Pay close attention to what doctors say to patients

In a report from the Archives of Internal Medicine, it was reported that most hospitalized patients (82%) could not accurately name the physician responsible for their care and almost half of the patients did not even know their diagnosis or why they were admitted.  Of the physicians, 67% thought the patients knew their name and 77% of doctors thought the patients “understood their diagnoses at least somewhat well”. Although 98% of physicians thought they discussed their patient’s fears and anxieties with them, only 54% of patients thought they did.

Blogger Dr. Toni Brayer suggested several possible explanations for the communication gap:

  • Patients are stressed while hospitalized and do not remember what is said.
  • Many patients are heavily medicated and that affects ability to learn and remember.
  • The trend to get patients out of the hospital quickly short changes communication time.
  • Nurses, consultants and hospitalists don’t communicate well together and the patient gets a different message from each visit.
  • Doctors are too rushed and deliver information too quickly to be understood.
  • Hospitalized patients have too many consultants and no one is identified as the “responsible physician.”

And I would add:

  • Doctors don’t pay enough attention to cultural differences.

There are cultural differences that we physicians encounter every day. In consult, during the span of a single day, I may see one or several of these (very generalized) stereotypes:

  1. The engaged patient.
  2. The type A personality (sometimes a subset of #1)
  3. The “you’re the doctor, I trust you, do what you think is right” patient.
  4. The foreign-speaking patient requiring a translator.
  5. Japanese: nod as a sign of respect, which we Americans assume implies understanding
  6. Indian: son, with parents and a comment to “don’t tell too much” to the elders
  7. Hispanics: full family, including grandchildren and a trusting, “doctor knows” attitude

The above are generalizations and are in no way meant to get myself in trouble with any particular group of people. They are just observations about how some people may act when they visit their doctor. Of course, I have seen all of those types of people act differently also.

The important thing to remember is that all of those wonderful “groups” of patients deserve, and I attempt to give, the same attempts at full disclosure, i.e. effective communication. It is difficult to imagine, therefore, that a stressed-for-time primary care physician can slow down enough to be able to communicate everything that needs to be said in the short time allotted. That’s where I come in. As a specialist, I have the luxury of having a bit more time to spend with each patient. So when a person says that their doctor didn’t communicate the findings or plan with them, I give that physician the benefit of the doubt, saying so to the patient, and then explain to the best of my abilities what they need to know.

As a specialist (interventional radiologist) I can’t tell you how often it is that I see patients in consult who tell me that their doctor “didn’t tell them anything.” I’ve come to realize through discussion with many of those referring doctors, that they of course did communicate some/all relevant information. There is obviously a disconnect between what a patient hears, what a doctor says, what a doctor hears, and what a patient says.

Another part of the problem may be that many doctors no longer know how to communicate using “normal English.” I remember being criticized by my OB attending (first rotation in med school) for not using medical terms enough when talking with my patients. I took that as a compliment.

I think the key from the doctor’s standpoint, is to pay extremely close attention to what we say, how we say it, and how the patient responds. Then we can be better assured that we have had a fruitful communication.

Paul Dorio is an interventional radiologist who blogs at his self-titled site, Paul J Dorio, MD.

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  • Cheapo

    great article, funny that it was written by an I.R. the job of explaining everything should go to the Hospitalist or PMD who ever is the attending on record, (a pulmonologist critical care or cardiologist can also do this), every patient will eventually say no one ever told them anything, the doctor didn’t say anything, but the fact is older people don’t really listen, i try explaining everything to my dad, i say the same things over and over, but they aren’t really listening, so you really have to get some insight if the patient actually knows what is going on, most doctors don’t do this even when they have the best of intentions, and when i come and explain everything clearly i look like a great guy, even if the specialist are doing all the work.

  • Micah

    I am a patient but used to be a paramedic. In my experience, both as an observer and a patient, I have found that doctors use too much medical terminology. And because they typically seem rushed, and many of the people going to the ER are generally in one of two groups: people who truly necessitate an ER visit, meaning they are not completely with it; or they are low-income, meaning they typically do what they are told and are not the type to ask questions when they don’t understand, especially when that person is “superior” to them.

