Don’t overwhelm patients with unnecessary detail

Dont overwhelm patients with unnecessary detail

It is not an easy time to be a physician in the United States.  Attempt to order an expensive test for a patient and an insurance company is likely to second guess your decision.  Try upholding the bottom line for your medical practice and the government will probably start questioning whether you are overcharging for your services.  To make matters worse, even patients are getting into the act, with an increasing number of them embracing their role as “empowered patients” to remind you that it is they who are the decision makers of last resort, not their physicians.

But there is a simple way for physicians to reclaim at least this last bit of power, a straightforward method of reclaiming their role as the final word in medical decision making; they need to do such a thorough job of informing patients about their medical alternatives—going into unrelenting detail about each risk and benefit of each and every treatment alternative, sparing no medical detail no matter how inconsequential—until bewildered patients have no choice but to ask their doctor for advice.

In Critical Decisions, I relay a portion of a conversation between a hematologist and a patient with a very serious malignancy.  The lengthy conversation is a bewildering mix of medical jargon interwoven with complex statistics.  To provide you with just a little sample:

“So if you look at complete cytogenetic response rates in the chronic phase,” the hematologist explains, “it’s about 80%, and if you look at the accelerated phase, it’s about 15%.  So, the drug doesn’t work in advanced disease very well. If you look at patients who get a complete cytogenetic response as their best response in the Iris trial, their risk of ever progressing in the next 4 years, so about 48 months roughly, is about 8% overall.”

“That’s good,” the patient replied.

“Yeah.  So, and this is divided into people who become Philadelphia chromosome positive but appear to be in chronic phase.  And half of these are people who go to accelerated phase or blast crisis.  If you look at people who had complete cytogenetic response, this is people who had complete cytogenetic remission at any time of the trial, … if you look at people who are at complete cytogenetic remission at 6 months like you are, this is probably less than 5%, so.”

“Over 4 years?”

“Yeah,” the doctor replied. “Now if you look at the curves, truth be known, there’s a steady decline.  It’s about a risk of losing progression overall in the study of somewhere between 2-4% per year.”

“Say that part again,” the patient interjects, “because I didn’t quite follow you.”

How would you respond if you were the patient at the other end of that hematology lesson?

I have not been a patient in that situation.  But just the other day I experienced my own smaller (and lower stakes) version of that state of bewilderment.  My research assistant, Lillie, came to me asking how I wanted to deal with a technical glitch on my website.  She explained my alternatives, each of which had their own pros and cons.  Something, I believe, about PHP program needed for such and such, and then something else about browser compatibility issues for whachamaheck.  And of course by now you know exactly how I responded to her: “Lillie, what do you think I should do?”  She told me which option she thought was best and I gladly accepted her recommendation.  I still have no idea what I decided!

A slew of studies in consumer psychology show that when people are overwhelmed by alternatives, they look for ways to avoid making a decision.  Place too many flavors of jam on the sampling table, and don’t expect to gain any new customers.  They’ll have so much difficulty deciding which flavor to choose, they’ll wake away without any flavor.  In medical care, on the other hand, people can’t always walk away with nothing.  They might have a serious disease like leukemia, requiring some treatment (chemotherapy versus palliative care, for example).  So rather than walk away without making a decision, they can instead simply defer to their physician. When overwhelmed by choices—especially when the choices are presented in jargon filled soliloquies—what better option than to defer to the doctor?

So docs: if you are frustrated that patients no longer accept your advice as if coming from a demi-God, just sprinkle in a few more big words, discuss a few more rare complications of each treatment choice, and the decision will be back in your hands.  Your bewildered patient will be dependent upon you for your wisdom and counsel.

On the other hand, if you want to truly serve your patients’ best interests, and share the decision making burden with them, then please take care not to overwhelm them with unnecessary detail.  And remember to use words that don’t require a medical degree to understand.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

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  • carolynthomas

    Dr. Ubel, thanks so much for this perspective on unnecessary detail in doctor-patient communication. At first, I feared you might be heading down that Good Ol’ Days road to the days when telling patients any details deemed unnecessary (by the doc) was simply not done – details like “your cancer is terminal”. But your hematologist script put my mind at ease – I was begging for mercy by the end of it.

    I’ve had conversations like this with cardiologists (somebody give these guys a cardio/English dictionary, please) and my only remedy was to raise my hand in mid-bafflegab and ask for a simultaneous translator to be brought in. That usually does the trick. It doesn’t mean, however, that I don’t still expect a thorough and clear explanation of whatever’s going on, as well as my doctor’s opinions on a range of options to address that.

