Patients’ Involvement in Decision-Making Linked to Lower Malpractice Risks
If patients are more involved in decision-making, it is less likely they will complain about the healthcare they received, according to the results of a recent study.1 “This survey was population-based in Denmark, where ‘complaints’ can include compensation claims and patient complaints about clinicians to disciplinary boards,” notes Michael J. Barry, MD, one of the authors and director of the Informed Medical Decisions Program at Massachusetts General Hospital.
Barry and colleagues gave 6,756 participants the example of prostate-specific antigen (PSA) screening in men age 45-70 years. Each participant received one of 30 different versions of a mock clinical encounter, which all differed in how much patients were involved, the patient’s decision (either PSA test or no PSA test), and the clinical outcomes. Researchers then measured respondents’ inclination to complain about care in the different scenarios. They found the urge to complain was greater if the patient was excluded from decision-making. “The main finding, that more patient involvement was related to a lower likelihood of complaint, was not surprising,” Barry offers.
The finding was consistent with earlier research.2,3 Although the authors studied the screening test offered in an outpatient setting, there are important risk implications for the ED. “When there is more than one reasonable treatment option, discussing the options with the patient and documenting the discussion may mitigate malpractice risk, especially in the event of a bad outcome,” Barry observes.
Engaging patients in decisions about their care in the ED “is critical to ensuring the best care,” emphasizes Chadd K. Kraus, DO, DrPH, FACEP, CPE, director of emergency medicine research and a staff EP at Geisinger Emergency Medicine in Danville, PA.
Patient decision-making capacity (i.e., to fully understand the risks of, benefits from, and alternatives to diagnostic tests or treatments) should be documented in the chart. Shared decision-making discussions are a great option, but so are evidence-based visual decision aids. This can help EPs describe risks for conditions such as acute coronary syndrome in patients with chest pain or possible outcomes for specific stroke treatments. “When patients are empowered to participate in decisions about their care, they are likely to have greater trust in their physician, to be more satisfied with their care, and to be less likely to fault physicians for adverse outcomes,” Kraus says.
Effective patient participation in shared decision-making in the ED works best if there is trust and a good rapport. Monika Smith, DO, MBA, suggests EPs start with casual conversation unrelated to the ED visit, such as asking about patients’ family members, pets, or hobbies. Decision aids “help EPs present information in a standardized format that includes all-important content,” says Smith, chief of the ED at Virtua Our Lady of Lourdes in Camden, NJ.
Ideally, treatment options (including risks, benefits, and alternative therapies) are discussed. The patient’s values and preferences are considered and incorporated. “Historically, one of the most common reasons for legal action is patients’ perception that providers withhold explanations or information,” Smith notes.
ED providers can mitigate this risk by making sure patients truly understand their diagnosis, treatment, and care details. “Shared decision-making is a two-way doctor-patient interaction meant to achieve a more legally and clinically robust decision than the traditional paternal model for patient-physician communication,” Smith explains.
Informed patients know more about their condition, are more likely to adhere to treatment plans, and more likely to return to the ED if their condition deteriorates, preventing bad outcomes and malpractice risks. “Engaged patients who participate in their decisions are more satisfied with their care, have more realistic expectations about benefits and harms, and feel more accountable for their outcomes,” Smith says. “This makes them less likely to pursue legal ramifications.”
- Birkeland S, Bismark M, Barry MJ, Möller S. Does greater patient involvement in healthcare decision-making affect malpractice complaints? A large case vignette survey. PLoS One 2021;16:e0254052.
- Barry MJ, Wescott PH, Reifler EJ, et al. Reactions of potential jurors to a hypothetical malpractice suit: Alleging failure to perform a prostate-specific antigen test. J Law Med Ethics 2008;36:396-402.
- Brodney S, Wescott P, Moulton B, et al. A decision aid may offer liability protection for a bad obstetrical outcome: Results of mock trials. J Law Med Ethics 2018;46:967-974.
When there is more than one reasonable treatment option, discussing the options with the patient and documenting the discussion may mitigate malpractice risk, especially in the event of a bad outcome.
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