    Even when I went into the ER a month ago because of an ankle injury, I was warned by the nurse and the doctor of the possibility of getting “drop foot.” And of course by that time, I was on percocet, but I’m thinking, “What is drop foot?” I’m the kind of person to ask questions, but in a state of pain and just wanting to leave already, I didn’t have the energy to ask. And I have no idea what my doctor’s name was.

    Working as a medic I was truly appalled by he lack of bedside manner in many ER docs. A symptom of having to be emotionally detached, a poorly-run ER system, not enough emphasis is med school, or just a gradual descent into complete indifference?

  • steve weaver

    I haven’t seen a doctor the whole time I’ve been here. I can’t tell you how many nurses have told me that patients have said this.

  • jsmith

    Amazing statistics really. They ain’t gettin’ what we’re sendin’. We need to do much better at communicating. They’re sick and scared, we’re not. It’s our responsibility.

  • Stella Fitzgibbons MD

    As a hospitalist I find this a genuine problem, especially now that I’m in a group that switches doctors every 7 days. I pass out my card a lot, and when I walk into the patient’s room I ALWAYS say who I am…even to patients who I’m sure know me (I knock at the door and say “Hi, it’s your doctor”).

  • http://ophthosurgery.com Ophthosurgery

    I’ve noticed that the education level of the patient has very little to do with communication as well.

    The average layperson will nod to feign comprehension of the doctor so not too appear stupid. Yet, the professional, “Type-A” patient often invokes medical terms incorrectly. I’ve found that it’s sometimes more difficult to correct a patient’s understanding of a disease if they are educated to the extent that they are unwilling to listen.

  • PAULMD

    Good post. Seems obvious but we clearly need repeated reminders on cues and conveyance of information.

    I do not use EMR but I nearly always cc to the patient any significant information with dictation and leave my card with their materials at the bedside or with family. It just makes sense. If I were the patient, I would find these simple things quite helpful esp after discharge.

  • Frances D.

    My doctor is a good listener and spends quality time with me
    so in that regard he allows me to explain any problems I am having with my health condition at every office visit that I spend with him. Only by listening to what I have to say then my doctor can draw a conclusion and offer me more treatment options. My doctor has a lot of patience and that is why we have a good patient doctor relationship. He also treats me with respect and never talks down to me which I appreciate it very much.

  • http://www.theblackribbonproject.org Beth Haynes, MD

    Recently having spent a lot of time helping my in-laws through hospitalizations and illnesses, I would add the hospitalist system itself is part of the problem. Although my father-in-law had the same physician for a week at a time during his most recent 3 week hospitalization, they were doctors he never saw before and never expected to see again. Thus, the effort put into connecting with the physician was was significantly less. Since a patient is not given a choice of who is his hospitalist, the primary expectations of trust in this situation is toward the hospital choosing someone who is competent and not toward building a lasting relationship with the physician. This is a very different situation from choosing a doctor who stays involved with your care both in and out of the hospital and over a period of years rather than days or weeks.
    I understand the advantages of this system, but it is important to be cognizant of the disadvantages and work to minimize them.
    Also, in their attempt to direct their interactions primarily with the patient (generally a good idea) the physicians never realized how cognitively deficient my 92 year-old father-in-law is. He is at that stage where he can appear to be comprehending what is being said to him, but he doesn’t. This is another problem with this particular division of labor.

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    Reading articles like this gives me continued faith in doctors.The word “professional” is overused today to the extent that sometimes it has no meaning. One element that defines a profession is the group’s ability to stop, think, analyze, critique itself, improve and move on. Most doctors are continually learning, analyzing, trying to be better. It’s important to realize this as we read all the critical information being published about our health care system. The problems are out there and need to be addressed, and most are being addressed. But I’m constantly impressed with the profession’s continued examination of itself and what it is doing. It’s not perfect, and there are probably some areas that need more scrutiny. But it gives me a good feeling to know that this self-analysis is so embedded within the system.

