Danielle Ofri, MD, who wrote this book on patient-doctor communication is a chip off the old block. Her book explores the practice of medicine as patients often experience it and reflects on how that looks on the other (doctor’s) side. Her stories are familiar in that I have shared virtually all of her related experiences and came to similar conclusions.
One problem exacerbated by modern medical systems is brought to mind by an unrelated story: I was traveling on United Airlines back in the day. The man in front of me had a Southern accent and was obese (speaks to prejudice). As soon as the wheels left the tarmac, with no warning, he adjusted his seat position full back and jammed my knee (speaks to unexpected behavior and resulting discomfort). I reacted loudly and slammed the back of his headrest in frustration (speaks non productive responses). He nearly came out of his seat. “What is your problem,” was his question. I told him. He did not care (which is yet a different problem) but I reflected on the root cause—the seats by intention were too close together and it was physically impossible for the seat to not be pressed fully back without hitting the knees of someone my height. They were packing us in to maximize the number of passengers on the flight (speaks to the design of how we were likely interact, all other things equal). That is a design problem if customer service and satisfaction are your endpoints. Most airlines, for the steerage compartment in any case, give only lip service to such goals (and your doctor, like airlines, should strive to improve on that) .
Medical systems are similarly faced with economic and quality issues that reflect design flaws that all of us have experienced.
She (the author) starts with communication which superficially is not a design issue made up by modern medical practices. It is pointed out that the jargon of doctors reflects prejudice and the patient is the object of that prejudice. This prejudice goes back to ancient times. We say,
“The patient failed chemotherapy.”
“The patient refused radiation therapy.”
“The patient was non-compliant.”
“The patient was a poor historian.”
That last is my personal favorite as I have used it often. We doctors are mostly blind to the implications of these stereotyped and deeply entrenched expressions but would also mostly agree that chemotherapy often fails the patient, and if asked, many of us would refuse radiation therapy, and doctors are no more compliant with medical treatments prescribed to them than the public……My wife will tell you I am often the one who is a poor historian……
Exploring the science of communication, one learns some obvious and not so obvious things. It is a two way process, so the patient owns some of the communication difficulties when encountered, just as a doctor does.
The patient needs to tell a story, sometimes packed with emotion or a situation their problem caused. The Doctor wants basic facts to flesh out an algorithm of what the possible problems are with an eye on what to do about it. While listening to the patient (if indeed, the doctor is listening) clarifying questions and possible tests are catching his/her attention. Details of the history are lost or not considered.
If the patient perceives that the doctor is not really paying attention to their story, (normal social norms apply: eye contact, body language, and clarifying questions) their delivery of the story can change — to test out how to better get the needed attention. This often does not go well; the communication can spiral downhill.
Doctors use jargon: “Did you get an Echo? Sounds like you may have been septic. Our armamentarium of drugs has yet to provide you with a cure.”
Patients use jargon: "I was dizzy," a word that has many meanings and is often misused."
“She had bad blood. They told me I might have a hole in my heart.” My favorite? “The Doctor told me I had fireballs of the Eucharist!” Translation: she had fibroids of the uterus.
At times, the real reason a patient came is difficult to bring up. The topics and focus of the visit meanders. The doctor looks at their watch and realize they still are’t sure what they need to do next but they are running twenty minutes behind schedule. Closing statements are given, the hand is on the door and the patient says, “Say Doc, is it normal to poop blood?” No, it is not and the history and exam to clarify a next step takes some time. This scenario is common and for doctors, very frustrating. How to improve?
One strategy taught to prevent this is to ask, "You made an appointment with me; what is the problem you are hoping I can help you with?" You give the patient a chance to state their problem without interruption. You summarize what they said. Then you ask, "Is there anything else?" You ask that until the patient can't think of anything else. THEN you prioritize with the patient which can realistically be addressed this visit.
Can you teach doctors who are innately poor communicators how to improve? Yes and no. There are pneumonic tools to help pay attention to effective communication tactics. Ask the patient why they are there. Don’t rush them—let them tell you the story without interruption. Make eye contact. Summarize what they say. If the story has sadness or pain in it, empathize. I learned most of these things on the job and saw their value. When there was a card next to the keyboard to remind me to do these things, I did not refer to it though when I lost my way with a particularly challenging patient (sometimes a patient can push your buttons), it might have been useful.
