Patient Advocacy: Are We Measuring Success by Intentions or Actions?

Most healthcare providers are inclined to refer to themselves as “patient advocates.” But, to what lengths would you say you truly go for your wound care patients? Do you always ensure that each patient understands what the agenda is during each individual visit? Are you certain that each patient always has ample time to ask questions and/or discuss concerns? Do you always explain how the coordination of care will unfold in advance of starting a care plan in an attempt to minimize those questions and concerns? Do you always address a patient graciously when he/she has a complaint? Do you always explain to patients the available choices of care so that they can help decide on which interventions to utilize? A typical issue that this author encounters frequently among wound clinics, and is a cause for concern, is when physicians fail to offer appropriate, necessary, objective testing before providing care that deviates from the norm or recommending an amputation. In today’s healthcare environment, we as providers often experience constraints that can threaten our ability to deliver optimal care, such as (to name a few) limited time, tight budgets, insurance difficulties, transportation issues (for patients), administrative red tape, and availability of education. We live and work at such a rapid pace that, as much as it pains me to say it, communication continues to suffer and a large number of clinicians do not seek educational opportunities due to time constraints. This tends to result in many of us relying on “what we know best,” which could be old, outdated data. Consequently, by the time some clinicians regularly employ newer evidence-based modalities, they may be a bit dated or, far worse, perhaps proven to be a failure by others. In the ideal world, we all would be able to provide the best possible patient experiences; but, realistically, we fail to accomplish this because we do fall short on providing true patient advocacy to the fullest extent possible (even when considering the difficult challenges we face each day). This column will offer advice on how we as an industry might be able to better support optimal patient advocacy in our wound clinics.   

COMPONETS OF ADVOCACY

There are many components related to patient advocacy that shouldn’t be overlooked when managing the day-to-day operations of a wound clinic — though they may be easy to neglect. And data tells us (almost) everything we need to know. Healing rates, including risk-stratified results and days to heal, as well as patient satisfaction scores and cancellation rates, are merely a few types of data points that offer proof as to whether or not we are providing the necessary, appropriate interventions and positive patient experiences. So, how do we try to ensure that our patients are getting what they need as well as what they expect? Many hospitals today are inclined to give individuals the title of “patient advocate.” While I once saw this as a positive approach, even to the extent that I considered myself to be the patient advocate for our health system (which does not offer the designation), my views on this have changed. We should not have one designated person to serve as the advocate because everyone who comes into contact with any patient should be considered a patient advocate. I am not a proponent of adding more responsibilities and processes to an already busy staff, but relying on one individual (or a few individuals) to enforce the patient advocacy of a healthcare staff ignores the true intent of advocacy. Let’s discuss what a true patient advocate is by definition. Merriam-Webster defines an advocate as “one who supports or promotes the interests of a cause or group.” According to the Institute for Healthcare Improvement, the role of the patient advocate is to be a “supporter, believer, sponsor, promoter, campaigner, backer, or spokesperson,” even if some of these descriptors seem to run together. Effective advocates are those whom patients trust are willing to act on their behalf as well as those who work well with other members of the healthcare team. To be an advocate, you must focus on patients’ needs and their quality of care, as well as ensure that their voices are not just heard but listened to, understood, and appreciated. As professionals, we all chose to enter this field to help others and to do right by those whom we serve. Physicians have historically taken the Hippocratic Oath for maintaining ethical standards, the modern version of which states that doctors will take care of the sick, avoid overtreatment and therapeutic nihilism, and not be ashamed to say, “I know not, nor will I fail to call in my colleague when the skills of another are needed for a patient’s recovery.” Similarly, the Nightingale Pledge for nurses is a modified version of the Hippocratic Oath that instructs nurses to do their best for their patients upon graduation. While this pledge has been altered (and even dropped) by some institutions, the tradition is widely known and recognized, and provides a baseline for ethics and advocacy before individuals begin practicing healthcare. 

UNCOMFORTABLE VS. NONCOMPLIANT

In my experience, which surely mimics the experiences of everyone reading this column, patients have often required assistance while navigating a complex healthcare environment that continues to rapidly change. Wound care patients in particular may not understand why they have a nonhealing ulcer, and they may have never set foot in a clinic for treatment prior to entering your care. They may not understand everything the physicians communicate to them or what they are being asked to do related to providing self-care at home. They may be unsettled while in a healthcare facility. They may have received less-than-optimal care somewhere else. They may perceive that their care will be costly and/or painful. Healthcare providers are often quick to label patients as “noncompliant.” Before we decide that to be true, however, we all should ask ourselves (and, more appropriately perhaps, our peers and patients) if we are doing better than an adequate job in assisting patients with all of their needs. To gauge your own level of advocacy, try asking your patients and your peers to rate you on the following qualities:

• knowledge and competency
• verbal communication 
• compassion
• attitude/disposition 
• listening skills
• ability to follow through and to make changes.

Specifically, effective communication is important when working with patients. What the patient says and what we hear should not be two vastly different messages. One rule of thumb is that patients will tell you 90% of what’s wrong if they’re allowed to talk for 3-4 minutes. According to an article published in 2015, physicians, on average, interrupt patients’ narratives of their symptoms after only 18 seconds.1 Keep in mind that the opposite of advocacy is to discourage, conceal, deny, dissuade, hinder, oppose, undermine, criticize, disapprove, refuse, protest, and so on. If any of these terms sounds like something you may have done, your advocacy may be rightfully called into question. 

Let me leave you with a real-life example. Let me preface this example by saying that I have been known to tell my administrators, my staff, and those I meet within this field that I would rather lose my job for standing up and doing what’s right by the patient than not. With that said, a patient who lives with diabetes was recently admitted to the hospital for management of an infected foot ulcer. The perception on admission by the staff was that she was going to be ok. Shortly thereafter, a physician told her that she would be scheduled to have a foot amputated on the following day. The patient and her husband were upset and demanded answers, not to mention that they wanted to speak to a lawyer. As the director of our wound care service line, I met with the couple along with my administration. Thankfully, I had previously attended an education session by Kevin W. Yankowsky, JD, and remembered learning that patients will sue in order to get the answers they seek. So, I gave honest answers, even suggesting that they get a second opinion from another hospital. That helped me establish trust, and I then looked further into the case while working with the physician to reassess his findings in an attempt to avoid amputation. The foot did not require amputation after all, and a successful outcome was reached. 

Frank Aviles Jr. is wound care service line director at Natchitoches Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapist/wound care consultant at Louisiana Extended Care Hospital, Lafayette, LA; and physical therapist/wound care consultant at Cane River Therapy Services LLC, Natchitoches.

Reference

1.    Joshi N. Doctor, Shut Up and Listen. New York Times. 2015. Accessed online: www.nytimes.com/2015/01/05/opinion/doctor-shut-up-and-listen.html