THE EXPERIENCE OF MALAYSIAN NEUROSURGEONS WITH PHYSICIAN-PATIENT CONFLICT IN THE AFTERMATH OF ADVERSE MEDICAL EVENTS – A HEURISTIC STUDY by RICHARD VEERAPEN MB,BS, Panjab University, 1976 LL.B (Hons) Wolverhampton University, 1999 LL.M (Medical Law), University of Northumbria, 2003 A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Arts in Dispute Resolution, School of Public Administration Richard Veerapen, 2009 University of Victoria All rights reserved. This thesis may not be reproduced in whole or in part, by photocopy or other means, without the permission of the author. ii SUPERVISORY COMMITTEE THE EXPERIENCE OF MALAYSIAN NEUROSURGEONS WITH PHYSICIAN-PATIENT CONFLICT IN THE AFTERMATH OF ADVERSE MEDICAL EVENTS – A HEURISTIC STUDY by RICHARD VEERAPEN MB,BS, Panjab University, 1976 LL.B (Hons) Wolverhampton University, 1999 LL.M (Medical Law), University of Northumbria, 2003 Dr. Eike-Henner Kluge, Department of Philosophy, University of Victoria Supervisor Dr. Patricia MacKenzie Departmental Member Dr. Peter Stephenson, Department of Anthropology Outside Member iii ABSTRACT Supervisory Committee Dr. Eike-Henner Kluge, Department of Philosophy Supervisor Dr. Patricia MacKenzie, School of Social Work and Institute for Dispute Resolution Departmental Member Dr. Peter Stephenson, Department of Anthropology Outside Member This research examines the experiences of Malaysian Neurosurgeons in managing communications with patients and their families in the aftermath of adverse medical events. These experiences were interpreted from a conflict avoidance and management perspective and the data from the research was analyzed using heuristic methodology. (Douglass and Moustakas 1985) The field of Neurosurgery in Malaysia was chosen firstly as a model of a high-risk medical specialty and secondly because of the researcher’s lived experience with the phenomenon being studied. Participants in the research were eleven Malaysian Neurosurgeons with at least ten years of independent clinical practice as specialists. Qualitative data was obtained through semi-structured in-depth interviews that were subsequently transcribed and analyzed heuristically, looking for different conflict management and patient-physician communication themes. The observations indicate that adverse medical events precipitate a major shift in the focus of tacit conflict management skill sets applied by the participants. The patient- Neurosurgeon relationship is abruptly transformed from one of high trust to one imbued with patient anxiety and suspicion of malpractice or medical error, and physician defensiveness. The observations also indicate that in multicultural Malaysia physician-family relationships were prioritized more than would be expected in a Western context. This may have implications for humanistic and interactive skills training for medical students and residents. iv TABLE OF CONTENTS SUPERVISORY COMMITTEE ......................................................................................... II ABSTRACT .................................................................................................................. III TABLE OF CONTENTS .................................................................................................. IV ACKNOWLEDGMENTS ................................................................................................ VI DEDICATION.............................................................................................................. VII CHAPTER 1: INTRODUCTION........................................................................................ 1 Brief summary of research focus....................................................................................1 Significance of the study.................................................................................................1 Research design..............................................................................................................2 CHAPTER 2: BACKGROUND INFORMATION.................................................................. 3 Context of research – Malaysia ......................................................................................3 Healthcare systems ....................................................................................................3 Multiculturalism .........................................................................................................5 Urbanization ...............................................................................................................6 Medicolegal environment ..........................................................................................6 Autobiographical elements ............................................................................................7 CHAPTER 3: LITERATURE REVIEW ................................................................................ 8 The patient-physician relationship .................................................................................8 Trust............................................................................................................................8 Conflict in the patient-physician relationship...........................................................10 Adverse medical events................................................................................................12 Error disclosure.............................................................................................................13 Apology.........................................................................................................................16 Physician Factors in the patient-physician relationship ...............................................17 Cultural considerations in patient-physician interactions............................................20 CHAPTER 4: THEORETICAL FOUNDATIONS................................................................. 23 Research aims and questions .......................................................................................23 Theory and conceptual framework ..............................................................................27 High-risk....................................................................................................................27 Medical error, adverse events and malpractice litigation........................................28 ‘Tacit knowing’ and conflict management by physicians .........................................29 Heuristic Inquiry .......................................................................................................30 CHAPTER 5: RESEARCH .............................................................................................. 36 Overview of chapter .................................................................................................36 Data collection method ............................................................................................36 Recruitment of participants......................................................................................39 v Interview questions ..................................................................................................40 Data collection..........................................................................................................40 Confidentiality protection ........................................................................................42 CHAPTER 6: DATA ANALYSIS...................................................................................... 43 Central components of analysis................................................................................43 Process of analysis....................................................................................................44 CHAPTER 7: OBSERVATIONS ..................................................................................... 45 Introduction and overview of main theme...............................................................45 Individual Depictions ................................................................................................46 Composite depictions and thematic elements of the experience of conflict management. ...............................................................................................................52 A. Strategies for communication with family members ...........................................55 B. Socio-cultural factors............................................................................................60 C. Impact of local medicolegal discourse and risk of negative publicity...................62 D. Fee waivers and discounts ...................................................................................66 Illustrative portraits..................................................................................................67 Summary...................................................................................................................73 CHAPTER 8: SUMMARY AND DISCUSSION ................................................................. 74 Overview.......................................................................................................................74 Socio-cultural ‘diagnoses’ of patients and families and the nature of physician communication skills ................................................................................................74 Impact of the local medicolegal discourse on Malaysian Neurosurgeons................79