Providing excellent patient care as an IMG

No matter where you work in the world, in medicine delivering excellent patient care is a priority. Therefore, clinicians need to understand the things that matter most to people about their care. Guidelines on delivering care may vary between countries but in the UK, many patient complaints are the result of unmet expectations that, if managed properly, could have been avoided. Dr Emma Green of Medical Protection discusses the universal principles of good communication. 

Good communication is key to an effective doctor–patient relationship and is important for all aspects of a patient’s care.

Many patient complaints are the result of unmet expectations. This is especially true within certain areas of medicine, for example laparoscopic surgery: the short hospital stay, the small scar and the anticipation that contemporary medicine is nearly perfect, all contribute to high expectations. While uncommon, it is important for the patient to understand that complications may still occur. 

The Picker Institute Europe is a not-for-profit organisation dedicated to improving patients’ experiences of healthcare by making their views heard. The following eight ‘Picker Principles’ were developed after conducting a wide range of focus groups comprising patients, family members, caregivers and clinicians.

Based on their 2019/20 Impact Report, the key principles are internationally recognised as signifiers of what matter most to all those who use care services and define the key elements that should remain in the delivery of care. These principles also fit with Good Medical Practice which is the standard expected by the GMC from doctors practicing in the UK.

Following these principles and being sensitive to these patient needs will help you to deliver exemplary patient care and reduce the likelihood of patient dissatisfaction.

Picker Principles of Person-Centred Care

1. Clear information, communication, and support for self-care
2. Continuity of care and smooth transitions
3. Involvement in decisions and respect for preferences
4. Attention to physical and environmental needs
5. Emotional support, empathy and respect
6. Involvement and support for family and carers
7. Effective treatment delivered by trusted professionals
8. Fast access to reliable healthcare advice

1. Clear information, communication and support for self-care

Understandably patients experience difficulties in assessing the technical competency of a doctor, so will frequently judge the quality of clinical competence by their interpersonal interactions. Developing good communication skills will therefore improve clinical effectiveness and reduce medicolegal risk. 

Patients want to be kept informed regarding their medical condition and involved indecision-making. Patients indicate that they want hospital staff to recognise and treat them in an atmosphere that is focused on the patient as an individual with a presenting medical condition. This means:

• Care should be provided in an atmosphere that is respectful of the individual patient and focused on quality-of-life issues
• Informed and shared decision-making is a central component of patient-centred care
• Providing the patient with dignity, respect and sensitivity to their cultural values.

Good Medical Practice paragraph 32 states that; “you must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs”. It is therefore important that doctors consider all of these elements when communicating with patients and consider what resources may be available to help. Leaflets and web resources may be helpful for some patients but not others. Consider delivering information in small, understandable chunks and avoid using jargon.

The case of Montgomery is an important court ruling relating to consent. It outlines the importance of giving patient’s enough information to make an informed decision and not make assumptions about what is important for that patient. Familiarity with this case may help with understanding the importance of giving patients the right amount of information. The GMC have also published guidance on decision making and consent.

2. Continuity of care and smooth transitions

Patients, in focus groups, expressed feeling vulnerable and powerless in the face of
illness. Proper coordination of care can ease those feelings. Patients identified three
areas in which care coordination can reduce feelings of vulnerability. They are:

• Coordination and integration of clinical care
• Coordination and integration of ancillary and support services
• Coordination and integration of frontline patient care.

Patients often express considerable anxiety about their ability to care for themselves after discharge. Meeting patient needs in this area requires staff to:

• Provide understandable, detailed information regarding medications, physical
  limitations, dietary needs, etc.
• Coordinate and plan ongoing treatment and services after discharge and ensure
  that patients and family understand this information
• Provide information regarding access to clinical, social, physical and financial
  support on a continuing basis.

Good Medical Practice states; “you must contribute to the safe transfer of patients between healthcare providers and between health and social care providers”. Medical Protection would advise doctors to consider the importance of discharge summaries and how information is communicated between providers.

3. Involvement in decisions and respect for preferences

Patients often express the fear that information is being withheld from them and that they are not being completely informed about their condition or prognosis. Based on patient interviews, hospitals can focus on three kinds of communication to reduce these fears:

• Information on clinical status, progress and prognosis
• Information on processes of care
• Information and education to facilitate autonomy, self-care and health promotion.

The GMC guidance on decision making and consent is clear that there are main principles which should be followed when having discussions with patients. It is clear that doctors should not make assumptions about what patients may or may not wish to know and that patients have a right to be involved in decisions about their care. Information should not be withheld from patients unless it would cause “serious harm”, the threshold for which can be high. Doctors should seek medicolegal advice if they are considering withholding information from patients.

4. Attention to physical and environmental needs 

From the patient’s perspective, physical care that comforts patients, especially when they are acutely ill, is one of the most elemental services that caregivers can provide. Three areas were reported as particularly important to patients:

• Pain management
• Assistance with activities and daily living needs
  Hospital surroundings and environment kept in focus, including ensuring that the patient’s needs for privacy are accommodated.
• Patient areas are kept clean and comfortable, with appropriate accessibility for visits by family and friends.

5. Emotional support, empathy and respect

Fear and anxiety associated with illness can be as debilitating as the physical effects.
Caregivers should pay particular attention to:

• Anxiety over clinical status, treatment and prognosis
• Anxiety over the impact of the illness on themselves and family
• Anxiety over the financial impact of illness.

6. Involvement and support for family and carers

Patients continually addressed the role of family and friends in the patient experience, often expressing concern about the impact illness has on family and friends. These principles of person-centred care were identified as follows:

• Accommodation, by clinicians and caregivers, of family and friends on whom the
  patient relies for social and emotional support
• Respect for and recognition of the patient “advocate’s” role in decision-making
• Support for family members as caregivers
• Recognition of the needs of family and friends

Families often face difficulties in speaking to those involved in care or getting an update of care that is being provided. Doctors should be mindful that discussions with families should consider the principles of confidentiality and should usually only take place when a patient has consented or if considered to be in the best interests of the patient.

It is also important to remember that different families may have different needs. For example, some may be unable or unwilling to visit the hospital and some may have religious considerations that need to be taken on board. You may find it helpful to speak with nursing staff about how to approach different families, or consider observing different staff speaking with families to pick up on techniques which are useful and those which are not.

7. Effective treatment delivered by trusted professionals

Positive therapeutic relationships are at the heart of person-centred care. People should receive clinically appropriate and effective care that meets their needs and is respectful of their preferences. Interactions with care professionals should inspire a true sense of confidence and trust.

8. Fast access to relevant healthcare advice

Patients need to know they can access care and advice when it is needed. There are a number of factors that may affect this, although they may not always be in your control. They include speed of assessment and treatment, the size of NHS waiting lists and previous experience. In the UK patients have the option to pay for private healthcare and may choose to do so for a number of reasons. 

• Some patients prefer to choose who treats them
• Availability of appointments when needed compared to the NHS
• Accessibility specialty services when a referral is made
• It may be reassuring for patients to know that they have more direct access to their specialist following a procedure
• Many patients simply want more time with their consultant than is possible with the NHS
• Certain procedures, whether they be medical or cosmetic, may be unavailable on the NHS

About the author

Dr Emma Green is a Medicolegal Consultant and has worked at Medical Protection for six years, previously working exclusively on medical claims. She has experience in delivering advice on all case types and regularly writes medicolegal articles and provides teaching on a range of subjects. She has worked in the NHS as an emergency medicine clinician up until 2021 and has worked closely with IMGs in the emergency department and when teaching advanced life support. Dr Green is also a GMC associate for the PLAB examination.