Your patient thought you said what?

You did everything you could think of to make yourself clear. So how come your patient's still baffled?

By Gail Garfinkel Weiss
Senior Associate Editor

Paul R. Ehrmann, an FP in Royal Oak, MI, calls it the 90/40 rule: "We doctors think patients understand 90 percent of what we say, but the patients understand only 40 percent."

Conveying information can be a tricky business. That's especially true if it's done on the run, but even if you take your time, you may not be understood. Internist Abigail Hagler of Yuma, AZ, tells of an octogenarian who needed to take low-dose aspirin: "She had brought her daughter with her, to be sure she heard everything correctly. Because she told me that aspirin irritated her stomach, I suggested that she take half a tablet of Alka-Seltzer, dissolved in water, daily.

"I explained that Alka-Seltzer contains aspirin but isn't as troublesome to the stomach as regular aspirin. I even wrote these instructions in block letters and asked the patient and her daughter if they understood. Both assured me that they did. But no sooner were they out of my office than the daughter—who had a master's degree—asked my receptionist, 'What did Dr. Hagler want my mother to take?' "

It's enough to make you toss up your hands in frustration.

Doctors' instructions are misconstrued in ways that range from laughable to disastrous. Fortunately, most "my patient doesn't understand me" stories fall into the first category. FP Richard E. Waltman of Tacoma, WA, had a patient who he thought was passing kidney stones. "I saw her on a Friday and told her to strain all of her urine and bring in whatever she got," he says. Sure enough, come Monday morning she showed up in Waltman's office with several bottles of strained urine.

Perhaps kidney stones somehow interfere with patients' common sense. FP Harris R. Hayman of Paoli, PA, was making hospital rounds when one of his patients stopped him in the hall. "He said, 'Doc, I just can't do it,' " Hayman recalls. "I asked him what he was referring to, and he said, 'I just passed a kidney stone, but I can't drink the 6 to 8 gallons of fluid daily that you wanted me to.' " Of course, Hayman had said 6 to 8 glasses of liquid per day.

Occasionally, something gets lost in the translation when patients discuss diagnosis and treatment with significant others. A middle-aged man came to FP James Moseley of Stevensville, MD, complaining of knee pain. "I told him I thought he had osteoarthritis," Moseley recalls. "When we discussed the problem, I indicated that this condition couldn't be cured, but that much could be done to help him live a normal life." So imagine Moseley's surprise when, later that day, he received a frantic call from the man's daughter demanding information about her father's "incurable" disease.

Then there are the stories that not only aren't funny, they're downright scary. Murad Alam, a dermatology resident at Columbia University in New York, recalls a young woman who was about to begin therapy with the teratogenic oral retinoid Accutane. The patient was told it was urgent that she confer with her gynecologist about birth control. She dutifully agreed, but according to Alam, "at her return visit, she was asked if she had chosen appropriate contraceptive methods. Baffled, she replied that she hadn't, since, as she put it, 'I was told I couldn't get pregnant while I'm taking Accutane.' She had assumed that the Accutane itself was a powerful method of birth control."

Just what is it about doctors' offices?

Some doctor-patient communication snafus can be chalked up to a patient's poor language skills, hearing impairment, dementia, or lack of intelligence. But more often than not, the patient is of sound mind, at least reasonably well educated, and speaks fluent English. The doctor's English isn't usually the culprit, either.

So what's the problem? Yes, managed care has thrust many medical practices into fast-forward, and doctors feel they can't take the time to explain and re-explain diagnoses, treatments, and instructions. But patients have been misconstruing doctors' orders for ages; no doubt even Hippocrates was flummoxed by the issue. Consultant Jacob Weisberg, whose Trabuco Canyon, CA, company, Creative Communications, works with physician groups, says the problem lies in the nature of doctor-patient encounters.

"People have difficulty processing information in times of stress," Weisberg says. "On top of that, the doctor is in a power position, much like a parent is with a child or a boss with an employee. The patient feels a mix of nervousness and awe that inhibits careful listening."

Barbara M. Korsch, senior attending physician at Children's Hospital/USC Medical Center in Los Angeles and co-author of The Intelligent Patient's Guide to the Doctor-Patient Relationship, says patients often tune out "if they try to engage the doctor on a particular issue and the doctor doesn't respond." In researching her book, Korsch talked to patients who asked, "Why didn't the doctor tell me what was wrong?" Yet videotapes clearly show that the doctor stated a diagnosis.

"When patients come to see a doctor," Korsch notes, "they have certain concerns and expectations. If those aren't addressed, the communication breaks down to the point where the patient can no longer hear what the doctor says."

