What? When Patients Just Don't Understand You

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Cover Story - April 2007  


ByErin Prather Stafford  

Picture yourself entering a room where a scientist hands you a textbook on nuclear physics. You are then told to read the first chapter in 30 minutes. Afterwards, you will be quizzed to test your understanding of the material, and you'll also have to tell the scientist what you comprehend. Understandably, the situation makes you feel intimidated and a bit overwhelmed.

This scenario is what Michael Speer, MD, professor of pediatrics and neonatology at Baylor College of Medicine in Houston and member of the Texas Medical Association's Board of Trustees, describes when educating colleagues about communicating with patients.

"A physician is not going to understand nuclear physics in 30 minutes. Most of us don't know the language, background, or exactly what nuclear physics is. Likewise, a patient is not going to understand medicine in 30 minutes. Medicine is an entirely new language for many patients, and it's the responsibility of physicians to ensure they understand what we're saying," he said.  

In February, the Joint Commission released a public policy white paper, "What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety." The paper examines communication gaps between patients and caregivers, and lists literacy, language, and culture as significant challenges.

"Effective communication is the cornerstone of patient safety," said Joint Commission President Dennis S. O'Leary, MD. "If patients lack basic understanding of their conditions and the whats and whys of the treatments prescribed, therapeutic goals can never be realized, and patients may instead be placed in harm's way."

As an example, the commission cited the experience of a 66-year-old man diagnosed with atrial fibrillation. He did not ask his physician to clarify the complex medication regime prescribed for him when he was discharged from the hospital. His physician was then surprised when the man returned to the hospital with internal bleeding caused by an overdose of the medications he'd been prescribed. He had ignored the physician's written instructions and orders for follow-up visits. They were useless because the man could not read. 

What Do They Understand?  

In the 2004 report, "Health Literacy: A Prescription to End Confusion," the Institute of Medicine (IOM) defined health literacy as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. The report says nearly half of all American adults have difficulty understanding and using health information.

Additionally, a 2005 article in the American Family Physician ( AFP ), "Health Literacy: The Gap Between Physicians and Patients," reports that while most adults read between the eighth- and ninth-grade level, most health care materials are written at the 10th-grade level. The authors suggest most physicians make the mistake of asking patients what highest grade level of education they've completed to determine literacy. Research has shown the final grade level completed is usually higher than the actual level of literacy.

Even a college graduate may have difficulty comprehending health information, warns Josie Williams, MD, director of the Texas A&M University System Health Science Center's Rural and Community Health Institute and a member of TMA's Board of Trustees.

"People with high literacy skills can also leave a physician's office without understanding what they're supposed to do regarding treatment. Research in chronic care management has shown a patient's lack of comprehension decreases compliance, increases hospitalization (particularly for the elderly), and can prove financially costly in addition to impairing the physician-patient relationship," she said.

States the AFP article, "Educational materials should be short, clear, and simple, and should include pictures… [S]implifying patient education material by writing it at a sixth-grade level or lower increases comprehension, and patients with adequate literacy prefer to read health information that is written at a lower grade level."

A 2006 study published in the Archives of Internal Medicine concludes that when initiating new medications, physicians often fail to communicate critical elements of medication use, leading to patients' failure to take medications as directed. In fact, patients who receive less counseling may be less likely to adhere to their prescribed regimen because they do not understand how to take their medication.

The article cited the following example of a physician's instructions to a patient about an antibiotic:

Physician: "If I'm writing antibiotics, are you allergic to penicillin?"
Patient: "No, I'm not allergic to anything."
Physician: "Okey dokey."

It is unclear what medication has been prescribed, nor was there instruction on how to take the medication. The physician also failed to mention potential adverse effects. The article suggests lack of instruction might lead patients to not complete an antibiotic course and could especially be a problem for those who have difficulty reading medication container labels.  

"Poor literacy skills have often been misinterpreted as the patient doesn't care or is incapable of understanding their treatment," Dr. Williams added. "Physicians must understand that one out of every two patients who come into their office will leave without understanding what they're trying to get them to do. But research has shown that if patients understand what their physician wants them to do, they are more likely to do it for a longer period of time."

