged the results. “Someone who is angry at a health professional or feels that heor she has been wronged or injured, may tend to view the doctor-patientrelationship less sympathetically than they had at the time of the initialencounter,” the column states.According to the June 1994 issue of Lancet, a group of Britishdoctors found similar results after interviewing 227 patients and relatives whohad sued their doctor. More than 60 percent said the doctor gave them inaccurate orunclear explanations when something went wrong. “Patients often blame doctors not so much for the originalmistake, as for a lack of openness or willingness to explain,” said the authorsof “Why do people sue doctors?”A June 2002 report in the Journal of the American MedicalAssociation added: “Patients who saw physicians with the highest number oflawsuits were more likely to complain that their physicians would not listen orreturn telephone calls, were rude and did not show respect.”The cultural divideBut if communication is one of the reasons behind malpracticecases, as suggested by several studies in peer-reviewed medical journals, whatabout the plethora of doctors treating patients in West Virginia who trainedoutside the country in another culture? The J-1 visa program supplies West Virginia’s medicallyunderserved population with doctors. The program allows foreign medicalresidents to stay in the United States after their training is complete if theypromise to work in a medically underserved area. About 30 percent of West Virginia doctors are foreign-trained,said Dr. Ahmed Faheem, a Beckley psychiatrist and member of the state Board ofMedicine’s complaint committee. About the same percentage of internationallytrained physicians work at CAMC, said Andy Wessels, spokesman.But many of West Virginia’s doctors who trained in anothercountry came from the Philippines, India or Pakistan, where they trained undera British model that focuses a lot more on patient interaction, said Faheem,former president of the West Virginia State Medical Association.Faheem, who trained in India, recalled a professor telling himthat he should have a good idea of what was wrong with a patient by justwatching them enter the room. Doctors abroad, he said, rely more on theirobservations from listening and looking at a patient instead of a lot oflaboratory or specialized tests.
    This is partially due to the limited resources available underBritain’s national health system, Faheem said “Several patients [here] have said they feel they get moreattention and more time from people from abroad as compared to locally traineddoctors,” he added.In 1987, the U.S. General Accounting Office looked at 31,395malpractice claims and found that foreign-trained doctors were not more likelyto be sued than U.S. medical graduates.In West Virginia, about 38 percent of Kanawha County doctorssued for malpractice from 1993 to 2000 went to medical school abroad. But theywere responsible for about half of all awards — about $20 million, according toboard of medicine records on damage awards reported by insurancecompanies.A lot of the Kanawha County specialists are more at risk ofgetting sued because they perform more complicated procedures trained inanother country, Faheem said. In 1998, for example, about 70 percent of the heart surgeons atCAMC did not train in the United States, along with about one-third of itsneurosurgeons and general surgeons, according to a 1998 CAMC directory. ButU.S.-trained doctors made up most of the orthopedic surgeons andobstetricians/gynecologists working at CAMC.“But unless there’s a language barrier, I don’t see why or howa foreign-trained physician would be lacking with his bedside manners or withappropriate interaction with the patients,” Faheem said.Foreign doctors already face more obstacles to getting amedical license in America. Unlike their American counterparts, internationallytrained doctors already have to pass a communication and clinical test withstandardized patients, among other added requirements, he said.Dr. Henry Taylor, the public health education program directorfor West Virginia’s Higher Education Policy Commission, authored a study thatcompared the number of lawsuits against foreign-trained doctors to physicianswho studied in the United States.Taylor, former state public health officer and secretary of theboard of medicine, could not produce a copy of the report. But he said therewas no difference between the quality of those doctors.“On the surface, it makes sense,” Taylor said. “But it seems todepend more on the doctor’s training and personality characteristics ratherthan their country of origin.”Provoking fear and secrecyTeaching students better communication skills may make thembetter doctors, but it won’t decrease the number of medical malpractice cases,said Dr. Roberto Kusminsky, a Charleston surgeon.“Teaching better behavior will not solve the problem ofmalpractice,” he said. “It may decrease the triggering mechanism — but it’s nota solution.”Instead, Kusminsky referred to reports by the National Academyof Science’s Institute of Medicine, an independent body that advises thefederal government on technological and scientific issues.“Blame-worthy clinicians” aren’t to blame for a majority oflawsuits, according to the “To Err is Human” report. Problems result from aninadequate health-care system, which relies too much on handwriting, humanmemory, poor communication systems and not enough understanding of theconsequences of fatigue, according to the report.The entire system needs to be reorganized. Because doctors fearlawsuits, they are too reluctant to report problems — even when it isn’t theirfault.“This requires rare breeds of courage or foolhardiness in alegal climate that provokes fear and secrecy,” according to thereport.The institute suggested a no-fault compensation system forpatients who are injured by doctors or hospitals. A state or region could starta pilot project that gave patients an option to waive their right to a trial byjury when they joined a health plan or entered a hospital, according to thereport.When something goes awry, an independent panel could quicklycompensate the victim and judge whether the doctor gave substandard care.Doctors who participated could pay lower malpractice premiumsif they agreed to immediately report any problems that occurred. Solving the problem?Lawmakers in West Virginia and nationwide are debating themerits of “tort reform,” or limits on medical malpractice lawsuits, as a way toslow the growth of doctors’ malpractice insurance premiums.Dr. James N. Thompson, executive vice president and CEO of theFederation of State Medical Boards, said he hopes testing medical students ontheir communication and clinical skills will tag future doctors who need moretraining. He also hopes the test will prove to the legal community thatdoctors are doing their part to reduce malpractice cases.“I think the profession is fulfilling its responsibility to beaccountable to the public,” said Thompson, former dean at the Wake ForestUniversity School of Medicine and former member of the national LicenseCommittee on Medical Education. “Maybe attorneys who defend patients will lookupon us in greater favor and use this as an opportunity to push for tortreform.”According to an analysis by the Gazette-Mail, however, lawsuitsmay have nothing to do with costly malpractice premiums. The number of claimsagainst the state’s doctors since 1993 has decreased and the amount of moneyspent to settle the claims has not changed, according to board of medicinerecords.To contact staff writer Joy Davia, use e-mail or call 348-1254.
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