Every physician in medical practice has at some time seen situations of past medical care that seemed inappropriate. In such situations physicians are placed in the position of determining the requirement for continuing medical care and the ethical need of patient explanation and possible disclosure of perceived medical error. Professional training in such disclosures is lacking and concerns of continued professional relationships and even fears of potential liability hinder important patient and other medical provider communications. Past studies have shown that over half of communication problems in medical care are those occurring between providers, followed closely by patient communications. Effective communication is critical in medical care and should include discussions of past care with patients.
“Jousting,” by medieval definition, involved two individuals in direct combat. However, the somewhat distorted use of the term in medical situations is an unfortunate practice of a healthcare professional making critical comments about another professional’s care, directly or indirectly, either to the patient or in the medical record. There is usually no opportunity for the other provider to respond immediately or even know about the comments. This type of commentary can appear in almost any form of communication, including oral, written and the medical record (paper or electronic). This type of “jousting” commentary represents a mistake and a self-inflicted physician problem.
How prevalent is Jousting?
One study of provider discussions with patients concerning their past care found that 29% of new provider comments supported past care and 4% were neutral. However, the remarkable statistic was that 67% were critical of the patient's past care even though it was known in this study that the past care was appropriate. The study's somewhat dramatic findings obviously cannot be extrapolated to every new provider, but the evidence of the problem has been present for many years.
The reason for jousting being a persistent occurrence is open to discussion. However, there is clearly a tendency by physicians to make conclusions about prior medical events. A critical opinion is being expressed in a failed attempt to be transparent to the patient. Also, in many cases, overworked and stressed physicians find themselves in a difficult medical situation without a good solution or immediate answer may react too quickly by blaming others or making some demeaning or highly critical comments.
Characteristics of Jousting
There are certain characteristics of jousting that have become evident over the years:
- First, critical comments about other providers are not the sole action of the current treating physician. Prior physicians may be involved as well as physician assistants, nurse practitioners, lab techs, X-ray technicians and others. In fact, all types of healthcare providers can be and have been involved in jousting situations.
- Second, virtually any form of communication within the healthcare world can be involved. Physicians and healthcare providers communicate in many ways, especially in the world of electronic communications, and any of these may include jousting. The methods can include the following:
- verbal comments intentional or unintentional,
- written comments intentional or unintentional,
- documented comments in medical record,
- electronic messaging (SMS),
- patient portal systems, and
- non-verbal communications, e.g., facial expressions or head and body movements.
- The most frequent type is the offhand comment to patients of other providers. Such comments are especially damaging in patient discussions, such as expressing surprise with a medical result, the implication being that something may have been inappropriate, or the type of treatment provided is not what a current physician would have undertaken. This type of offhand comment is usually unplanned and involves all kinds of providers. The comments clearly are not intended to cause harm, but the damage and resultant difficulties are still present no matter the intention.
- Third, there is a tendency to conclude about past patient care before knowing past facts. It is an absolute truth that the provider being critical often does not have all the facts. Also, patients may not and frequently do not know all the medical details concerning their medical situation. Therefore, they may unintentionally distort what happened in the past or may not be willing to provide all the facts to the current provider.
Potential Results of Jousting
When physicians criticize other physicians or providers, patient satisfaction and quality of care may be adversely affected. Frequently initial unsupported critical comments about another provider's care lead to reduced patient trust and compliance and increased physician liability. In one example situation of a hospitalized patient, the family practice physician received a consultation from another provider. As the medical conditions worsened, the family practice physician ordered a transfer of the patient to another facility over the objection of the consultant, who felt the patient was not stable enough for transfer. The patient died during the transfer. The consultant noted in the EHR that his advice had been ignored and he was "proven right." The entry tended to justify the position of the doctor making the entry based on the eventual bad outcome of death. The consultant may have felt some satisfaction in saying he was correct, but the documented statement was of no assistance to the patient. Both physicians were sued for malpractice.
When disagreements and jousting occur between healthcare professionals, patients easily come to very negative conclusions that the actions warrant legal action on their part, such as filing a medical malpractice claim. The jousting frequently creates an impression of injury when in reality, none may exist. Additionally, it diminishes the patient's confidence in the related physicians and healthcare in general. Every physician should remember that in problematic medical situations where one physician criticizes another, both will be at increased risk for a medical malpractice claim. An inadvisable, quick, uninformed comment with a quick conclusion may lead to very unpleasant depositions and legal action. When malpractice claims occur, defense is necessary whether or not there is physician fault. The jousting by uninformed, critical comments can easily make defense much more difficult. These inadvisable comments in the format of medical records, whether paper or EHRs, may destroy the chance of a successful defense.
Risk Management Advice
- The primary consideration is the immediate care of the patient - whatever thoughts there might be about the past care.
- All healthcare providers should refrain from use of the internet and social media to discuss a patient’s care.
- In providing appropriate care to the patient, there is usually no requirement to make an immediate and complete judgment about past medical care during a patient discussion. Speculation clearly is not necessarily the truth and will not contribute to the situation. Consider the political tactic of strategic ambiguity by not stating suspicions or just remaining silent. Remember “not only to say the right thing in the right place but far more difficult still, to leave unsaid the wrong thing at the tempting moment.” This piece of advice has been credited to Benjamin Franklin.
- The best consensus advice, especially in written documentation, is to get all the facts before making any conclusion, which would apply to verbal statements as well as written.
- A conversation with the past provider will often clarify past events and reasons for medical actions. Good advice is to use a respectful and professional approach in communication with the prior treating physician or physicians. The advisable approach is simply to talk to the involved colleague and have a private “colleague to colleague" conversation. Many feel that there is a professional responsibility for this direct approach. The discussion should be done with an attitude of finding information and not with an accusatory or confrontational attitude. The discussion should be framed in such a manner as to minimize the other physicians expected defensiveness and allow documentation of what's discussed. Using that type of discussion approach can determine what kind of disclosure is to be done and by whom. In short, there can be a joint cooperative plan on how to proceed in the patient's best interest.
- Remember that statements can be long-lasting. In an age of electronic systems, there is a high tendency for records to be permanent. Such documents may well be reviewed and discussed by many and even projected in courtroom situations, so plan with that in mind.
- Good documentation is vital to medical care and malpractice defense but avoid implying in any situation that the care is now going to be more difficult due to the actions of other physicians.
- Thoroughly document all patient encounters. There is nothing new about keeping documentation objective, and this is a critical point to remember. The documentation should only be objective and indicate the care and treatment, avoiding subjective commentary and editorializing.
- If, after the information is obtained, the patient’s past medical care seems inappropriate or incompetence is involved, other avenues can be followed with the understanding that formal reporting is a serious undertaking and cannot be based on speculation. Other forums are available, i.e., hospital governing bodies and medical boards.
There will always be room for disagreement between physicians and other providers in medical practice. But there is no place in medicine for unprofessional actions such as disrespectful and critical comments about other providers during medical care. It does not improve medical situations and creates problems for patients and providers.