In the past few decades, the “patient revolution” has empowered patients to become informed, active participants in their own health care experiences. Strong patient-physician communication is at the heart of this revolution. Unfortunately, physicians may be inadvertently undermining this effort due to our underdeveloped communication skills. As part of my doctoral program in consumer behavior, I read more than 300 transcripts of conversations between patients and physicians to better understand how they communicate with each other. As I did, I was struck by the difficulty many physicians had communicating effectively with patients despite their best efforts. In 2017, my colleagues and I published an ethics paper in which we described several ways physicians struggled to communicate with patients and offered some suggestions for improvement.
One major way physicians struggled was in providing information in a clear and concise manner. The transcripts, which were obtained from 2008 to 2012 within four Veterans Affairs medical centers across the country, showed that in an attempt to fully inform patients, physicians often provided lengthy, convoluted explanations. For example, Dr. Maxwell* said the following when trying to explain to Mr. Seward* that he had prostate cancer:
Dr. Maxwell: We grade prostate cancer on how it looks under the microscope. We give it a score between six and ten.
Mr. Seward: Is that the Teason?
Dr. Maxwell: That’s the Gleason Score.
Mr. Seward: Oh, Gleason Score, ok.
Dr. Maxwell: Yep, so six is what we consider the most low-grade, least aggressive-looking, but it’s the most ... it’s just abnormal enough for us to call it cancer. If it were any less than that, if there were less atypical looking cells, we couldn’t call it cancer. So it’s just enough to get a grade of cancer and then that goes all the way up to a score of ten, which is very abnormal looking and is more aggressive.
Mr. Seward: But six is the beginning number?
Dr. Maxwell: Six is the least aggressive, ten is the most aggressive.
Mr. Seward: I’m used to like, one (laughing)
Dr. Maxwell: Yeah well, the way we typically split it up is into thirds: low risk, intermediate risk, and high risk.
Mr. Seward: Right.
Dr. Maxwell: Low risk is Gleason six, intermediate is usually sevens, either three plus four or four plus three, depending on how it looks under the microscope, and then eight, nine, and ten are all high risk. So yours was an intermediate risk. So it’s in the middle. It was three plus three and three plus four, so just enough of the atypical cells of the grade four to make it three plus four, which means you’re intermediate risk.
I believe Dr. Maxwell had good intentions and was sincerely trying to educate Mr. Seward about his cancer. Unfortunately, he seems to have forgotten that words like “Gleason score” and “atypical cells” are probably unfamiliar to most patients. In medical training, we spend so much time learning a whole new language in order to communicate clearly and precisely with other medical professionals, it’s easy to forget what words are “normal.” In addition to using medical jargon, physicians also struggle to communicate clearly due to a perceived “ethic of information.” In other words, we feel an ethical and legal responsibility to ensure that patients are fully informed and educated about their medical conditions. Unfortunately, this can backfire when it leads to long-winded monologues and an overabundance of details that may not be relevant for the patient and/or can result in “information overload.”
As noted above, strong patient-physician communication is a key part of the patient empowerment revolution. After reading these transcripts and having my own clinical experiences, it is clear that we have a long way to go. Communication, like any skill, requires training, practice and feedback in order to hone the skill and improve. I wrote my entire Ph.D. dissertation about patient-physician communication, but I still slip up and occasionally provide long-winded, jargon-ridden explanations without realizing it. As a physician, I love when my patients provide feedback and ask for clarification when something I’ve said is unclear. Unfortunately, patients face numerous barriers when trying to speak up, and many struggle to become fully active participants in their own health care experiences.
At a minimum, we as physicians should be more attune to the language we’re using and how the patient is receiving it. Even better? We should actively seek feedback from our patients about how we can improve our communication, and then put it into action.
*Names have been changed to protect the privacy of individuals.
Karen Scherr is a first-year resident with the Duke Family Medicine Residency Program. Email karen.scherr@duke.edu with questions.
Editor’s note: Duke Family Medicine residents guest blog every month. Blogs represent the opinion of the author, not the Duke Family Medicine Residency Program, the Department of Community and Family Medicine or Duke University.