Chapter 17: The Office of Medical Affairs: Patient Concerns, Patient Advocacy, Conflict Resolution

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Chapter 17: The Office of Medical Affairs: Patient Concerns, Patient Advocacy, Conflict Resolution

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Dr. Rodriguez discusses another important role of Medical Affairs: to provide support for patient who wish to voice complaints. This segment covers sources of patient complaints and distress, the importance of communication, the role of Patient Advocates and the sources of stress in that role. (She notes that patients can become abusive because they would like a second opinion to be a different, hopeful opinion, but often a lack of options is confirmed.) She notes that having an Advanced Directive conversation is a quality indicator and explains the issues that this raises. She notes that there is more emphasis now on selecting health care providers who have communication skills.

Identifier

RodriguezA_03_20150501_C17

Publication Date

5-1-2015

City

Houston, Texas

Topics Covered

An Institutional Unit; The Administrator; Building/Transforming the Institution; Multi-disciplinary Approaches; Growth and/or Change; Understanding the Institution; The History of Health Care, Patient Care; Offering Care, Compassion, Help; Patients; Cancer and Disease; Patients, Treatment, Survivors

Transcript

Alma Rodriguez, MD:

That’s our responsibility. Secondly is to ensure that we are also providing our patients with the opportunity to voice their complaints or their dissatisfaction, and that we also support patients when they have concerns about whether their care has been appropriate or ethical. So to that end, I also oversee the Clinical Ethics Group, the Physician Advocacy Group—

Tacey A. Rosolowski, PhD:

And that’s all part of this office?

Alma Rodriguez, MD:

Mm-hmm [affirmative]. I have a Conflict Resolution Advocate. And we also formed a group called—a council called the Psychosocial Council that brings to the table, really, all the domains of practice that somehow touch on psychosocial care. For example, psychiatry, psychologist or behavioral medicine, social workers, patient educators, integrated medicine services, etc. So we bring all these individuals to the table and we talk about, you know, what would be important processes for us to improve; what’s a key issue that we should be addressing. And again, from the national perspective, one of the endpoints of quality, actually, that organizations are going to be asked to report is on whether we are assessing patients for distress, and how we are addressing distress. Now, that’s a very—the word “distress” is very general. I mean, people can be distressed due to physical symptoms, but they can also be distressed due to emotional issues or economic issues or social issues, or their transportation—so it is so broad, that it is very hard to put one’s arms around it. But nonetheless, you know, there’s some—there’s some initiatives that have attempted to build, if you will, boundaries around what—how do you ask patients about distress, and what might be some of the domains of distress that are most common that should be addressed? It turns out the most common domain of distress is usually the patient has anxiety about their test reports. And once they’ve seen the doctor and gotten their test reports, they feel better. But then there’s the others that have true emotional distress or spiritual distress, or socioeconomic distress. And those domains of care really are not—you know, the Physicians are not going to be the best to provide support for those initiatives, or for that category of distress. So integrating what we call psychosocial services into the delivery paradigm in cancer care is important. So—

Tacey A. Rosolowski, PhD:

Have you seen, with the issues of patient distress and psychosocial issues, have you seen changes in the issues that are stressing patients over the course of ten years that you’ve been with the office?

Alma Rodriguez, MD:

Not really. So, I’m going to talk about the complaints more than the distress issue, because the distress question is something we push out to the patients. The complaints are something the patients initiated.

Tacey A. Rosolowski, PhD:

Yes.

Alma Rodriguez, MD:

So those are more, if you will, objectively measurable. So the most common, and still persistent issue with patient complaints is communication. And despite the fact that we now have all kinds of devices to communicate, it still remains the same thing. And part of it is—paradoxically, I think what may be happening is that the expect—people, the expectation that people have now, given that everybody emails and texts everyone everywhere on the planet, the expectation is almost that there will be an immediate response. Well, we wish we could respond to everyone, but the truth is, I am sitting here right now talking to you. If this had been somebody just wanting to know am I going to be at such-and-such a meeting at such-and-such a time, I’m not going to call them back.

Tacey A. Rosolowski, PhD:

Yeah.

Alma Rodriguez, MD:

I’m not going to answer to them. I’m here to talk to you. I’m here for you. You’re here. They’re not. They’re home or at another office, or whatever. So the social expectation of what is appropriate timeliness to communication has eroded. I mean, people used to be patient and thoughtful, I think that that’s eroding. (laughs) I think patients and thoughtfulness are eroding in our culture. And so how are we going to resolve that? I don’t know. I don’t think that there are any good solutions to that. And what is unfortunate is that this continuous barrage of asking, asking, asking puts those individuals who truly should be listened to immediately, puts them at risk.

