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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