The following is an excerpt from Danielle Ofri’s new book, What Patients Say, What Doctors Hear, out Tuesday.
Doctor-patient communication is a two-way highway of information, with each person endeavoring to convey information to the other. But there can be numerous roadblocks and detours, as anyone who has been party to our medical system can attest.
One of the most information-laden points of contact between doctor and patient is upon discharge from the hospital. There are medications to talk about, as well as follow-up appointments, tests, and referrals. Then, of course, there is the most basic information that patients ought to know: their diagnosis and the name of their doctor. Amazingly, even these can be poorly communicated.
In one study, 73 percent of patients knew that there was one primary doctor in charge of their care, but only 18 percent could name him or her. The doctors, however, were sure they had conveyed this information—two-thirds were confident that their patients knew their names. An even larger percentage of doctors (77 percent) were confident that their patients knew their diagnoses. But only 58 percent of patients in this study could name said diagnosis.
How could patients not know their diagnosis or the name of their doctor? Seems hard to believe. But if you’ve ever been hospitalized, you know what a Byzantine and surreal environment a hospital is. The phrase “medical team” hardly does justice to the armada of people in white coats who traipse in and out of your room. In a teaching hospital there are students, interns, residents and attending physicians, plus consultants from other specialties. There are nurses and physical therapists and dietary aides and respiratory technicians and nutritionists and case managers—all of whom might be wearing white coats.
Even if every last one of these white-coated folks conscientiously offer their name and role to you, it’s difficult for even the most organized human being to keep track of who’s who. Especially if you are flat on your back in bed, feeling rotten, receiving assorted medications that can make you dizzy, nauseated, itchy, gassy, or worse. But that doesn’t mean it’s impossible to adequately communicate under these conditions—it just means that we medical staff have to be more cognizant of the challenges.
An interesting comparison can be made right on the hospital ward. In a survey of 250 hospitalized patients, only 32 percent could name even one of their treating doctors. But 60 percent could correctly name their nurse. Nurses tend to spend much more time in the rooms with patients than doctors do. Nurses are also much more likely to touch the patients, while doctors often stand at a distance and talk.
It’s not that doctors don’t think about this or try to improve communication, but the tools we use aren’t necessarily the most effective. In one study, researchers dispatched a group of actors portraying patients into doctors’ offices along with tape recorders. The actors had been trained to offer the identical clinical presentation and background information, in this case about having gastric reflux symptoms. The researchers found that doctors’ most common strategy for conveying information was repetition. Doctors repeated information once, twice, sometimes three times. While repetition can enhance remembering, it can also come across as haranguing, which rarely works.
The next-most-common strategy was explanation. Done correctly, this can be very helpful, but doctors easily get mired in excessively detailed, jargon-heavy explanations that end up burying the key take-home messages.
But not one of the doctors in this study used the strategies with the strongest track records: summarizing the information, suggesting that the patient take notes, and asking the patient to restate the key points. Why don’t doctors use these techniques?
When I think about my own practice, I realize that there is so much information to convey to a patient (in such a preposterously slender allotment of time) that the thought of asking the patients to repeat back what we’d just reviewed is simply too daunting. But we can be selective and prioritize.
For one thing, I now make it a point now to repeat my name both at the beginning and end of a visit and always accompany that with my business card. I also remind myself about the limited utility of constant repetition. On my better days, I try to catch myself if I’m starting to harangue and instead ask, “What are the hardest challenges in dealing with your illness?”
Nine times out of 10, that question yields the most important kernel of the medical visit. If we are striving for efficiency—in the true sense of getting the most clinical meat within the short time allotted—that’s the kind of question we doctors should be asking upfront.
Most research focuses on how much patients remember of what doctors say. But what about the opposite: How much do doctors remember of what patients say? I could find no comparable studies testing what doctors remember of patients’ names, diagnoses, or medical histories.
But there is one real-life experiment regarding physician memory that happens, unfortunately, a little too regularly. Electronic medical records have been revolutionary in many respects—a patient’s chart can no longer be adrift in the cardiology clinic and a crucial X-ray can’t be languishing in a surgeon’s back pocket. However, by dint of being part of a computer, it is susceptible to freezing and crashing, just like your computer at home.
Recently I’d been writing a particularly complicated note about a patient with multiple chronic illnesses who was on more than a dozen medications and had numerous lab values out of whack, when I was interrupted by a phone call about an abnormal X-ray for a different patient. I had to open the second patient’s chart to untangle then issue, and when I finished, I went to close that chart so I wouldn’t commit the cardinal sin of mixing up two charts.
