Managing patient expectations

• A trusting therapeutic relationship and good rapport with your patients may prevent future complaints relating to mismatched expectations.
• Determine what issues are important to your patients and develop a shared understanding and responsibility for decisions.
• If it becomes clear that your expectations and those of your patient cannot be aligned, consider referring the patient to another practitioner.
• Terminating the doctor-patient relationship should be a last resort but may be unavoidable.

All patients come to a consultation with expectations about their treatment and care. These expectations may be realistic and achievable, or unrealistic and impossible. An important part of your role when planning a patient’s care is to determine what their expectations are and discuss those expectations with the patient. If a patient’s expectations are not addressed, the patient may become dissatisfied with the care.

Developing rapport with your patients can provide a good foundation for a strong therapeutic doctor-patient relationship and assist in determining patients’ expectations. It is also useful to 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 concerns. 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 “Is there 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 what you consider to be an appropriate expectation of treatment.

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 self-diagnosed conditions 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 spend 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 due to practice policy. For example, you might say “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 if 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 that the patient has an expectation that cannot be met, 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 seek a second opinion.

If neither of these options work, as a last resort, you can decline to treat the patient. However, this needs to be done carefully. You should endeavour to 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 during which 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.

There are specific requirements which apply for patients seeking cosmetic procedures. You will need to review and meet those additional requirements set by the Medical Board of Australia (Medical Board of Australia’s guidelines for cosmetic surgery).

At the end of the discussion ask the patient if they have any questions but be aware that some patients will say that they have no questions even though they do have concerns. This may be because they feel naive, 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, including any specific patient questions and the responses you provided to those questions.

There will be times when your patient has unmet expectations. Often these expectations were not voiced by the patient during the consultation, but rather afterwards to reception staff during billing. This means that you may be unaware of the issue.

It is important to encourage support staff to pass on any patient feedback to you in a timely manner. As soon as you become aware of the issue, whether through support staff or directly from the patient, 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 which you provided previously. Note that you have given this information in the patient’s records.

If it is a concern you were unaware of, work with the patient to manage 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 after treatment has concluded, it is still appropriate to contact the patient and tell them that 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 that you are sorry the patient is unhappy with the outcome. How best to do this will depend on the situation. 

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

For medico-legal advice, please contact us here, or call 1800 128 268, 24/7 in emergencies.