Author: Paul M. Lewis

Apologize, acknowledge, amends: respecting patient autonomy

Posted September 19, 2022

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

A sense of excitement and apprehension filled my thoughts as I started my first emergency department shift of clinical year. It was the tail e­nd of the latest spike of COVID-19 cases, and I steeled myself for a tense environment given the numerous notifications I had received over the past few weeks about an overwhelmed emergency department with wait times over 24 hours for in-patient transfer.

I met my preceptor for the day—Dr. Joshua Stillman, a grounded and perceptive emergency medicine veteran—who would observe and guide me through patient encounters. His gentle and approachable demeanor paired with an emphasis on learning opportunities set me at ease in this new environment, and I went to find our first patient of the shift—Mr. A. The chart listed his chief concern as a wound check. I walked into the packed waiting area and began calling the patient’s name. I received no response and continued searching among the numerous masked patients waiting to hear their name. Silence or head shakes followed each call until, I noticed a young man with bandages wrapped around his left hand rising from his seat to approach me.

“Are you Mr. A?” I asked.

“What do you think? You made me wait two hours!” he replied raising his voice.

I apologized for the delay and attempted to confirm his name again. As we walked from the waiting room to one of the emergency department stations, the patient continued to vent:

“I’m here with a wound that could have been bleeding out, and you just leave me out here for hours. Do you all even care? Of course, you don’t. It’s just another day for you, and you’ll get your money either way.”

Amidst his statements of slander and profanity, I felt like all I could do was listen, validate, and use “I wish we could…” statements. Having been on clinical year for only one month, I had a limited repertoire from my oncology and step-down unit experiences. For me, it had only been a few minutes into my shift, but for this gentleman who had been waiting with a wounded hand, it had been hours. Telling Mr. A that as a medical student I was not being paid—or more accurately I was paying to be there—felt like an inappropriate response as it would not have changed the outcome of delays in care that he experienced. I chose to focus on Mr. A by talking about his hand, but he refused to show it to me and instead continued to vent his dissatisfaction with the healthcare system.

I alerted Dr. Stillman who soon took over—he continued with heartfelt apologies and attentive acknowledgements of the patient’s frustrations, and finally asked the patient how we could make it up to him and offered to care for his wound. After a few minutes, Mr. A stormed off. We went to look for him but couldn’t find him.

I was reassured by Dr. Stillman that Mr. A would likely be back. He suggested the patient still needed to feel in control, but we had gotten through to him by being receptive to his needs. He shared his strategy for managing conflict—Three A’s: Apologize, Acknowledge, and make Amends—and his hotel analogy helped paint a clear picture of the strategy. When a hotel guest complains about dirty sheets, the hotel manager will apologize, acknowledge the mistake of dirty sheets, and make amends by offering the guest a free night or a complementary meal. The guest might still be upset in the moment, but after calming down, they usually realize that the hotel is customer centric, is on their side about the mistake, and wants to make it up to them.

About an hour later, Mr. A returned to the emergency department. He apologized, and his calm demeanor starkly contrasted his earlier presentation. We also apologized again for the past, acknowledged the initial difficulty with the hospital system, validated his frustrations, and expressed how glad we are that he returned, so we could ensure he received care.

He confided in us about his mother’s hospitalization, financial hardships, and worries of his wound impacting his employment. After examining his hand, we ordered an x-ray, cleaned, and wrapped it. Mr. A continually expressed words of appreciation throughout his visit, and he left the emergency department reassured about the state of his wound, with instructions for cleaning and pain management, and details about infection and follow-up.

For most patients, it’s encouraging to have a clinician who shows empathy, takes time, validates their worries, and respects what they have been through so far. By being gentle, respectful, and reverent, we preserved his dignity as a patient and restored his broken trust in us as caregivers. This lesson in humility has already shaped my response to other patient interactions and will remain with me for the rest of my career.

Paul M. Lewis is a third-year medical student at Columbia University Vagelos College of Physicians and Surgeons (VP&S). He holds a Bachelor of Arts degree from Harvard College where he concentrated in Neurobiology with a secondary in Global Health and Health Policy. Passionate about education, mentoring, and public health, Paul created the International Young Researchers’ Conference (IYRC), which hosts an annual Medicine and Research Summer Program at Columbia VP&S to teach youth from around the world about foundations of clinical medicine. Outside of medicine and mentoring, he enjoys immersing himself in books, novels, and stories.

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