Quick guide

• A trusting therapeutic relationship and good rapport with your patients may prevent future problems with mismatched expectations.
• Determine what issues are important to your patients and develop a shared responsibility model for treatment decisions.
• If it becomes clear expectations cannot be met, consider referring the patient to another practitioner.
• Terminating the doctor-patient relationship should be a last resort.

All patients come to a consultation with expectations about their treatment and care. These may be realistic and achievable, or unrealistic and impossible. In today’s healthcare environment it is increasingly likely that patients will have informed themselves about aspects of their condition before their appointment, a factor that may contribute to their expectations. An important part of your role when planning a patient’s care is to determine what these expectations are and discuss them with the patient. If these expectations are not addressed, it can lead to the patient being dissatisfied with their care.

Determining patients’ expectations

Aim to develop a trusting therapeutic relationship and good rapport with your patients to establish a good foundation for the ongoing doctor-patient relationship and to support understanding.  Actively listen to your patient in an unhurried manner to give them the opportunity to share their story. Give the patient time to explain their story. It is important not to interrupt or pre-empt what you think the patient is trying to say. When they stop speaking ask an open-ended question such as “Anything else?” to ensure you have heard all their concerns and expectations.

Discussing and addressing unrealistic expectations

If during a discussion with a patient you become aware they have unrealistic expectations that need addressing, you should gently reinforce an accurate understanding.

Some examples of unrealistic expectations are:

• the amount of time and availability you will have for the patient
• that you will have a working diagnosis after one appointment
• that you will treat their self-diagnosed condition without a full assessment
• the outcome of a treatment or procedure
• receiving a prescription with every appointment, such as wanting an antibiotic to treat a viral illness.

If the patient has an unrealistic view about their diagnosis or treatment it is worth spending some time to identify why the patient has this view and, where possible, address and correct it.

It might be helpful to explain that you cannot meet a request in terms of practice policy, such as “Unfortunately I can’t prescribe opioids for you in this instance” or “we don’t allow live filming of procedures” it is against practice policy.

Explain that your decision is in their best interests such as, “There’s not enough time to deal with each of those issues properly. It would be better for you if we give each issue full attention. How about we deal with the most important one today and the others at your next appointment, which we can book as an extended consultation?”

Explain the clinical reasons why further tests or referrals are necessary before a definitive diagnosis can be reached such as “I will need to get some blood test results to help to work out what’s causing this”.

If after a full discussion it is clear the patient has an expectation you cannot or choose not to meet, you have a few options:

• Try to further educate the patient by giving them information to read and ask them to come back for a second appointment.
• Depending on the situation, it may be appropriate to recommend the patient seeks a second opinion.
• You can decline to treat the patient. However, you should discuss the reasons why with the patient in person and then follow the discussion with a formal letter.

Expectations with procedures and other interventions

Expectations are often identified during the consent process for a procedure or new treatment. Your approach to these discussions should be one of shared decision making where you inform the patient of the options, risks and recommendations, and equally encourage the patient to discuss with you their concerns, expectations and goals. Both parties need to take responsibility for the decisions and outcomes.

Inform your patients of what to expect during and after treatment. For example, discuss:

• the possible side effects and how they can deal with them, when to be worried and when to seek advice
• the consequences of lack of compliance with instructions
• the financial cost for the procedure and possible further costs if complications arise.

When the patient is seeking a cosmetic procedure it is important to fully explain the underlying condition or natural history of any disease process. Without a full explanation of what might occur with or without treatment, the patient may attribute the outcome to the conduct of the doctor and not to the underlying condition.

At the end of the discussion ask the patient if they have any questions but be aware that some patients will say no even though they do have concerns. This may be because they feel stupid, intimidated, rushed or confused.

Ask questions such as, “From the information I have provided today, what will you tell your family when you get home?” Doctors report that when they ask this question they are often surprised by the discrepancy between what the patient says and the information they were provided. Other questions might be:

• What do you think of the plan we have discussed today?
• Is this what you thought would happen today?
• Is there anything in the information sheet that you don’t understand?

You should document the discussion in the patient’s medical records.

What if your patient’s expectations are not met?

There will be times when your patient has unmet expectations. Often these expectations were not voiced by the patient, leaving you unprepared and unaware of the issue. As soon as you become aware of the issue, you should discuss it with the patient and identify their concerns.

If the issue was something you have previously covered, reinforce your advice and remind them of the discussion. Give them another copy of any handouts or information you provided previously.

If it is a concern you were unaware of, work with the patient to manage it and address it. If it arises during the relevant treatment course, stay in touch with your patient and monitor their progress as appropriate. If it arises afterwards, it is still appropriate to contact the patient and indicate you are aware of their concerns and encourage them to come in to discuss the issues. Addressing the patient’s concerns upfront can help avoid the situation escalating.

It can be appropriate to say you are sorry the patient is unhappy with the outcome. How best to do this will depend on the situation. Avant has additional factsheets on adverse events and responding to unwanted online feedback.

Further discussions with the patient should be documented in their medical record. If their concerns escalate to a formal complaint, correspondence regarding this should be kept separate from the patient’s medical record. For further information: Responding to direct patient complaints factsheet.

Disclaimer: This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practice proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgment or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published.