Two words that hurt communication between physicians and patients

by Paul Rousseau, MD

Communication between physicians and patients is critical to quality care and improved outcomes, however, such discussions often seem labored and fraught with anxiety and stress.

Physicians commonly speak too much and listen too little, while patients feel swept up in an unfamiliar and frightening situation with loss of control and little-to-no input into care.

As I have observed conversations between physicians and patients, many of them involving medical students, medical residents, and even attending physicians, I have become troubled by the use of two words: “You know.” These two words are omnipresent in today’s conversations, yet they are two words that contribute very little to communication, may be obstructive to the clinical intent of conversations, and certainly lack professionalism. How these two words have become so thoroughly ingrained in modern dialogue is beyond understanding, although I am certain they must provide some obscure comfort during difficult and uncomfortable conversations.

The following are three conversations taken from interactions between a fourth year medical student (MS) and a patient (P), a medical resident (MR) and a patient, and an attending physician (AP) and a patient.

Case 1

MS: “Hello Mrs. Jones, we’re from palliative care, and you know, we have been asked by your primary team, you know, to talk to you about hospice. Did they tell you we’d be coming?”

P: “Yes, they told me you’d be comin’.”

MS: “You know, can you tell me about what’s going on with you, why you’re in the hospital?”

P: “I came in with bad pain, real bad, and I think they’re gonna do some radiation treatments. You know, I have cancer all over my body.”

MS: “Okay, how is your pain, you know, is it better with the medications they’ve given you, or, you know, is it the same?”

P: “It’s the same, but I’m hopin’ it will get better.”

MS: “We’re going to work with your primary medical team to get your pain under control, and, you know, we’ll be seeing you everyday to make sure we control the pain.”

Case 2

MR: “Hi Ms. Jones, we’re from the Palliative Care Team, and you know, your doctors asked us to come by and talk with you and to see how we can help you. Can you tell me about what you’re in the hospital for?”

P: “Yes ma’am, I got this heart failure, and I’ve been havin’ trouble breathin’, can’t catch my breath. I know I’m getting’ near the end, but Lord, I need some help.”

MR: “I’m so sorry you’re having such difficulty Ms. Jones, can you, you know, tell us what you mean by needing some help?”

P: “I need some medicines to help my breathin’, you know, and I need some help at home—I live alone.”

MR: “It must be hard Ms. Jones, living alone and taking care of yourself with your heart problem. You know, we can help you with some medications, and also getting some help at home.”

P: “That would be wonderful, I mean, you know, I was told you’d be talkin’ to me about hospice?”

MR” Yes ma’am, we’re going to discuss hospice. You know, hospice is a wonderful program that could help you in so many ways.”

Case 3

AP: “Ms. Jones, I am Dr. Toblaminally, the attending physician for the medical team, and you know, the medical resident has told me all about your case. I’m so sorry you’re having all this trouble, but I think we can help you.”

P: “Thank you so much doctor, you know, I thought I was going to die last night with this chest pain and not bein’ able to catch my breath.”

AP: “We have started some medications that should help your pain and shortness of breath, and we’ve also asked Palliative Care to visit you with us today. You know, they can really help you and your family in situations like this, so I’m going to let them talk to you. And, you know, we’re always here, so you have the nurses call us if you need anything.”

While these brief conversational segments extracted from longer conversations demonstrate concern, compassion, and empathy, they also demonstrate widespread use of the words “You know,” words that commonly provide hesitant, if not nonexistent value in physician-patient encounters. Moreover, when taken literally (which is usually not the intent of the physician or patient), “You know” insinuates knowledge or understanding on the part of the patient, which may be misleading, or quite simply, untrue—the patient may not “know,” or may not understand.

But in spite of questionable value, the words “You know” remain pervasive in the professional environment, and have become inclusive in contemporary English language. So why are these words so frequently used? Four reasons come to mind:

  • they serve as a verbal crutch (particularly when the physician is anxious or nervous);
  • they are the result of a void within the medical education system that does not address, or inadequately addresses, communication skills;
  • they have become a habitual phrase devoid of meaning but acceptable to the physician and medical community at large; or
  • a combination of the three.

Regardless of the reasons for their use, should we allow their continued incursion into the realm of communication, even though their value and intent is unclear and not conducive to transparent, professional, and constructive communication? Although I’m not certain that I have a practical or convenient answer, I personally favor eliminating the words in medical communication. How this can be accomplished may be problematical, but I propose four strategies:

  1. incorporating communication training into all medical schools’ curriculum;
  2. promoting educational endeavors in communication skills, such as Grand Rounds and continuing education activities (and even consider mandatory education in communication for medical licensure or re-licensure);
  3. mentoring medical students and young physicians in the principles of communication;
  4. acknowledging students, residents, and faculty who advocate good communication skills and serve as role models.

I realize that my petition to eliminate a phrase so ingrained in communication will be difficult if not impossible, but I beseech my colleagues to cast aside these two useless words and return to simple yet professional dialogue—you know?

