November 12, 2013 | 1
“Ms. M,” the resident says, “I saw in your chart that the last time you had surgery you had a pulmonary embolism.” She nods with recognition: “I felt like I couldn’t breathe. It was really scary.” Then: “I sure don’t want that again.” The resident lifts up the covers and sees that the patient’s calves don compression boots. “Make sure you keep the boots on,” he says, pointing.
What do boots have to do with breathing? The full story of what the resident meant was this: a pulmonary embolism, or blockage of a lung artery, is most commonly caused by a blood clot formed in the leg that breaks off and travels up to the lungs. Wearing compression boots increases blood flow in the calves, helping to prevent those clots.
Perhaps Ms. M. was aware of that. But there was a mental leap involved in that conversation. By bypassing the more thorough explanation and instead jumping from the topic of lungs to legs, the resident made an implicit assumption that the patient was following his train of thought.
It’s just one example of a more widespread lapse in communication with patients: sometimes, we skip steps. We assume understanding of intervening explanations that may be missing from the words we actually say aloud.
In some ways, medical training is like learning to speak a foreign language. We spend our first two years of medical school in classrooms, trying to absorb terminology and draw conceptual connections as quickly and as comprehensively as possible. Then in our third year, we enter the hospitals and actually get to speak it. On a daily basis, we converse with words we hadn’t known two years ago and link them in ways that were not intuitively obvious. As we use that language more and more, we get better with it. The more fluent we get, however, the more terse we can become too.
I worked with one doctor who explained that style in front of patients as “talking shop.” We do it frequently on rounds. We ask one another questions and answer them with relevant physical exam findings, lab values, and imaging results – often without explaining how those findings help answer the question, as it’s taken for granted we know what they imply. She’s complaining of post-op abdominal pain, I might say, and my chief resident asks could she have an abscess? And I mention her high white cell count (implying she might). Are we worried about cholangitis? asks the attending, and I state his liver function tests within the normal range (implying it’s less likely).
It’s reflected in our questioning at the bedside, too. A man comes to the emergency room with back pain, and we might ask about urinary incontinence. A woman presents with loss of menstrual periods, and we might ask about changes in vision. To the untrained eye, some (or much) of what we ask might seem unrelated. I remember a patient presenting with abdominal pain once tried to redirect me when I asked about back pain, thinking my question was a misunderstanding: “no, no – it’s my stomach that’s hurting!”
I understand the temptation; skipping words saves times. Extra explanations may be redundant among certain crowds. And there’s something satisfying about the universal nature of the medical language, such that even if you meet healthcare workers whom you’ve never met before, you can launch into shop talk and appreciate that they’ll get it. There’s satisfaction in the fact that the same concepts will trigger similar understanding, with similar follow-up thoughts, questions, and concerns.
The glitch, however, occurs when we take those mental frameworks and communicate them to patients with similar scaffolding. We forget who speaks what.
The problem is that less than complete explanations translate to less that complete understanding – which translates to less than complete ability to follow recommendations. I’m less likely to take a daily walk, wear uncomfortable boots around my calves, or exhale into my incentive spirometer multiple times a day if I don’t know why I should. But I’m much more likely to do those things if I can connect them to the last time I was post-op and came down with trouble breathing. I’m less likely to continue my medications at home if I cannot connect them with the consequences of not taking them.
Moreover, if we don’t complete our explanations, patients may fill in the gaps themselves in ways that might not be accurate. It’s certainly not their fault. It’s human nature. Our brains try to make sense of the information we gather, accumulating bits and pieces and trying to form a coherent story out of them. Once I launched into questions about family history – including family history of cancer – and the patient, relating that with the questions I had just asked her symptoms, suddenly looked stricken: “what I have isn’t considered cancer, is it?” I had left a break in the transition, and she had filled it in with a more malignant scenario.
Granted, there’s a range of complexity involved in medical lingo, along with widely varying levels of health literacy, and the goal should not in any way resemble condescension to patients. However, we also should not presume a grasp of medical topics that require multistep reasoning. Some connections only seem intuitive because we’ve seen and said them time and time again, but are actually quite complex – just as they were to us – when heard for the first them. It’s possible to strike a balance; I’ve seen a handful of wonderful doctors, true models for excellent communication, who manage to tailor their explanations so that all their patients leave the doctor’s visit neither insulted nor confused.
I’d rather err on the side of clearer explanations. I’d rather err away from potential unexplained gaps and unanswered questions. If patients do not follow up, I hope we don’t automatically wonder where they went wrong. I hope we can instead reflect carefully on what we said – or, more likely, what we did not say.