Tacey A. Rosolowski, PhD:

Yeah, because they’re just lost.

Alma Rodriguez, MD:

They’re lost in the noise, OK?

Tacey A. Rosolowski, PhD:

Yeah. Yeah.

Alma Rodriguez, MD:

And we have not yet come up with a good solution to the true triaging, if you will, of what requires immediate response, versus not. I think this will only—I mean, this will take some time, some evolutionary process, I think, that we’ll leave the communication experts to tell us, to look, perhaps, for certain clues, certain terminology. But it’s interesting because patients get wise to that. And we knew this even way—I mean, it’s well-known in the pain literature, for example, so there are people who have true pain, and then there are people who are drug seeking. And how do you distinguish? I mean, it’s really very difficult, because pain is a purely verbalized—there’s no objective measure of pain. Although I have to say people who are truly in pain also have vital sign changes that go along with that. But then there’s also the so-called adaptation to pain, so over time, the body becomes adapted to pain. And then the vital sign signals are not there.

Tacey A. Rosolowski, PhD:

Yeah, that’s the normal.

Alma Rodriguez, MD:

So how do you know when people are really in pain? You have to go by what they say. And so again, in the noise of the saying, the pain seekers or the drug seekers versus the truly ill patients—you know, the signals are very difficult to interpret. So we know from that discipline that it is very, very difficult to separate signals of true distress from just demanding people. It’s going to be difficult. So that’s one of the challenges we face, quite frankly. That is still the number one complaint. And true complaints about the quality of care are relatively small, compared to the volume of just the “You didn’t answer my phone call,” “You didn’t tell me about this,” “The timing on my card for the appointment was wrong,” I da da da da, da da da da da.”

Tacey A. Rosolowski, PhD:

Yeah.

Alma Rodriguez, MD:

It’s continuous, continuous—

Tacey A. Rosolowski, PhD:

All the little things that seem overwhelming to people when they’re going through the cancer process. But not really, in the grand scheme, essential—

Alma Rodriguez, MD:

Correct.

Tacey A. Rosolowski, PhD:

—situations.

Alma Rodriguez, MD:

Correct. And that, unfortunately, can derail a relationship.

Tacey A. Rosolowski, PhD:

Yeah.

Alma Rodriguez, MD:

It can derail, if you will, the harmony of relationship between the patients and the providers.

Tacey A. Rosolowski, PhD:

Yeah. Yeah.

Alma Rodriguez, MD:

And that’s unfortunate.

Tacey A. Rosolowski, PhD:

What about on the issue for advocacy for Physicians?

Alma Rodriguez, MD:

Very interesting question. Are you asking do we have a body of people who advocate for the physicians? Or—

Tacey A. Rosolowski, PhD:

Yeah. You said that there was a Physician Advocacy Group.

Alma Rodriguez, MD:

No. It’s a Patient Advocacy Group.

Tacey A. Rosolowski, PhD:

Oh, a Patient Advocacy Group. I’m sorry.

Alma Rodriguez, MD:

Yes.

Tacey A. Rosolowski, PhD:

So that’s why—but maybe we could talk about the two halves of that coin.

Alma Rodriguez, MD:

Well, you know, they are an incredibly important group of people. And they put up with a lot of stress. I mean, they face a lot of stress.

Tacey A. Rosolowski, PhD:

I mean, are you talking about the p hysicians?

Alma Rodriguez, MD:

The advocates.

Tacey A. Rosolowski, PhD:

The advocates. OK.

