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Winning the Popularity Contest

June 4, 2015

I have to take issue with an article published several days ago by the New York Times about communication and the prevention of malpractice litigation (http://nyti.ms/1FXDcH1). Aaron E. Carroll, the article’s author and himself a doctor and healthcare policy writer (like me, only way more famous), has oversimplified the discussion quite a bit.  You see, communication is a two-way street.  There are characteristics on both sides of the table that hinder true understanding.  Let’s take one of Carroll’s examples :

A short while ago, the Annals of Emergency Medicine published a study that examined patient-physician communication in the emergency room on the management of acute coronary syndrome, which is chest pain caused by decreased blood flow to the heart, as with a heart attack or angina. About two-thirds of patients left conversations thinking they were having a heart attack, while physicians believed this to be the case less than half the time. The median estimate of whether a patient might die at home of a heart attack was 80 percent in patients and 10 percent in physicians. Doctors and patients were reasonably close in their estimates of danger only 36 percent of the time. They clearly weren’t hearing each other.

Here we have a classic case of misunderstanding that arises from the fact that the two communicators don’t speak the same language.  An old friend of mine says that medical school is all about learning about 100,000 new words.  So the patient thinks “heart attack” and the doctor thinks “myocardial infarction”.  That would be fine except there are ST elevation myocardial infarctions (big heart attack) and NON-ST elevation myocardial infarctions (little heart attack).  Myocardial infarctions can look very different depending on which vessel is blocked, how many are blocked, how long they’ve been blocked, and if they’ve been blocked before.  ALSO, “angina” does not mean “myocardial infarction”.  Angina is only a word for the symptoms that arise from the blockage of a vessel.  “Chest pain” is not the same thing as “angina” unless the pain is related to the heart.  Angina and heart attack are not the same thing.  Acute Coronary Syndrome is actually a fairly new term that encapsulates all of the above. ALSO, there are other problems that LOOK like a heart attack which are not heart-related at all, there being more inside your chest than just your heart.  FINALLY, it isn’t always immediately clear what, of a myriad of possibilities, a person with “chest pain” has.

How could there possibly be any confusion?

Communication is hindered not only by language, but by differences in underlying knowledge base specific to the subject at hand and to differences in receptivity. I might have a patient who is a car mechanic and he can talk ’til he’s blue in the face about cars and I won’t understand him, and I could talk about medicine ’til I’m blue in the face and he might understand me.  Neither of us is stupid or uneducated.  Our underlying knowledge of our respective areas of expertise provide unspoken background that, in essence, translates what we are saying to ourselves, without us realizing that the other person doesn’t have the same background.  Additionally, even solid background information doesn’t help when extreme emotional turmoil is occurring for one of the parties involved.  For example, Dr. Carroll cites the following:

To understand why patients file claims, we have to talk to them. Many researchers have. A study in 1992 found that about a quarter of mothers who had sued physicians because of deaths or permanent injuries in their newborn infants “needed money.” But there were answers given more frequently that had nothing to do with remuneration. A third of respondents said that their doctor would not talk openly to them, half said their doctor had tried to mislead them, and 70 percent said that they were not warned about long-term neurodevelopmental problems in their children.

Maybe the mothers who sued were all lawyers, or librarians, or rocket scientists.  No matter how educated they were, they didn’t necessarily have the knowledge base to understand that the obstetrician might have been talking to them because they were trying to save the babies’ lives at the time.  They might not understand that obstetricians are not pediatricians and don’t actually know anything about neurodevelopmental problems.  It is also possible that the obstetrician did in fact explain what was going on but the mothers were, understandably, freaking out and didn’t hear or retain the information.

The third way communication breaks down is in the areas of emotion and perspective. Human-ness, if you will. Dr. Carroll:

Decades-old studies have shown that primary care physicians sued less often are those more likely to spend time educating patients about their care, more likely to use humor and laugh with their patients and more likely to try to get their patients to talk and express their opinions. It seems that more likable physicians are less likely to have claims filed against them.

Ah.  The popularity card.  But didn’t your mother tell you that not everyone in the world is going to like you?  “Liking” someone or something is a matter of taste.  One patient could really like a doctor one day and another patient could think that same doctor is a jerk the next day.  Maybe one patient likes the doctor because the doctor gives them whatever they want.  Maybe the patient who thinks the doctor is a jerk was really just mad because he had to sit in the waiting room for an hour with nothing but a 3 year old copy of Musclemania.

I’m not saying all doctors are great communicators.  But suggesting that the whole problem with the doctor/patient relationship is that doctors aren’t communicating is akin to what the guy in the lookout perch on the HMS Titanic saw (Smell ice can ya?  Blimey!):  not the whole story.

 

 

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