Both Dr. Williams and Dr. Speer recommend that physicians encourage their patients to repeat the treatment instructions they've been given. Dr. Speer says it sometimes takes patients with low literacy skills two or three times to repeat instructions appropriately, especially for medication.

"Asking the question 'What do you understand about your illness?' takes very little time and can help a physician conclude whether a patient does or does not understand the nuances or realities of their illness," Dr. Speer explained.

"The physician does not necessarily have to be the one to ask the question. Someone on his or her staff can conduct the follow-up. Do not say, 'Do you understand?' because anyone wanting to look halfway intelligent is going to reply, 'Yes.' Physicians need to make sure patients can expand on what they understand and that they can address areas of confusion. Just think of all the misunderstandings and after-hour calls that could be avoided if this step is taken." 

More Than Spoken Words  

At TMA's 2007 Winter Conference in February, University of Toronto oncologist Robert Buckman, MD, made a presentation on patient-physician communication. Specifically, he discussed the importance of physicians acknowledging their patients' emotions and being sensitive communicators.

"It's not simply what we say that counts, but how we say it," he stressed. "The physician-patient relationship can, in fact, change the outcome of that patient's treatment."

Using anecdotes, Dr. Buckman illustrated how poor or good communication alters a patient's perception of his or her physician.

One example concerned a physician who was being trained in patient communication. The scenario he was given was of a patient with lung cancer. Her chest x-ray showed the tumors had grown. The patient began sobbing and cried out, "Oh my God!" The physician, taking his first stab at empathetic communication, said, "You know, they're not that much bigger." He then tried, "There's no need to cry." The instructor suggested the physician try, "This must be awful for you."

"That response worked," said Dr. Buckman. "It's a basic empathetic response that gives the other person permission to feel terrible, it legitimizes the awfulness of the situation, and for a few seconds it changes the subject. Right then, for a few seconds, the physician and patient are talking about her emotions. This surgeon wasn't stupid or insensitive; he just had no idea what to say at that particular moment. He had not been taught how to respond to a patient crying."   

Until recently, many physicians learned to communicate with their patients through watching senior physicians and personal experience, because such skills were not taught in medical school.

Dr. Speer recalls those days. As a student he was told an authoritative stance when talking to a patient was the norm to follow. His outlook changed when he witnessed a cardiologist enter a patient's room, sit down on the bed, take the woman's hand, make direct eye contact with her, and then explain her medical condition in simple terms.  

"He was in and out of the room faster than the traditional model, her family obviously adored him, and the patient understood what was happening. From that point, the cardiologist's example became my model. As a neonatologist, I sometimes have to give bad news. I always try to sit down at an equal or lower level to the parents and use simple words to explain what is going on."

Dr. Buckman emphasizes the importance of eye contact. He recommends physicians keep their eyes on the same level as their patients. Otherwise, he warns, the patient might think the physician isn't listening. Regarding a patient's emotions, Dr. Buckman suggests identifying existing emotions and their source and responding in a way that shows.

"Start with open-ended questions such as 'How are you feeling?' or 'How's it going?' And when the other person is talking, be quiet. The trust you can build by letting people say what they feel is incredible. And when you respond, use a word or phrase from the other person's last sentence. That kind of repetition signals, 'I heard what you said.'"

While face-to-face and written instructions have traditionally been the primary methods for physician-patient communication, many physicians are incorporating technology to address patients' needs. E-mail allows physicians to send written follow-up instructions and test results and give patients educational materials.

Patients in turn can easily reach their physician concerning routine health matters. Nonetheless, although the patient receiving the e-mail likely is literate, physicians should still write messages in clear, simple terms. Likewise, information presented online or as attachments should also be at a lower literacy level.

"The main thing is not to overwhelm your patient with too much information," said Dr. Speer. "If you're explaining a complicated condition and treatment, break it down for the patient. People when presented with more than two or three new ideas are not going to remember them. One is best, two is pushing it, and three is really pushing it, unless the third has something to do with the first two. It's just impossible. When communicating information to patients, the language texture needs to be very basic."  


Selected Patients Stories

The Joint Commission says communication breakdowns stemming from poor health literacy can take many shapes. Furthermore, people with literacy impairments come from all walks of life; however, educational level, socioeconomic status, and age are all associated with lower levels of health literacy.

Here are a few examples the commission cites of how poor communication can affect treatment.