  • http://www.theblackribbonproject.org Beth Haynes, MD

    Doug–Thank you for the observation and reminder. Amidst all the turmoil, it can be far to easy to forget to admire the process.

  • Jeff

    Perhaps if patients paid doctors directly (instead of insurance companies), like one does an attorney or an accountant, and the doctor could bill by the hour, I’d be willing to bet that patients (and their families) will hear every single word the doc says.

  • Frances D.

    I don’t have medical insurance at this current time and do
    pay my doctor directly in cash all the time. My doctor does
    give me a discounted rate on my office visits about a 20% discount off the regular price. It takes at least 28 to 30 days
    for doctors to receive payment from their patient’s insurance companies. With a cash patient a doctor doesn’t have to wait and has no paperwork has to be filled out plus he can just pocket the money and pays no taxes on it.

    • Heart Patient

      This is a great article, from a patient’s standpoint. I’m both #1 and #2, but I also take my nurse-sister along with me if I need to go to the ED for anything, or to visit new doctors for what may be a serious problem (ie neurosurgery consult). I also am fortunate to use her as a sounding board after other Dr visits. I continually feel bad for the older/elderly patients I see in my cardiologist’s office…I wonder how they can even keep up with all the information about successfully managing this disease. So please continue to explain things without medicolese as possible for those patients. I’m one of those who ask questions if I’m told something I don’t understand….just love having those fellows in the examining room…I’ve learned much from them.

      My real intent of this comment was to follow up on the Frances D comment of 12/28 “With a cash patient a doctor doesn’t have to wait and has no paperwork has to be filled out plus he can just pocket the money and pays no taxes on it.” I hope she realizes this is NOT true of most physicians….the “pocketing of money” comment. She makes you sound like crooks, which is patently not true for the majority of physicians. I found this to be an insulting comment about the medical profession.

  • http://drpauldorio.com Paul Dorio

    Thanks for reading and for some very good comments. Self-analysis is essential for anyone and everyone. Helps us continue to improve as individuals.

  • Frances D.

    In response to the comment, I made regarding me being a cash patient with no insurance. I apologize and didn’t mean it the way my statement came across but that is the article I read on the internet when doing my research on “Do Physicians give Cash Patients Discounts? According to this article that is the exact words that was used that doctors like cash patients because they receive their payment up front and have no waiting period. Plus doctors can make a decision on how much they want to charge his cash patient.
    I was put on a sliding fee scale at least my doctors office
    does this to me. I will be attending college next Spring in 2011 and will be studying Medical Insurance, Coding, and
    Billing procedures so I will be able to have a better assessment of what actually happens with doctors
    receiving payments through their patients insurance company. Although the physician has to fill out a lot of paperwork in the process and the medical insurance company makes the decision whether to cover a required test and prescription medication that the doctor prescribes to his patient. Everything is being monitored closely by these insurance companies to make sure there isn’t any fraudulent activities going on in the medical profession. So I will be able to find out the truth on how insurance companies operate and how doctor receive their payments this way.
    If I have offended any doctors please accept my apology.
    Sometimes it is very difficult to express emotion in a posted message on this blog. I also wanted to say that my doctor has given me the best treatment and he is a very cares a lot about the welfare of his patients including myself.

  • http://notimetoteach.com/2010/empowermen/ Fran London, MS, RN

    This can be avoided if physcians followed the recommendations of the American Medical Association and Joint Commission, and asked the learner (often, but not always the patient) to teach back essential information. That gives the physician an opportunity to correct misunderstandings on the spot, and reinforces content.

    How to do this? Here’s a great resource, free online:
    Weiss, B. D. (2007). Manual for clinicians: Health literacy and patient safety: Help patients understand. 2nd. from http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

    To see the process in action, here’s a link to a video:
    AMA Foundation. (2007) Health literacy and patient safety: Help patients understand. retrieved from
    http://www.youtube.com/watch?v=cGtTZ_vxjyA