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Clinical Scenario
Mrs. Jones is a 38-year-old woman who has returned to Dr. Smith’s office to learn the results of focused imaging and a fine needle aspiration biopsy of a large unilateral neck mass, which was performed the prior week. Mrs. Jones is accompanied by her husband and young adult daughter, and all are quite anxious to receive the results. Dr. Smith enters the room, greets the family, and, while standing and leaning against the cabinet, tells Mrs. Jones that the diagnosis has been made.
Dr. Smith: You have Hodgkin’s disease, which is a proliferative neoplasm of the lymphoid tissues in the body.
Mrs. Jones: Wha– what does that mean?
Dr. Smith: It means you have cancer in the neck, Mrs. Jones.
Mrs. Jones: (Gasps.) Oh, no! How could that be? I’ve been in good health and I don’t have any history of cancer in my immediate family.
Dr. Smith: Well, sometimes these things just happen. I’ll refer you to a medical oncologist who will continue the evaluation to stage the cancer and treat you. She’ll conduct the follow-up exams, so I won’t need to see you back.
Mrs. Jones: But, what are my chances, Dr. Smith? And, what about the risk that my daughter will get it?
Dr. Smith: Now, no need to worry yourself about this. This is easily treated and the risk to your daughter is really quite low. Just go out for a nice dinner and a good night’s sleep. You will hear from the oncologist’s office to schedule an appointment with her. Have a nice day.
Mrs. Jones: What do you mean about not to worry? How can I keep from worrying?
Dr. Smith: Mrs. Jones, I’m sure you’ll do just fine—you’ll probably live to be 100!
In the car on the way home, Mrs. Jones says to her family, “Well, it doesn’t sound too bad if I’m going to live to be 100 years old, right?”
What are the five ways this patient interaction could have been done differently? See below for a discussion.
Discussion
One of the hardest responsibilities physicians need to learn in medical training is how to effectively communicate with patients in a manner that respects their autonomy, engenders trust, and provides information that’s critical to the patient’s understanding of his or her disease and treatment. Experience in communicating with others begins in childhood and is often a product of the examples set in the home and in the educational system. There is a range of personal capabilities and comfortableness among healthcare providers in their ability to communicate effectively with patients: Some are very good at it, some are not so good, and the rest of us try to do our best. Fortunately, there’s always room for improvement, and that can be a professional goal.
As someone who has taught medical students and residents for 50 years, I find that young trainees most often make the communication mistake of using terminology that’s stilted, too sophisticated, and often poorly understood by the patient. I trained at a medical school that had a high population of rural patients, most of whom I could relate to because I came from that same background. Too often I’ve heard a resident physician explain to a patient, “You have a high nasal septal deviation that’s impinging on the middle turbinate and causing sphenopalatine neuralgia,” or some such description of the pathology in confusing terminology. And I have seen the blank look on the patient’s face as they turn to me to decipher the language of medicine for them. Words do matter, especially when the patient doesn’t understand them.
So, how do we teach trainees to consider the words they use and decide what form of explanation should be used to educate a patient? One of the best ways to teach is to emulate proper communication through your own discussions with patients when trainees are present. Sometimes, a physician has to probe a bit to garner an appreciation for a patient’s level of understanding and receptivity when presenting what can be confusing and overwhelmingly complex medical information. This is where experience is quite helpful. Listen to the patient and pose questions before engaging in conversation.
As my mind tends to work on the more “simple” side of communication, I think I’m as good as the next physician in simplifying my communications with patients. Once I get to know a patient, I like to tailor my communications in a manner that might resonate with his or her own life or work. For instance, it’s fairly easy to explain Eustachian tube dysfunction or the Venturi effect on nasal and sinus airflow due to a deviated septum to a plumber or airplane pilot—they’ll get it. Similarly, for patients who understand skin cancers or have had them, I can relate glottic (vocal fold) squamous cell carcinomas to skin cancers owing to the stratified squamous lining of the vocal folds, as well as the effect of “funneling” and concentrating cancer-producing particles in tobacco smoke through the narrow opening between the vocal folds. By using anatomical charts to identify those structures and showing the direct effects of smoking on them, the patient both hears and sees what I’m trying to communicate to her. Additionally, if a medical student or resident is present, they can watch and learn.
