Originally published August 2012
Today's physicians recognize that many patients are making their well-being a priority and are often taking a more active role in managing their healthcare. Physicians should be aware of the medico-legal implications of this rise in patient engagement and of the accompanying physician accountabilities.
Patient engagement in their own healthcare
In September 2011, the Health Council of Canada (HCC) released a report on patient engagement in primary care.1 This research found that about half of Canadians feel involved and are actively participating in their healthcare. The report noted that engaged patients are happier with their care and more likely to participate in disease prevention, screenings, and health promotion activities.
Many patients want to be engaged in their own healthcare. These patients take an interest in their health, come to appointments with clear questions and concerns, are involved in their care plan, and adhere to agreed upon recommended tests and treatments. The growth of the Internet and the increasing promotion of good health have helped prompt and facilitate this engagement. Patients may carry out their own research on relevant health topics and seek in-depth explanations from their primary care and specialist physicians.
Physicians treating engaged and informed patients can usually work effectively with their patients to identify and achieve desired health goals and outcomes. If patients present with incomplete or inaccurate information, it is important for doctors to present the facts, address misinformation, and answer questions.
Patient rights and patient charters
Recognizing the increasing number of engaged and empowered patients, many healthcare organizations have developed statements about patients' rights and responsibilities. For patients, knowing and understanding their rights and responsibilities can help to make relationships with healthcare providers mutually beneficial. Patient rights often relate to treatment with respect, privacy, confidentiality, standards of care, and participation in decision-making. Patient responsibilities relate to providing complete information, keeping appointments, complying with the treatment plan, and following rules and guidelines about patient conduct.
In all Canadian jurisdictions, patients have the right to make decisions about their own health. Specifically, patients have the right to ask questions about their healthcare, and seek second opinions, if desired.
Physicians should know and respect patient rights and be aware of patient charters. Doctors may wish to discuss their approach to patient engagement and clarify areas of responsibility with their patients. When both parties meet their responsibilities, the likelihood of successful outcomes and satisfied patients grows.
Access and time with patients
Patients rely on timely access to healthcare to address their health needs. The Health Council of Canada report on patient engagement found the biggest barrier to patient engagement is time, and those patients with long waits or who felt they didn't have enough time with their doctor did not feel as engaged in their care.2
While patients recognize that waiting is often inevitable, they should be kept informed of any changes to the waiting period. Physicians should therefore be aware of their wait lists and actively manage these. Physicians remain responsible to place patients in the queue and to adjust that placement based on changing clinical priorities. The need to make reasonable attempts to manage the queue so it adapts to patients' changing clinical needs cannot be overstated. This requires telling patients how to recognize symptoms that indicate they need further medical attention. For more details, see the CMPA's publication, Wait times — a medical liability perspective.
Patients and families want and deserve sufficient time with their doctors. This includes time to follow up on current health issues, as well as time to discuss concerns or to ask questions. Physicians are encouraged to give patients the opportunity to express their health concerns, and use their clinical judgment to decide which health concerns could be deferred to a subsequent visit. While physicians need to be effective time managers today more than ever, they should always be respectful and diplomatic in their approach with patients.
Some physicians attempt to manage their time by limiting patients to one medical issue per visit. They communicate this to patients by posting signs in their offices or placing notices on their websites. This approach, however, has the potential to raise other problems and expose physicians to medico-legal risks and to complaints to medical regulatory authorities (Colleges). Colleges in a number of provinces have advised against this practice. Even though physicians are trained to be on the alert for urgent or emerging health issues while attending to patients, the risk of not detecting serious health problems may increase if patients are limited to one issue per visit. The risk may also increase if a patient misunderstands the reasons for placing limits and perceives such a policy to be rigid or insensitive.
Empowered patients will want to understand the risks and benefits of diagnostic investigations and treatments, including alternative therapeutic options, before consenting. The explanation given by the doctor, and the dialogue between doctor and patient about the proposed treatment, are important elements of the consent process. The consent form is complementary to the explanations given and is a written confirmation that the patient agreed to what was proposed. The CMPA recommends that members familiarize themselves with its guide on consent, Consent: A guide for Canadian physicians, as it outlines the obligations associated with consent.
Patient safety issues
Empowered patients are more likely aware of patient safety issues, including the importance of managing medication, controlling and preventing infection, and avoiding falls.
Moreover, engaged patients understand the value of informed consent, reporting incidents and near misses, as well as the importance of disclosing an adverse event. Physicians should be mindful of this, and follow the CMPA's advice on how to communicate with patients if an unanticipated poor clinical outcome has occurred during care. Doctors can access the CMPA's publication, Communicating with your patient about harm: Disclosure of adverse events.
Online support to patients
The growth of health websites and electronic health records are adding to patients' awareness and heightened expectations of digital information and communications. Physicians should seek to understand what their patients' expectations are of electronic communication (e.g. email, health information on physician websites, health portals), and determine how best to meet patient needs while managing the privacy requirements set by legislation and the Colleges. Physicians should be aware of privacy legislation and inform patients about the use of technology in their practice. The CMPA website has more information and guidance on protecting patient health information in an electronic environment, such as the article, "Privacy and a wired world – Protecting patient health information".
Patient engagement is also evident when groups of patients become involved in service delivery planning or in advocating for more resources. Patients may solicit physician involvement in advocacy work, recognizing the influence and profile a medical professional can bring to a specific issue. While doctors often want to support their patients, advocacy can place physicians in a precarious situation with health authorities or hospitals. The CMPA believes doctors should advocate for the interests of patients, while being cognizant that inappropriate or overzealous advocacy may be disruptive to the provision of care.
Patient engagement at the system level
In many cases, successful programming is based on patient and community involvement and needs-based planning. Patient advisory groups can also help to plan, develop, implement, and evaluate health services. Where appropriate, physicians should encourage patients to take an active role in health services planning. Doctors should try to be familiar with opportunities for patient engagement.
Patients can also engage in system-level activities, for example, by providing input and helping to plan broader community health services or health policy. In 2011, the Health Council of Canada hosted a widely-attended national symposium on patient engagement and indicated that such engagement is crucial to the future of the healthcare system. The HCC also noted that engaging patients in planning and designing healthcare services is an important means to improving the quality of care and to strengthening accountability in the system.3
By working with patients in health systems planning and in appropriate quality improvement initiatives, physicians play a central role as health system leaders. Together, patients and physicians can be a force for change and contribute positively to a high quality healthcare system.
Contact the CMPA
Physicians value patient engagement and empowerment. Engaged patients generally contribute positively and productively to their own healthcare and to the healthcare system. At the same time, patient engagement can add to the already complex healthcare environment in which members practise. Members should not hesitate to contact the Association for advice. CMPA medical officers, physicians with extensive medico-legal experience, can provide guidance on specific cases or general issues.
Health Council of Canada. "How Engaged are Canadians in their Primary Care?" September 2011. Retrieved June 2012 from: http://www.healthcouncilcanada.ca/rpt_det_gen.php?id=148&rf=2
Health Council of Canada. "Turning what we know into action: A commentary on the National Symposium on Patient Engagement." 2012. Retrieved June 2012 from: http://www.healthcouncilcanada.ca/rpt_det_gen.php?id=321