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Rapport with patients gets hard look

Actors trained to fake an illness test West Virginia University

medical students on their bedside manner and ability to diagnose patient

problems.

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 she

had to ask me what I meant,” said Burbridge, now a fourth-year medical

student. “It’s something stupid that you wouldn’t think about. Now, it’s always

in the back of my head.”

Nationally, more medical schools are using a test similar to

the one used at WVU, according to the Federation of State Medical Boards. By

2004, all medical students may have to pass a communication and clinical test

with standardized patients before they get their license.

One of the reasons behind the test cuts to the heart of the

medical 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 a

doctor when something goes wrong.

“A lawyer once told me about the No. 1 defense to getting

sued,” said Dr. Michelle Nuss, assistant professor of medicine and psychiatry

at WVU. “If the patient likes you and you screw up, they’ll be less likely to

sue you.”

Medical students are book smart, but can they communicate with

their patients? That was one of WVU’s goals when it first made students take

the Objective Structured Clinical Examination four years ago, said Nuss, one of

two WVU professors teaching the yearlong class.

“It can be a disaster,” Nuss said. “Some students just don’t

have 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 the

next several months, said Dr. Howard Hunt, the osteopathic school’s associate

dean for clinical education.

‘A desire to seek retribution’

Not all victims of medical negligence sue. And not all

malpractice lawsuits result from doctor negligence.

So what makes some patients sue when something goes wrong when

others may not?

Four University of Rochester doctors tackled this question,

wading through 45 plaintiffs’ depositions from settled malpractice suits from

1985-87.

Here are some of the findings of their June 1994 Archives of

Internal Medicine article:

  • Plaintiffs had a bad relationship with their health-care

    provider in 71 percent of the cases.

  • Patients who were deserted by their doctors accounted for 31.5

    percent of the suits. Patients may have had trouble contacting their doctor, or

    the physician sent a surrogate — usually a medical resident — to deal with the

    patient. This is the most common relationship complaint, the study said.

  • In 29 percent of cases, the doctor did not take seriously the

    patient’s symptom or the opinion of the family or patient.

    “When the observations and opinions of patients or their

    families are summarily rejected ... and then their opinions subsequently turns

    out to be correct, their initial anger can evolve into a desire to seek

    retribution,” the report said.

    But a year later, an Archives of Internal Medicine commentary

    challenged the results.

    “Someone who is angry at a health professional or feels that he

    or she has been wronged or injured, may tend to view the doctor-patient

    relationship less sympathetically than they had at the time of the initial

    encounter,” the column states.

    According to the June 1994 issue of Lancet, a group of British

    doctors found similar results after interviewing 227 patients and relatives who

    had sued their doctor.

    More than 60 percent said the doctor gave them inaccurate or

    unclear explanations when something went wrong.

    “Patients often blame doctors not so much for the original

    mistake, as for a lack of openness or willingness to explain,” said the authors

    of “Why do people sue doctors?”

    A June 2002 report in the Journal of the American Medical

    Association added: “Patients who saw physicians with the highest number of

    lawsuits were more likely to complain that their physicians would not listen or

    return telephone calls, were rude and did not show respect.”

    The cultural divide

    But if communication is one of the reasons behind malpractice

    cases, as suggested by several studies in peer-reviewed medical journals, what

    about the plethora of doctors treating patients in West Virginia who trained

    outside the country in another culture?

    The J-1 visa program supplies West Virginia’s medically

    underserved population with doctors. The program allows foreign medical

    residents to stay in the United States after their training is complete if they

    promise 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 of

    Medicine’s complaint committee. About the same percentage of internationally

    trained physicians work at CAMC, said Andy Wessels, spokesman.

    But many of West Virginia’s doctors who trained in another

    country came from the Philippines, India or Pakistan, where they trained under

    a 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 him

    that he should have a good idea of what was wrong with a patient by just

    watching them enter the room. Doctors abroad, he said, rely more on their

    observations from listening and looking at a patient instead of a lot of

    laboratory or specialized tests.

    This is partially due to the limited resources available under

    Britain’s national health system, Faheem said

    “Several patients [here] have said they feel they get more

    attention and more time from people from abroad as compared to locally trained

    doctors,” he added.

