American College of Physicians: Internal Medicine — Doctors for Adults ®


What did you say? Tips for talking more clearly to patients

From the December 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Christine Wiebe

While seeing a patient with high blood pressure, you explain how the patient's condition affects her heart and tell her to exercise and take her medicine. When the patient leaves, you feel like you've given her enough information to help keep her healthy until her next visit.

But have you? If exchanges like this one seem typical, communication experts say, your patients are probably not taking away as much information as you think.

According to Robert C. Smith, FACP, a professor of medicine and psychiatry at the University of Michigan who has studied physician-patient communication, patients often forget half of what their doctor tells them. And because physicians tend to do a lot more explaining than actual treating, Dr. Smith said, unclear communication can cause the whole medical encounter to fall apart.

While physicians' lack of time is one barrier to good communications, there are other problems. Whether it's using terminology that patients don't understand or not making sure that patients understand what's being explained to them, many physicians use communication techniques that simply don't make the grade. Residents, who are straight out of medical school and trying hard to impress, can be the worst offenders.

"In medical school we spend a lot of time learning how to take histories to get information from patients, and almost no time learning how to give patients information," said Christine A. Laine, ACP Member, assistant professor of medicine at Thomas Jefferson University Hospital in Philadelphia and a Deputy Editor of Annals of Internal Medicine.

Even among veteran physicians, the problem is more prevalent than many suspect. Dr. Laine has compiled preliminary results of a study examining what patients remember after seeing a doctor, and the outlook isn't good. "What we found was that patients lacked the basic knowledge that was going to get them from this visit to the next," she said.

How can you do better? Experts say that by paying attention to some of the subtle clues that patients provide and focusing your patient interviews, you can communicate better—without spending a lot of extra time. Here are some tips:

Get rid of the lingo. The communication gap often begins the moment a physician enters an exam room, experts say, because clinicians' information base—and their vocabulary—is so different from that of patients. " 'Esophagus' might not seem like a big word to us," explained Dr. Laine, "but a lot of patients don't know what that is." To get away from using language that patients may not understand, she tries to think of the patient as a layperson close to her—her mother or grandfather, for example—and then talks at a level that person would understand.

But learning to talk without lingo is a challenge, particularly for housestaff early in their training. Theresa T. Pham, ACP Associate, chief internal medicine resident at Good Samaritan Hospital in Portland, Ore., said that housestaff fresh from medical school tend to get caught up in the technical side of medicine. "As an intern, you're sort of selling your role as a doctor," she explained.

To resist the urge to overuse medical terminology, Dr. Pham tells residents to break down clinical information into common terms. She said this not only helps housestaff explain difficult concepts to patients, but it also helps residents understand them better themselves.

Be clear, be organized. When talking to patients, rely on the simple communication techniques that apply to all interpersonal interactions.

To start, said Dr. Smith from the University of Michigan, speak in short, clear sentences. And when you're presenting more complicated information, he said, try falling back on an old English class rule: Put it in outline form.

Instead of launching into a detailed explanation of how high blood pressure affects the heart, for example, Dr. Smith suggested this type of explanation: "First, we're going to talk about the heart, and then we're going to talk about the blood pressure."

Be specific. Instead of telling patients to "take your medication and get some exercise," try giving more specific advice, Dr. Smith said. His suggestion: "Take a pill when you first get up and another at bedtime, and walk around the block once in the morning, and again in the afternoon."

When you're talking about specific parts of the body like the heart, Dr. Laine added, it can help to draw pictures. She noted that some doctors even sketch drawings on the paper covering their exam table.

Ask first. Ask patients what they know about their condition and treatment plan before you talk to them, said Dr. Smith.

While some patients will have researched their condition on the Internet, for example, others will not even recognize the name of their disease. Because of such a wide range of patient knowledge, said Wendy S. Levinson, FACP, chief of general internal medicine at the University of Chicago School of Medicine, it's often useful to start out with a comment like, "It would help me to know what you already know about high blood pressure." In addition to learning what patients already know about their health, you'll pick up on the patient's attitude about health care, information that could affect how they process information you give.

Quiz your patients. Even if you think you're doing a great job of communicating, don't assume that the patient understands what you've explained, experts warn.

The only true measure of how well you're doing, Dr. Laine said, is to ask patients what they're hearing. "We should not assume that if they don't ask, they understand," Dr. Laine said. "We need to ask them whether they have any questions and ask them to repeat information back to us."

Dr. Levinson from the University of Chicago said that many physicians fail to consider that a patient might not be receptive to the information they are doling out. Just because a doctor explains something clearly, "that doesn't mean the patient believed us or incorporated the information," she said. The only way to determine the outcome is to question the patient and give him the opportunity to express any doubts or differences of opinion, she said.

For instance, asking patients if a treatment plan sounds too complicated gives them an opportunity to admit that they have no intention of following it, Dr. Levinson said. At that point, you may need to alter the treatment plan or spend more time educating the patient.

Just to make sure that you and the patient are on the same page, Dr. Smith suggested concluding patient encounters this way: "We've talked about a lot of things; let's make sure we understand each other." Then he asks patients to explain what they have learned during the visit.

Write it down. If you're not sure whether you're getting through, Dr. Smith said, try writing out your instructions, particularly for elderly patients with multiple conditions and medications. Preprinted handouts can also be very helpful for common conditions like diabetes and high blood pressure.

Give more, not less. While you want to avoid overwhelming patients with information they don't really need, experts say you shouldn't worry about overloading patients with too much information. In fact, more than one study has found that the real problem is just the opposite. "Doctors aren't giving nearly as much information as they think they are," Dr. Smith said, "and not nearly as much as patients want."

Focus on priorities. At the same time, physicians can only spend so much time with a given patient, so they need to focus on the most important topics, said Dr. Pham from Good Samaritan in Portland. She encourages residents in her program to start each interview by establishing the issues they will deal with that day. For instance, a resident might start this way: "We have 20 minutes today, so how can we make the best use of our time?" If other pressing issues remain, Dr. Pham said, the resident should ask the patient to make another appointment just to talk further.

To help residents learn to focus their patient interviews, Dr. Pham said, faculty regularly meet with housestaff to discuss difficult patient encounters. Residents are also encouraged to videotape their patient encounters so they can see first-hand what is going on.

Dr. Levinson said that an even easier approach is to record a patient interaction using a hand-held tape recorder. Residents can learn a lot from listening to themselves talk, she said, because many mistakes are fairly obvious. "When we draw our own attention to it," she said, "we can change."

Christine Wiebe of Providence, Utah, writes frequently on issues related to medical residency.

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