The gap between what physicians believe they communicate and what patients actually take away from those conversations can be wider than the metaphorical gulf of Venus and Mars. The scary part is that miscommunication can carry dire consequences.
Consider an anecdote that was recently shared with the CreakyJoints community: We heard about a patient, whose doctor diagnosed her with rheumatoid arthritis and prescribed methotrexate. During that office visit the doctor told her that she “can’t” get pregnant while taking methotrexate. The patient took her doctor literally and grew lax in her contraceptive use, simply because she was following his orders. But the physician meant “you shouldn’t get pregnant,” not “you can’t get pregnant.” Methotrexate, of course, is known to cause birth defects, as well as other problems.
This misunderstanding could have easily been corrected if the doctor checked to ensure that the patient understood everything they had just discussed — especially the really important parts. Of the 23,658 cases that the CRICO insurance program assessed between 2009 and 2013, 30 percent involved communication failures, it noted in its 2015 national report on malpractice risks. In 7,149 cases, that miscommunication harmed patients, and the total losses incurred were $1.7 billion, according to the report.
Most hauntingly, 37 percent of all cases of high-severity injury involved a communication failure. ProPublica notes variations in the reported scope of medical errors — perhaps even the third largest killer after heart disease and cancer — but even if one adopts the most conservative numbers, it’s still a huge problem.
One way that doctors can mitigate these enormous risks is to ask the patient to repeat the instructions. “To ensure each patient understands and remembers important information about their treatment, their doctor can ask him or her to describe the plan in their own words, a strategy known as the teach-back method,” an anesthesiologist told the Wall Street Journal a few years ago.
Other communications problems abound as well. “Patients spoke, uninterrupted, an average of 12 seconds after the resident entered the room,” according to a 2001 Family Medicine study. “One fourth of the time, residents interrupted patients before they finished speaking.” Danielle Ofri, an associate professor of medicine at New York University, “advises that doctors ask their patients, ‘Is there anything else?’” reports the University of California, Berkeley’s Greater Good Science Center. “She acknowledges that this can be daunting for doctors, because it opens a Pandora’s box of dialogue that may cut into other patients’ appointment times.”
A Pandora’s box here is preferable to the alternative, however. Writing in the New York Times in 2014, two physicians described a close friend and cancer patient who had gone to see a renowned specialist. “When the friend started asking questions about the treatment plan, the doctor had stopped him mid-sentence, glared at him and said, ‘If you ask one more question, I’ll refuse to treat you,’” they wrote. “‘What could I do?’ the friend later said. ‘He’s the best, and I wanted him to take care of me, so I shut up.’”
There is a need throughout the profession today to be more patient-centric. Rather than telling patients to shut up, physicians ought to be open to listening more and having dialogues rather than one-way lectures.
“Physicians and medical students often have limited insight into how they come across when talking with patients, and little opportunity for formal feedback,” they wrote. “While most doctors really are invested in their patients making the right decisions for their circumstances, many lack the skills to show that they care. After all, their admission to medical school was not based on a validated assessment of their ability to relate to other human beings.”
The good news is that the problem increasingly surfaces on the radar screens of doctors and other medical professionals. There are a variety of creative efforts underway to improve physician-patient communication. But the example of the doctor informing a patient that she “can’t” — rather than “should not” or “must not” — get pregnant while taking methotrexate underscores the work that remains ahead of us.
Seth Ginsberg is president and co-founder of the Global Healthy Living Foundation and CreakyJoints.