Culture Clash
A concerned wife consented to have a "percutaneous endoscopic gastrostomy tube" inserted into her husband, not knowing it was a '"feeding tube," which was against the family's wishes.

Physical Impairment
Mr. Garcia needed to have his surgical staples removed. So when a resident entered his room, he asked the man in bed if he was Mr. Garcia. The man smiled and agreeably nodded his head. He then had his staples removed … prematurely. He was not Mr. Garcia. Rather, he was a man who did not hear well and who had the habit of smiling and nodding in response to something he did not understand. Mr. Garcia's hearing loss contributed to the error.

Overwhelming Forms
One woman put it this way: "I've had a lot of illnesses, but I preferred to stay home, until I get better by taking anything I can. Because being asked to fill this out, to fill that out, I feel embarrassed to ask for help, to ask them to fill them out for me. They might get upset or they would say, 'This lazy lady, she never learned to read,' that's how I think."

A complete copy of the Joint Commission white paper, "What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety," is available online at  www.jointcommission.org.


Toolkits Ensure Patients Understand Medications

The American Academy of Family Physicians (AAFP) Foundation and the American Medical Association Foundation have developed toolkits   and resources to enhance physician communication about medication.

Patient education resources in the AAFP Foundation toolkit, Play It Safe … With Medicine, include:

  • Separately developed English- and Spanish-language brochures that include specific guidelines to help patients better understand and follow their physicians' medication instructions;
  • Pictorial stickers to help readily identify some of the more common types of medication;
  • An English- and Spanish-language DVD featuring testimonials from physicians, patients, and pharmacists that can be played in the waiting room to highlight the proper steps involved in taking medications; and
  • A pillbox display designed to help patients take their medication properly.

The toolkit also contains physician tools and resources, including a prescription pad cover with an accompanying prescription pad reorder request sample, both of which incorporate a language checkbox so that patients can request patient education materials in their native language from the pharmacy.

AAFP members pay only a $14.95 shipping charge for the toolkit; nonmembers pay $25.95 plus the shipping fee. The toolkit may be ordered online at  www.aafp.org or by calling (800) 944-0000 and requesting item No. 660.

The Health Literacy: Help Your Patients Understand Educational Kit is the AMA Foundation's primary tool for informing physicians, health care professionals, and patient advocates about health literacy. The kit includes:

  • A documentary and instructional video,
  • An in-depth manual for clinicians,
  • Continuing medical education credit, and
  • Additional resources fro education and involvement. 

Kits can be purchased for $35 each through the AMA Bookstore ( www.ama-assn.org ) or by calling (800) 621-8335. (If you're calling, mention AMA Bookstore item No. 0P221002.)


Insurers Offer Tips on Communicating With Patients

The Texas Medical Liability Trust (TMLT) and The Doctors Company have advice for physicians on communicating with patients. Good communication, they say, not only improves the overall physician-patient relationship, but it also might keep you out of a courtroom.

TMLT has a wealth of information in "Rx for Success: Communicating to Reduce Risk," posted on its Web site. Log on to www.tmlt.org, click on Reduce Your Risk, then Risk Management Publications. The article, which was reviewed by TMA's Advisory Committee on Risk Management and the TMA Office of the General Counsel, includes communication information that both physicians and office staff can use in all aspects of a medical practice's operations.

"The management skills of physicians and office staff are frequently learned by accident, rather than purposefully developed," the article says. "Inexperienced and poorly trained staff are put in positions for which they are not prepared. Inadequate skill in communication and patient relations, as well as in appointment management and complaint resolution, often result in staff members becoming as frustrated as patients and problems remaining unsolved. In the long term, this lack of attention to staff development and quality service results in poor financial returns."

The Doctors Company says in a risk management article on its Web site ( www.thedoctors.com ), failed communications "is the most common element in adversarial physician-patient relationships." The company says communication issues "are at the crux of many medical malpractice claims. A medical malpractice claim almost always fails to reveal the unseen emotional and psychological factors that triggered the patient's visit to an attorney."