Paul Rousseau is Medical Director, Palliative and Supportive Care Program, Medical University of South Carolina.

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  • Bradley

    My mother, a 61 year old RN, uses “you know,” so much, it’s extremely pervasive. She uses it at least 10 times per minute, usually more like 20, during every conversation we have. I have tried to point it out to her gently and with compassion, but she states, “Oh I don’t think I use it that much.” What can I do, besides make a recording and play it back to her?

  • http://www.thesecriticalmoments.com/ Kate

    These words are definitely fillers. I am a transcriptionist and I commonly eliminate these words from completed transcripts, but for those that require a strict verbatim style, they are often shocked to find the number of “you knows” in their transcripts. The answer might be as easy as requiring additional English classes during the education of physicians and other health care workers, and I would suggest that each and every resident be required to edit their own transcripts that are completed in a strict verbatim style for a period of time. It has been said that we learn best by doing, and I believe that by editing their own transcripts and having to submit the before and after product to either their professors or their residents that they will absolutely change their manner of speaking and make them better communicators.

  • http://Www.drmartinyoung.com Martin Young

    Bit like ‘Y’all know what I mean?’ or ‘Understand what I’m saying?’ I hear this most of all on television programs about the US prison system.

    Either nervousness or a verbal tic. An opinion from a linguist would be useful.

    Know what I mean?

    Know what I mean?

  • http://drsamgirgis.com Dr Sam Girgis

    It would be nice to eliminate the phrase “you know” from our interactions with patients, I agree. Another phrase or word that should be eliminated is “okay”. “We’re going to start you on antibiotics, okay”. “We’re going to send you for an ultrasound, okay”. While we’re at it… let’s eliminate the word “okay” at the same time. Thanks.

    Dr Sam Girgis
    http://drsamgirgis.com

  • http://www.myinterpersonal.com Mike Moyer

    Affirmation phrases used during the entire communication process can be destructive. Using those terms many times during a conversation are not just fillers, but may very well make the patient feel uncomfortable asking questions. When you say “you know”, the person you are communicating with may interpret it as “You should know”. This may prevent questions from the patient.

  • Mindy

    As a patient, I could care less what common conversational words a doctor says to me as long as I’m not talked down to, interrupted, or dismissed.

    With all due respect, I opened this column expecting to see worse words than “you know”.

  • BladeDoc

    You know is merely a verbal tic, meaningless and edited out by selective hearing in almost every individual except those in which it is a pet peeve. Similarly, “like” which was the purview of only valley-speak 15 years ago is an accepted way to express the gist of an event or paraphrase in modern parlance.

  • Natalie Sera

    Instead of “you know”, one could say “ummm,” “errr”, or “ahhh”. The Japanese say “Eh toe neh,”. It JUST a filler, when the next word won’t come to your tongue readily, and is absolutely meaningless. People all over the world have their filler words; why shouldn’t we? It’s not natural to talk without breaks, pauses or fillers. NO one talks like a news reporter, who is reading from a script anyway. How about spending your thinking time on something medically useful, rather than acting like a pedantic English teacher?
    Natalie A. Sera, BA, UCLA, Linguistics.

    • Andrew

      I argue that this remark is a bit unfair. I think the point here is that “you know” isn’t actually meaningless, that overuse of “you know” is sending the wrong message to patients who need to be able to feel comfortable asking important questions. Being told “you know” over and over again, in my opinion, puts people in a position where they tend to feel uncomfortable asking important questions. While your Japanese filler comparison is interesting, I find it a bit tangential.

  • conzag

    These annoying interjections were imprinted long before medical school, and are quite resistant to change. A far more noxious attack on English comes from Twitter and its ilk!

  • Andrew

    When I was in speech class in college we had in exercise that helped me to eliminate Uhhhs, Ummms, Likes, and other unnecessary and diluting speech elements. Whenever a speaker would use one of these words the entire class would snap their fingers. It was a very embarrassing exercise but I swear it worked miracles.

    Great article. I hear “you know” about a hundred times in speech, daily, and it is quite distracting. Spot on analysis!

  • http://twitter.com/phlu phlu

    Personally, I believe use of the term “any” (versus the term “what”) is far more destructive to physician-patient communication. For example: “What questions do you have?” as opposed to “Do you have any questions?” Using “any” tends to shut down discussion (or lead to a “no” from the patient). Using “what” recognizes that the patient probably has more to say, and is getting an invitation from her doctor to share it.

  • http://www.rugbymedical.com Zev

    I agree that it would be nice if people would speak more fluently and not lapse, into “umms” and “you know”, etc.

    However, I feel that a more important aspect of communication goes beyond what is said or told to the patient. Giving advice and explaining procedures is essential – but before that, the doctor should make an effort to really “see” the patient as they are – a person in pain who wants help. They should make it clear – verbally – that they empathize with the patient’s plight. That empathy will ease a lot of the patient’s pain – just knowing that someone really cares.
    That I believe can go a long way in improving doctor-patient communication. Not to mention husband/wife, parent/child relationships.