    I liked what Dr. Joe Ketcherside observed recently about patients in his response to a post about Medical Googlers: For example, he wrote:

    “Normal people gather information on all kinds of topics and evaluate its content and reliability all the time. We have to decide what car to buy, what type of mortgage to use on a home purchase, where to vacation. We often also have a job that has professional responsibilities and must maintain our knowledge of our specialty. We sometimes have actually gone to college and even graduate school where we learn all about doing research.

    “So – sorry to the other physicians who disagree – but a
    great many of your patients are perfectly capable of researching their
    illness and in short order, knowing more about it than you do.”

    • randommomster

      Indeed. I don’t have a medical degree, but I don’t need baby talk, either. It’d be nice if the doc took his/her cue from the patient’s language. If I use the word “urinalysis” then I am probably fine with discussing its results, and not those of the “pee test.”

  • Shirie Leng, MD

    What people don’t realize is that while you may be able to look up your diagnosis and “know more about it than the doctor does”, every patient is different and every disease acts somewhat differently in each person. Patients don’t have the broader experience with multiple patients with the same disease.

    Your disease is your own personal experience, and you can make decisions about you with your disease. But you can’t extrapolate your experience to anyone else’s. Some people want a lot of information, some don’t want any. Your primary care doctor might know you well enough to communicate in the way you want but a specialist doesn’t. What he says might not be enough for one patient and scare the next one half to death.

    • meyati

      I just want the truth so that I can deal with it. 3 doctors- 3 opinions. I think that I do want door number 3-I’m betting my life on it.

  • WarmSocks

    Up until the final paragraph, I was going to point out that patients bewildered by too much jargon-filled detail are not dependent on an arrogant doctor to make the decision. Patients will go find a doctor who understands the subject well enough to explain it clearly.
    Unless you ask, you don’t really know how much information the patient wants or is able to understand. My former doctor didn’t want to “overwhelm” patients with too much detail. I don’t even need all the information directly from the doctor. A list of reliable websites so I know where to find trustworthy information would be a great starting point.

  • Peggy Zuckerman

    The most important message is the the patient should “not be overwhelmed with unnecessary detail”. Few people would argue with that. Unnecessary details are simply unnecessary, but the essential facts and the information that is necessary needs to be given to the patient–in an effective manner. To discuss PFS, p value, cohorts and such is not the same as explaining that “Patients who are very much like you seem to respond better by 40% to treatment one, and this is due to the medication, not to chance. Nevertheless their disease can also come back, which seems to happen to 2 in 5 of patients after about 3-4 years.”

    It’s all about be effective in communication, not using a language that is more a dialect spoken between 10 families in a certain mountain pass.

  • Dike Drummond MD

    One of the most important skills of a good doctor is translation. This is a two-way art. I translate the way a patient describes their symptoms into language I can understand prior to making my diagnosis. Then I translate my diagnosis and all the medical information back into THEIR language so the they can understand. Everyone is different.

    A college professor
    A carpenter

    A non-english speaking farm worker
    You, the reader.

    My job is to translate into your language. I do my best and then comes the most important step. I ASK YOU IF YOU HAVE ANY QUESTIONS OR IF THERE IS ANYTHING YOU DON’T UNDERSTAND. I would say I am sorry about those caps … and I am not. Failing to ask questions is the #1 largest black hole in any doctor’s communication skill set.

    The doctor in this example is droning on and on in his own head with the patient only as a witness to his ramblings. THAT is a crappy doctor who is involved only at the intellectual level with this patient. I hope he was only temporarily knocked out by this particular diagnosis and is not like this with all his patients.

    Ask questions. Always assume you are NOT communicating perfectly. Help them to help you. And it saves time too, by eliminating the kerfuffles that result if you fail to communicate.

    Dike Drummond MD

    • meyati

      Just because a patient understands doesn’t signify that a patient can decide which state to go to for the treatment in 90 seconds. Whether it’s physician speak or farm worker speak-a person should have a day to make up their mind about radical cancer surgery and where to have it. I think that my doctor is desperate to help me, but I needed some time and a chance to see the rest of the doctors that he recommended me to. As far as talking to a carpenter-in one post-my father had a construction company-he also became head of the UCLA math department. We shouldn’t stereotype-

      • Dike Drummond MD

        Of course 90 seconds is not adequate to make an important decision meyati. Not sure where you got that from my reply. That expectation of a snap decision on such an important decision is unreasonable and flat out strange. In most cases you have time to think and consider your options. Unless it is an in-the-moment life or death situation. Unfortunately those emergencies do come up sometimes.