Inevitably, doctors' speaking medicalese is often a factor, too, even among those careful to avoid terms like "ischemia" and "morphology." FP Gil L. Solomon of Malibu, CA, thinks that doctors become so accustomed to saying such things as "incision" instead of "cut" that they forget they didn't always use the former term—and that it might be unfamiliar to laypersons.

Even simple language is open to interpretation. Murad Alam points out, "In dermatology, we make frequent use of topical medications, including retinoids and corticosteroids. Given the physician's extreme familiarity with these medications, there's a tendency to hand a patient a prescription with only the most rudimentary instructions, such as 'apply twice daily.' " Patients, however, have various understandings of the twice-a-day mandate. "Some smear thick, opaque layers of medication over their entire body," Alam says, "while others dab minute amounts on only the most affected areas."

Making yourself clear the first time around

Communicating well with patients makes for fewer telephone inquiries, encourages good word-of-mouth about your practice, and keeps malpractice lawyers at bay. It also cuts back on the need for corrective action, since your patient is less likely to mistakenly take three pills once a day rather than one pill three times a day. So it's no surprise that when researchers at the Centre for Studies in Family Medicine at the University of Western Ontario in London, Ontario, looked at 21 studies of patient-doctor communication, they found a positive correlation between good communication and good outcomes. "Simply put, clear communication improves patient health," says CSFM Director Moira A. Stewart.

Doctors often alter their own communication techniques after learning the hard way that their message hasn't gotten across. James Moseley, after finding a large malignancy in an elderly woman's breast, called her family into the office to break the news. "I pointed out that a large tumor was growing in the breast, and there was already evidence that the disease had spread," he says. To the doctor's amazement, though, the son said, "But doctor, what is her cholesterol level?" Since then, Moseley says, "I always begin any discussion of serious problems by asking everyone present what their concerns are, so I can dispense with those first. It's then easier to move on."

Some other don'ts and dos:

• Don't assume that anything is obvious. Those words have been mantra for FP David P. Watkins of Angola, IN, since the day he gave a young mother vitamins for her infant. "She was to administer one dropperful daily," he says. "Later that week, she called to complain that the drops were staining the baby's skin after she instilled them into its eyes."

• Don't expect patients or family members to read between the lines. Many years ago, FP Stephen D. Helper of Bakersfield, CA, diagnosed lung cancer in a patient. When the patient's wife called for the X-ray report, "I told her the X-ray 'didn't look good,' " Helper says, "and that her husband needed to see a chest surgeon." It was the surgeon who informed the man that he had cancer. The patient died not long after, and the wife never forgave Helper for not being forthright about the bleak diagnosis. "I stopped using euphemisms then," he says.

• Beware of flash-point words like hospital. "Sometimes a patient is too emotional to hear the doctor's message after being told that he has a grave illness or that he should have tests in the hospital," says Barbara Korsch. "You might need to back up a bit if you notice your patient looking frightened or overwhelmed."

• Ask the patient to repeat your instructions, in her own words. Jacob Weisberg calls this "reverse paraphrasing," and says it's far more effective than repeating the point over and over. "Reverse paraphrasing lets you know how well the patient understands your instructions, your thinking, and your treatment approach," Weisberg says. "If the doctor just tells the patient, and doesn't get any inkling of what she's understanding or whether she's bought in, then the chances of compliance are reduced."

• Reinforce what you say by handing patients additional information. According to Dorothy R. Sweeney, vice president of The Health Care Group in Plymouth Meeting, PA, "In a doctor's office, patients concentrate so hard on listening that they often don't hear exactly what's being said. There are many excellent handouts that clarify information for the patient—and for family members who weren't present during the office visit." Sweeney adds that physicians can develop their own handouts.

Gil Solomon says he's been tempted to hand patients a pencil and paper so they can take notes. "I've never had a patient write down anything I said," he says—something that amazes him. So he tries to ensure compliance by distributing handouts with step-by-step instructions.

• Have a nurse or medical assistant follow up. Chances are, patients think you're in a hurry, even when you're not. So they may feign understanding, because they don't want to take up any more of your time. That's why, Dorothy Sweeney advises, it's a good idea to instruct a staff member to ask, "Is there anything else we can answer for you?" before the patient leaves the office.

"No one communication strategy works for all patients," says Barbara Korsch, "so it's best to individualize explanations and advice." You might try asking questions such as: "Would you like me to draw a picture or write out the instructions?" or "Do you want a brochure about that?" or "How about if my nurse calls you in a week, to see how you're doing on the medication?"

Korsch also warns against minimizing anything that's of tremendous importance to the patient, such as pimples or a tendency to put on weight. If you want to be heard, Korsch says, "you have to get into the patient's head and address the issues that make sense to that person."

Gail Weiss. Your patient thought you said what?.

Medical Economics

2000;3:249.