Of interest, I read years ago that college students could make reasonable predictions of, “likelihood to be sued for malpractice’” when watching short 5 second clips of physicians speaking to patients—-even when the words were intentionally garbled. The tone of speech and body language was all there was left and one can predict the likelihood of a law suit based on that alone. Effective communication is an over looked and cost-saving tool from so many points of view.
We doctors all lose our way. The system of providing medical care, even before computers was a set-up to fail with quality, service, and efficiency as markers for a good patient-doctor interaction. I have a Victorian era cartoon of a doctor on skates skating by a row of patients, all sticking their tongues out for inspection. Today, if your doctor takes insurance, he/she is graded on the quality of care delivered as measured by immunization rates, cancer screening rates, and perhaps hospitalization and mortality data. Patients are asked to put a number to their satisfaction of the visit with the doctor; this data is organized and provided to the doctor periodically and is part of contract negotiations. Payment from, not to mention participation with, insurance plans can depend on these things as well as the volume of visits. Spending an hour and communicating really well does not get you paid nearly enough.
A common scenario: a middle aged patient with diabetes and hypertension presents for back pain. While listening to the story of how the back pain evolved, how limiting it is, and how nothing has helped it get better, the doctor clarifies if there are "red flags" suggesting something scary about the back pain and if absent, multi-tasks with concerns about recent testing, and today’s blood pressure being a little high. A reminder pops up that a mammogram is overdue. The last tetanus shot was over ten years ago and the patient has never been immunized for Shingles.
The doctor can sort out relatively quickly that the back problem is benign, a nuisance, and will pretty much take care of itself or with a short structured care plan. Back pain like this will not kill you. Hypertension and Diabetes can kill you or leave you disabled. The pressure builds and the communication falters. If you are “score” oriented as many young doctors are, your need to check the boxes of problems addressed overrides any reasonable attempt to effectively communicate with such a patient with their specific problem at hand—the one about which they came to see you. It is a balancing act. It helps to have a relationship with the patient when working through these variables. Seeing a different doctor each visit makes this problem worse.
With respect to that treatment plan, it turns out communication really matters. If you give an IV dose of a narcotic to someone in pain and tell them, “this is really going to help, you watch,” their pain scores improve much better than if you ask them what they would like for lunch as you inject the medication. In fact if you don’t inject the medication and give a positive prediction, they do better. And if you give the same narcotic and say, “This is not likely to help much but it is all we have,” the pain score will not improve. This principle applies to virtually any treatment plan a doctor and patient discuss. We build expectations with our words and often are blind to the specifics of what expectations are being developed. Having experience with a patient helps build the vocabulary that will work best for them.
When I was young, in an attempt to be ethical, I presented a just-retired mail worker with a terminal diagnosis—he had metastatic liver cancer diagnosed in the setting of grave illness in the hospital. I was empathetic, made good eye contact, and was kind —but unsparing in the details of what this meant. I thought I did a good job. I left the room, his wife following me, and she fired me on the spot. “You just took any hope he might have. You tore it up and threw it in the trash. Shame on you.” I was later troubled by the fact that he spent over $100,000 on Laetrile treatments in Mexico. I had to rethink the point and style of communicating bad news. I decided with time to be honest, and give basic information and let the patient come to me with questions and clarifications on their own terms. I now take the long view for the patient even as my internal voice is saying something very different ( I still want to be complete, wrap it up with a bow and be done). I knew a terminally ill patient with months to live and who was virtually bed bound who planned a trip to Europe—she had never been—before she died. She never openly acknowledged her coming death. I freaked out at such planning and “what if…” but then took a breath and held to the long view: eye contact, clarifying open ended questions, and empathy. Despite the plans, she stayed put and died in hospice—the satisfaction of the European fantasy a plus.