        If that is not the case, you need time to decide once you understand the different choices and their implications That’s why it is important for the doctor to ASK if you have any further questions in that moment.

        Once you have your initial questions answered, more will come up in the days following an important discussion like cancer surgery, My intention is to make sure in this first encounter that you leave with your questions answered in that moment.

        More questions would ideally trigger further discussion and/or second opinions, until you feel able to make a decision on how to proceed.

        I am not stereo typing. Your father and I would have a discussion that was appropriate for his experience … as BOTH a construction company entrepreneur AND a head of a UCLA math department and that discussion would be very different than if my patient were a short order cook, another doctor or any of the myriad types of people in the world. The doctors job is to practice the skill of putting the information in YOUR language and not just couching it in the medical jargon that we use with other doctors.

        Make sense?

        Dike Drummond MD

        • meyati

          I think that you and my father would get along well. My father taught me how to adapt my syntax and word choice to the group that I was in, because hopefully a person speaks to communicate. I believe that both of you would have had a time, as he was also a surgery medic at Ft. Riley. But let’s admit it, if you met him on the Saturday morning Dean’s breakfast talking with mathematicians, engineers, and physicists. You would have spoken to him differently than if you saw him in worn and stained work clothes finishing a concrete floor for a new auto showroom that he designed. You would have asked him for his boss. I’m sure that we’ve all met people that speak for self-importance, domination, to cause trouble with mind games, etc. This past week, I was actually in the situation of deciding if I wanted my right side of my face, including bone, eye, etc. removed. I stared and stuttered. I was asked if I was interested in the only thing that would help me. I said, “Yes, I’m interested” to get full information from an oncologist that was closing down; referrals to other doctors; talk to my family; and most of all-to consider all options. As odd as it might sound to many people, I also have an academic interest in this. Then Thursday night and the doctor wanted to know where I wanted the surgery. He had a telephone conference with different oncologists. These are good doctors, and they’re trying to keep my treatment from being mired in paper work. I was given a definite diagnosis 11/16/12. What’s ironical is that the doctor and I were communicating fairly well, and the nurse social worker didn’t comprehend. When I saw the nurse social worker for radiology, she asked me why the first nurse said that I was mentally confused and didn’t know what was going on, because I had a very clear and logical mind. At first the doctor was condescending, when he was collecting my data. He made a comment that I had a little bit of training. I opened my wallet, and he commented that he believed me that I had a GED. I pulled out my Phi Kappa Phi and Phi Beta Kappa membership cards, and explained that I taught high school math to juniors. He crossed many things out-rewrote, and then the nurse was asea. I had to explain to her that I have atypical BCC attached to hair follicles in many pores. Then she kept saying “that’s a face transplant, that’s a face transplant.” She didn’t know what a MOHS was. The doctor and I looked at her like she was a 3 year old. I have requested somebody else if possible. How can I talk to her? Mean while, I’m reading your article with this experience happening, and you know that all readers interpret from their life experiences. By the way, I ran off some brats at a rodeo, and had the NM State Police on me. The brats were Gov. Tony Anaya’s boys. I still didn’t want them near my horse and tack. I didn’t change my syntax either-I wanted them gone.

  • Howard C. Berkowitz

    Some patients, however, want and can process detail. For myself, I often find it useful, with a new clinician, to give them my written goals for the visit, which are phrased in “doctor speak”. Another approach is to ask that the communication be as it would be to a peer, and I promise to interrupt if I don’t understand. It’s most difficult, in my experience, to get this level of communication from nurses, as long as they are in a model of “educating the patient”.

    How would the clinicians here like to be told that detail is desirable, for the particular interaction, and confidence intervals won’t be obscure?

  • Maura69

    Back in 1974 the Doctor I was working for told a patient that she had Carcinoma. The daughter came out of the room ecstatic saying “Thank God my mother does not have Cancer!” I went in to the room and asked to speak to the Doctor in his office and told him what was said, he was mortified. From that day forward he was far more cautious. Years later when my husband was diagnosed with Fibro-Sarcoma of the head and neck he accused me of being too professional. I found that I had the tendency to professionalize my emotions with my husband due to fear. Many years later I think I have gotten better but there is always the emotion that we try to shield ourselves from.

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