    In 1987, the U.S. General Accounting Office looked at 31,395

    malpractice claims and found that foreign-trained doctors were not more likely

    to be sued than U.S. medical graduates.

    In West Virginia, about 38 percent of Kanawha County doctors

    sued for malpractice from 1993 to 2000 went to medical school abroad. But they

    were responsible for about half of all awards — about $20 million, according to

    board of medicine records on damage awards reported by insurance

    companies.

    A lot of the Kanawha County specialists are more at risk of

    getting sued because they perform more complicated procedures trained in

    another country, Faheem said.

    In 1998, for example, about 70 percent of the heart surgeons at

    CAMC did not train in the United States, along with about one-third of its

    neurosurgeons and general surgeons, according to a 1998 CAMC directory. But

    U.S.-trained doctors made up most of the orthopedic surgeons and

    obstetricians/gynecologists working at CAMC.

    “But unless there’s a language barrier, I don’t see why or how

    a foreign-trained physician would be lacking with his bedside manners or with

    appropriate interaction with the patients,” Faheem said.

    Foreign doctors already face more obstacles to getting a

    medical license in America. Unlike their American counterparts, internationally

    trained doctors already have to pass a communication and clinical test with

    standardized patients, among other added requirements, he said.

    Dr. Henry Taylor, the public health education program director

    for West Virginia’s Higher Education Policy Commission, authored a study that

    compared the number of lawsuits against foreign-trained doctors to physicians

    who studied in the United States.

    Taylor, former state public health officer and secretary of the

    board of medicine, could not produce a copy of the report. But he said there

    was no difference between the quality of those doctors.

    “On the surface, it makes sense,” Taylor said. “But it seems to

    depend more on the doctor’s training and personality characteristics rather

    than their country of origin.”

    Provoking fear and secrecy

    Teaching students better communication skills may make them

    better 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 of

    malpractice,” he said. “It may decrease the triggering mechanism — but it’s not

    a solution.”

    Instead, Kusminsky referred to reports by the National Academy

    of Science’s Institute of Medicine, an independent body that advises the

    federal government on technological and scientific issues.

    “Blame-worthy clinicians” aren’t to blame for a majority of

    lawsuits, according to the “To Err is Human” report. Problems result from an

    inadequate health-care system, which relies too much on handwriting, human

    memory, poor communication systems and not enough understanding of the

    consequences of fatigue, according to the report.

    The entire system needs to be reorganized. Because doctors fear

    lawsuits, they are too reluctant to report problems — even when it isn’t their

    fault.

    “This requires rare breeds of courage or foolhardiness in a

    legal climate that provokes fear and secrecy,” according to the

    report.

    The institute suggested a no-fault compensation system for

    patients who are injured by doctors or hospitals. A state or region could start

    a pilot project that gave patients an option to waive their right to a trial by

    jury when they joined a health plan or entered a hospital, according to the

    report.

    When something goes awry, an independent panel could quickly

    compensate the victim and judge whether the doctor gave substandard care.

    Doctors who participated could pay lower malpractice premiums

    if they agreed to immediately report any problems that occurred.

    Solving the problem?

    Lawmakers in West Virginia and nationwide are debating the

    merits of “tort reform,” or limits on medical malpractice lawsuits, as a way to

    slow the growth of doctors’ malpractice insurance premiums.

    Dr. James N. Thompson, executive vice president and CEO of the

    Federation of State Medical Boards, said he hopes testing medical students on

    their communication and clinical skills will tag future doctors who need more

    training.

    He also hopes the test will prove to the legal community that

    doctors are doing their part to reduce malpractice cases.

    “I think the profession is fulfilling its responsibility to be

    accountable to the public,” said Thompson, former dean at the Wake Forest

    University School of Medicine and former member of the national License

    Committee on Medical Education. “Maybe attorneys who defend patients will look

    upon us in greater favor and use this as an opportunity to push for tort

    reform.”

    According to an analysis by the Gazette-Mail, however, lawsuits

    may have nothing to do with costly malpractice premiums. The number of claims

    against the state’s doctors since 1993 has decreased and the amount of money

    spent to settle the claims has not changed, according to board of medicine

    records.

    To contact staff writer Joy Davia, use e-mail or call 348-

    1254.


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