It took only a fraction of a second. Before I’d even released my finger from the mouse, I realized I’d closed the wrong tab. I kept my finger depressed on the mouse as long as I could, hoping that I could will that brief gesture into reverse, but no, it had all evaporated into the ether. (And if you thought our vaunted electronic medical-record system has something practical like auto-save to prevent such a mess, dream on!)
I’d lost all the information I’d taken down during our conversation and all the analysis I’d been writing after she’d left the room. Honestly, I just wanted to cry. The injustice of it all punctured my day, and everything just deflated around me. I’d entered that special circle of hell created by cocksure computer programmers whose systems can incinerate hours of work with breathtaking nanotech efficiency.
Even in my despair, though, I had to reluctantly acknowledge that my Dantean melodramatics were bordering on the histrionic. I’d lost a note, after all, not a patient. Despite all the effort that went into it, it was still just a bunch of writing. And as our middle-school teachers have always patiently reminded us, everything is a teaching moment, and doctors losing their electronic notes is a fortuitous—if excruciating—natural experiment in measuring their recall of patients’ words. Regrettably, this happens frequently enough to accumulate an informal mass of data.
Once I’ve chiseled myself up off the floor, the most expeditious thing to do is to simply grit my teeth and start writing from scratch, however repugnant it feels. Whenever this happens, I am always amazed that I actually do remember many of the things I’ve written. What comes most effortlessly is the HPI, the history of the present illness. This is the information surrounding the primary reason the patient has decided to come to the doctor. In this case, I could easily remember that this patient had been treated for H. pylori gastritis a year ago, and she had continued the acid suppression treatment until the five refills of the prescription ran out. She didn’t have time to get back to the doctor because she had a new job and was a single parent with a tenuous child care arrangement. The symptoms gradually returned, though when I questioned her in detail about the specifics, the symptoms seemed much more like reflux than gastritis.
The other part I find easiest to remember is what’s called the social history. I remembered that she was from the Pacific coast state of Guerrero—unlike most Mexicans in New York City, who come from the landlocked state of Puebla—and that she’d completed one year of university studying psychology. But then she and her husband decided it would be better for their daughter to be raised in America so they emigrated together. Unfortunately, their marriage didn’t fare as well as their relocation and they separated soon after arriving in New York. She was working in a nail salon and studying to get a manicurist license. The hours were long, and she usually arrived home after her daughter was already asleep. The daughter was recently diagnosed with mild autism and had started therapy in her kindergarten class.
But then I struggled with some of the other details. What year did she say her last Pap smear was? Was it her aunt who had colon cancer or her grandmother? Did she say she had a tetanus shot at another clinic, or was she talking about a PPD test for tuberculosis?
When I think about this from a literary perspective, the reason is obvious. The HPI is a story—there is a plot with twists and turns, challenges and conflicts. Stories are always easier to remember than lists of facts. The social history is what writing teachers refer to as “fleshing out the character.” Story and character are what make great literature memorable. I may have forgotten what this patient’s diastolic blood pressure was, but I could never forget the pained expression on her face when she spoke of how her job made her miss reading bedtime stories to her daughter each night and how she wasn’t confident that the babysitter was reliably reading those stories to her daughter, who so needed the extra enrichment.
However, I’m well aware that this software-glitch experiment measures my memory only of what I heard the patient say. It doesn’t tell me what I missed. It doesn’t tell me which facts I filtered out. It doesn’t indicate what subtle body language sat unnoticed. It doesn’t tell me if or how my internal biases altered, blocked, or otherwise transmogrified the information my patient was trying to convey to me.
Short of videotaping every doctor-patient interaction and then individually grilling the participants afterward, there isn’t a foolproof way of precisely measuring what each party gleans from the conversational give-and-take. But there are a few simple things that doctors and patients can do. For the patient, there is always the standard advice to come to the doctor with a list of what you want to discuss. My only caveat is to be realistic with that list. Countless times I’ve had patients unfurl Iliad-length treatises with scores of questions single-spaced, footnoted, annotated and cross-referenced. So prioritizing the top two or three is crucial if you want to achieve anything beyond the superficial. At the other end of the visit, it really does pay for the patient to take a few notes. Jotting down the key points is invaluable.
For the doctor, briefly summarizing what the patient has said—the technique least used in the study with actors but the most effective—can work without taking as much time as we fear. “Let me see if I’ve got this right” is a simple way to initiate a brief restatement of the facts. Not only does this serve as a great way to get the facts straight, but it’s also a solid indicator to the patient that you are actually listening.
The doctor-patient conversation is the single most powerful diagnostic tool in the medical armamentarium. Enhancing the efficacy of this conversation and ensuring that each party is hearing as accurately as possible is one of the best prescriptions for good health.