The Doctors Company article lists 10 bad listening habits physicians should avoid because they can lead to serious misunderstandings and problems:

  1. Dismissing the subject matter as uninteresting. Effective listening requires attention, patience, and suppression of the urge to control the conversation.
  2. Feigning attention. Most people can sense when someone is pretending to listen or is merely showing superficial interest.
  3. Avoiding difficult material. There is often a tendency to shy away from material that seems to demand more of our thoughts and time.
  4. Allowing distractions. When communicating with a patient, do not allow distractions that steal attention and make it difficult to listen effectively.
  5. Finding fault with the speaker. Focusing on a patient's mannerisms or physical characteristics can prevent you from focusing on what is being said.
  6. Listening only for details or facts. Medical training and examinations are geared toward facts and figures and fail to take into account the equally important emotions, behavior, and intentions of the patient.
  7. Becoming overstimulated by something the speaker says. Becoming enthusiastic about a speaker's style or presentation can cause you to suspend judgment about what the speaker is actually saying and to misinterpret what is being said.
  8. Allowing emotion-laden words to arouse personal antagonism. Certain words or phrases can trigger negative emotional reactions in the listener and lead to distraction from what is being said.
  9. Taking notes. Although taking notes is essential to obtaining a patient's history, it can distract your concentration or continuity of thought and increase the patient's anxiety.
  10. Wasting the advantage of thought-speech speed. Most people can assimilate 500 words per minute but can speak at only 125 words per minute. The extra time is often used to think of something other than what the speaker is saying. Communication is more effective if you focus only on what is being said. 


TMA Practice e-Tips Can Help, Too

TMA Practice e-Tips , the monthly electronic newsletter hat gives you hands-on, use-it-now advice on subjects such as coding, billing, reimbursement, HIPAA compliance, office policies and procedures, and practice marketing has addressed physician-patient communication issues.

In 2005, for example, e-Tips provided some guidance on how to handle patient confrontations:

Recognize Your Weaknesses
The human body reacts quickly to challenge, and the natural tendency is to fight or take flight. So the first step in managing a confrontational situation is to recognize your personal physical and emotional reactions and then take steps to get them in check. Do you become flushed or begin to cry? Do you avoid eye contact and begin to make excuses, or do you lose your temper quickly or get sarcastic and nasty right back? Ask your family and coworkers for some feedback so that you can take proactive steps to improve your communication style.

Verbal Communication Techniques
If you communicate in ways that show empathy for and understanding of a patient's situation, you will stand a better chance of reducing tension and resolving problems, even if you disagree with the patient's point of view.

Try this three-step assertive response to take control of the situation.

  1. Wish I could . This phrase is an empathic way to say "no." Use it with a sincere tone of voice to let the patient know that you really would like to help, but you can't. "I wish I could do that for you, Mrs. Baker, but our policy is very clear."
  2. Agree in principle . Rather than argue over an issue, use this technique to acknowledge that the patient's point of view is possible and then present what you are willing or able to do. "I can understand how you might see it that way. …" This technique not only shows empathy for the patient but also validates your understanding of the complaint.
  3. Broken record. This technique is most effective with patients who keep trying to get you to do something their way. Your response is to stay firm, use a calm tone of voice, and repeat over and over what you are willing or able to do. Don't waste time coming up with new excuses or reasons why; this just engages the patient in an argument and suggests that the policy can be changed. Simply repeat your position politely and calmly. This technique is particularly effective with patients using abusive language, whether in person or on the telephone.

Tips for Nonverbal Communications  

  • In a confrontational setting, your tone of voice should become slightly firmer and deeper, not necessarily louder.
  • Be careful to keep a calm, businesslike tone even though it is very easy to be sarcastic or patronizing.
  • Keep direct eye contact with the patient and a straight posture. This adds to your credibility.
  • Put yourself at the patient's eye level. If the patient is standing, stand up, or if the patient is sitting, sit down. Also, if you are much shorter or smaller than the patient, you may appear to be at a physical disadvantage. Asking the patient to sit down with you reduces that difference.
  • If possible, move an angry or disruptive patient to a private office so that other patents and staff are not disrupted.

You can subscribe to TMA Practice e-Tips by sending an email to Pat Overton, or through an RSS feed by clicking here. You can download an RSS reader, such as Feedreader, Sharpreader, Sage, or NetNewsWire Lite. You also can subscribe to RSS feeds for TMA news releases, for Blogged Arteries , for Action , and for TMA's new weekly newsletter on the health information technology industry. 

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