I filled in for another doctor once, and saw a middle aged woman with intractable arthritic pain in her left knee. She was obese. I took her history, examined her knee, looked at the X ray, and reviewed the problem. She was a bit young for a knee replacement so medical therapies were what she would continue to use. I could not refrain from telling her that the problem would be helped if she lost weight. I told this to a woman I had never met before. She complained about my insensitivity and my “service marks” for that quarter noted her complaint. Most doctors hearing my frustration over this thought they would have done exactly what I did but as I thought on it further, I disagreed. I learned long ago that berating patients-however kindly- for their “poor lifestyle choices” is a clearly ineffective strategy—even if you do it well. You can check the box: “I warned them smoking was bad for them.” Patients know when their lifestyle choices are bad. The communication trick is to not belabor the issue but align with them emotionally, a long strategy to be sure, and ask questions that help them think through their options. It requires a relationship to be effective. My “intervention” should have been deferred and the primary care doctor for this patient would have done a better job. Motivational Interviewing (look it up!) is a wonderful tool for effectively communicating concerns, exploring options, respectfully and in a relatively efficient time frame.
The book has a chapter: Chief Listening Officer and it tells the story of a Dutch woman who made a career of helping to foster doctor-patient communication. Interestingly it started with her having to come to the aid of her estranged and psychologically damaged mother in the face of a cancer diagnosis. The doctors were planning a treatment plan to suppress the incurable cancer and the daughter told them, “She may not want to do that.” The doctors were astounded. How could she not want to be treated? “Ask her,” was the response. The mother refused and died under Hospice. This process stimulated a career. For a hospital that was failing its patients on many levels, she was designated “Chief Listening Officer” and she took the time to effectively communicate with patients and then translate what she learned into suggested policy changes. The hospital ’s performance improved. She now runs a consulting firm that helps people with communication in health care. She is aware of the pressures on doctors to cut to the chase and she is aware of the need for patients to tell their stories. She helps coach them on prioritizing what is most important about that next medical visit, and how to tell the story clearly and in a compelling way so as to start the visit off correctly and facilitate the doctor’s many jobs. THAT is a great exercise for all of us: the elevator speech with prioritized concerns for ones next doctor visit, automobile service check with squeaks to be sorted, the tax consultant, or the conversation with a friend about the loan they need.
I wish doctors would take this on as well. It was common for me to see a patient within weeks after a hospitalization. I was fascinated that they often had no clue what the names of their doctors in the hospital were. If asked about discharge instructions, they often opened a folder with twenty pages of single spaced typewritten nonsense. Relevant information was in there but I had trouble finding it—at the clock was ticking. A summary discharge instruction to a patient from the hospital or clinic should be easy to read and a direct communication with simple “to do’s.” Too few of us take the time to write that even though the benefit (Oh, I take the cholesterol medicine at night time!) is clear.
She makes note that perhaps 10-15% of the US population is functionally illiterate…..we doctors rarely take this into consideration as we type away. Occasionally, patients are poisoned by their spouses. We never consider that possibility………
She devotes some time to prejudice. She notes medical doctors in the US have a bad track record with respect to care provided to minorities. Diagnoses considered, treatment options, including pain medication are demonstrably different in many studies when comparing minorities to white people. If communicating clearly, both ways, is a root cause, this history adds to the difficulty trying to get that right. She points to a different prejudice: how do doctors communicate with morbidly obese people, drug addicts, people with personality disorders, and so on. When I began my private practice in Salinas, I did operative obstetrics and as a family practitioner. This drew prejudicial attitudes on the part of the OB-GYN’s at my new hospital. They did not believe Family Doctors should be doing C-Sections. “Fine, you have surgical privileges so you can take community call, like the rest of us,” was a comment I heard. Taking community call was considered odious by this group and I was being punished having to share that duty with them. Community Call meant taking unknown patients, often with no prenatal care and more importantly, unclear means to pay for services. I had been helping such patients my whole residency at the county hospital so I was not sure I understood this prejudice. Some of the best patients of my medical practice in Salinas came to me because of this “duty.” I did not share the same prejudice as my OB-GYN colleagues even as I understood the difficulty of helping people who did not communicate well or had made less than optimal choices about their health and life. The reality is that we all have people who “trigger” in us less than desirable communication styles and responses. The “why” is deeply rooted and even with great effort, unlikely to be trained away. Our author returns to “blocking and tackling.” Take time to listen, clarify, empathize, ask questions and wait for the answers. Collaborate. Set realistic goals and have a long time frame for seeing them bear fruit.
Good advice for those of us not in the medical profession as well.
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