Too often I’ve heard a resident physician explain, “You have a high nasal septal deviation that’s impinging on the middle turbinate and causing sphenopalatine neuralgia,” or some such description of the pathology.
Another method for teaching and practicing effective and ethical communication with patients is through simulation. You can have trainees serve as both the patient and the physician. One trainee is the “patient” and is requested to listen to the “physician’s” discussion as she would imagine a real patient might. After reversing roles, in almost every simulation both trainees better understand the importance not only of straight talk, but also of empathetic talk, and they learn to avoid confusing and difficult medical terminology. Debriefing the trainees after each simulation will also provide an excellent forum to emphasize the important elements of clear and supportive patient–physician communication and the lessons learned from the encounter.
Give and Take
Effective communication with patients isn’t a one-size-fits-all effort. Each patient may require some consideration regarding how to convey information and how to know that he or she heard and understood it. Sometimes during the discussion, the physician will speak and the patient will listen; conversely, it’s important for the patient to speak, usually asking questions for clarification, while the physician listens. In essence, this should be a good “give and take” discussion.
It usually becomes easier to communicate with a patient once you’ve established a strong bond. Discussing important medical information with a new patient, however, requires more resourcefulness to gain a rapport and determine the level of sophistication or simplicity required to convey the information; you’ll need to listen—really listen—for understanding. Above all, communication should be patient-centered, not physician-centered. And, to paraphrase my fifth grade teacher, “patience is a virtue” in the context of these communications.
Effective and caring patient–physician communication is essential to establish a proper and effective patient–physician relationship—in fact, they’re inextricably connected. All the virtues that a physician should possess are used during patient care communication and relationship building: trustworthiness, compassion, understanding, discernment, valuing the patient, consideration, and moral integrity. Further, it isn’t just the words we use, but also how we say them that can convey these integral virtues.
What Went Wrong
In the clinical scenario above, we can identify a number of ways that Dr. Smith failed to provide effective communication, both verbally and nonverbally.
- First, he assumed a nonchalant pose in the room, leaning against the cabinet rather than sitting at eye level with the patient, a more compassionate position for presenting unfavorable news.
- Second, he conveyed the diagnosis in terminology that wasn’t familiar to the patient, nor could it be expected to have been familiar. In an attempt to clarify, he bluntly gave her the cancer diagnosis.
- Third, he failed to appreciate and respond to the patient’s obvious concern about her future outcome and the potential for the cancer to develop in her daughter.
- Fourth, he didn’t take the opportunity to express his concern for her as his patient and as a human being after he delivered the diagnosis. He expressed no words of empathy to her—not even an “I’m sorry to have to tell you this.”
- Fifth, he made no effort to follow the patient in the future, effectively abandoning her, which may have amplified her feelings of uncertainty and devaluation.
Just being present for the patient, listening, perhaps holding her hand or gently laying a hand on her shoulder, is a form of communication that can mean a great deal to patients, perhaps even more than the correct words. Abraham Verghese, MD, MACP, the Linda R. Meier and Joan F. Lane Provostial Professor of Medicine at Stanford University, had it correct in his commencement remarks to the graduates of Stanford Medicine in 2014: “You can heal even when you cannot cure by that simple human act of being at the bedside—your presence.”
There is a sixth communication error in this scenario: when Dr. Smith dismissed the patient’s concerns and minimized the seriousness of the disease and the future struggle Mrs. Jones is about to undergo. His words rang with a false sense of hope and created a misunderstanding for the patient regarding her potential outcome from the future therapy. A physician doesn’t have the authority or the prescience to propose a longevity of “100 years” to a patient with cancer (or any other disease), no matter what the state of technological treatment advances or stage of her disease. Our moral integrity begs our adherence to professional trustworthiness and honesty. Words do matter to patients, and they should also matter to us in the care of our patients.
Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.