Alma Rodriguez, MD:

And the advocates have to balance between what is a legitimate issue that the patient is facing, that we, you know, that requires immediate attention, versus what might be unrealistic expectations, what might be, in fact, what make—and it does happen—what might be in essence, unfortunately, an abusive patient that is making unrealistic demands of their provider, in which case, then, we have to take a stance for advocating for the Physician rather than the patient. And that’s incredibly—that’s an incredibly tough job, and requires a number of processes of discourse within the advocacy group. Some of them float up to my office personally, some of them—most of them, actually, they resolve themselves. There are some really interesting issues in oncology. I mean, it’s true in healthcare in general in our country. But oncology, in particular, and for our organization, because we get referrals of patients who have been treated already by their community oncologists, and they’re failing treatment. Well, I’m going to rephrase that, because the patients, obviously, would never want to fail the treatment. But their cancer is not responding to the treatment. So the patients get sent to us, and the patients expect, or hope, that we’re going to tell them differently, that there is something else that can be done, and that it will work. But unfortunately, that is not the case for many, many, many patients that are referred to us. I mean, that’s just a reality. And often, these individuals have invested a great deal of resources, both emotional psychological and economic to get here, and to hear the same narrative from us as they heard from their oncologist at home sometimes makes them very unhappy. Sometimes, frankly, abusive. And it makes, then, the dialog difficult. It makes the experience very difficult. If you ask any of the physicians here what is their biggest stressor, it is that. How to have the difficult conversations with patients who are not ready to hear that their disease is not going to have a favorable outcome. And although, there’s a lot of literature about how we should and must be having these poor prognosis conversations with our patients. In fact, one of the quality indicators is, have you discussed with your patient within the first three office visits about advanced directives?

Tacey A. Rosolowski, PhD:

Right.

Alma Rodriguez, MD:

Which the patients immediately interpret as, “You’re telling me that I’m dying, right?”

Tacey A. Rosolowski, PhD:

Right.

Alma Rodriguez, MD:

Which is not the case. For newly-diagnosed cancer patients, that’s not the case. You know, more than two thirds of newly-diagnosed cancer patients are going to be well. It’s the patients who come with recurrence of disease and/or multiply treated—multiple treatment events, those are the patients who really are not likely going to do well.

Tacey A. Rosolowski, PhD:

Well, with any, you know, with any topic that has a really big emotional charge to it, you have to plan very carefully how you situate that conversation in the midst of many other conversations.

Alma Rodriguez, MD:

And that’s the interesting thing. And so it is why it’s so interesting to me that there is now almost a mandate that we must do this. And the mandate is being placed upon the physicians. I don’t know if the public knows that, but it’s one of the national quality indicators for oncologic care. And so, as you said, you know, how do you do that in the midst of time pressure, volume pressures? You must—you know, patients have to be seen within a certain timeframe because there’s only so many rooms, right? So many hours in the day. And there are twenty patients who expected to be seen today by you, so how do you carefully orchestrate, and time, and so on? That’s the biggest stressor for Physicians today in our practice. How to have the time to have the meaningful conversations when they are appropriate, how to deal with the patients who are not ready to hear them. And how and where are those conversations best done when we do have certain external pressures.

Tacey A. Rosolowski, PhD:

And I’m even thinking, you know, backing up a few years and saying, well, how do you get the skills to have them? I mean, those are special conversations. And you know, you have to be able to bring those issues up and read people’s body language cues and all those non-verbal cues in a conversation that can help you help a person process that information. And—

Alma Rodriguez, MD:

Well, and that’s even a larger and more complex issue, which goes back to how do we select individuals for healthcare professions. And up until now it has been, or even now in most medical schools, the overriding criteria are about academic performance, they’re not about communication skills or personal skills.

Tacey A. Rosolowski, PhD:

Right.

Alma Rodriguez, MD:

Personal interaction skills. And yet, progressively, or most critically, that’s going to be an essential element.

Tacey A. Rosolowski, PhD:

Interesting.

Alma Rodriguez, MD:

So very challenging.

Tacey A. Rosolowski, PhD:

Yeah, very challenging, but a fascinating area that’s emerging. And this role, these advocacy groups, they were formed when?

Alma Rodriguez, MD:

Patient advocacy has been around for a long time. They precede me. When I joined MD Anderson, we already had Patient Advocates in this organization. I don’t know exactly the history as to how far back it goes. But I know it was well—you know, I came in here in the late 1980s, they were already here.

Tacey A. Rosolowski, PhD:

Yeah. I see.

Alma Rodriguez, MD:

So—and over time, we have expanded the numbers, obviously, as the organization has grown. And we are focusing more and more, as you said, on the issues of how do we select, you know, personal communication skills, if you will, certain philosophical perspectives. I mean, these are individuals who have to be well—for lack of a better word—well-balanced. They have to have some skills for self-care, so that they are not overwhelmed by the task at hand, and so on.

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Chapter 17: The Office of Medical Affairs: Patient Concerns, Patient Advocacy, Conflict Resolution

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