Mrs. Jones is a 38-year-old woman who has returned to Dr. Smith’s office to learn the results of focused imaging and a fine needle aspiration biopsy of a large unilateral neck mass, which was performed the prior week. Mrs. Jones is accompanied by her husband and young adult daughter, and all are quite anxious to receive the results. Dr. Smith enters the room, greets the family, and, while standing and leaning against the cabinet, tells Mrs. Jones that the diagnosis has been made.
Explore This IssueSeptember 2021
Dr. Smith: You have Hodgkin’s disease, which is a proliferative neoplasm of the lymphoid tissues in the body.
Mrs. Jones: Wha– what does that mean?
Dr. Smith: It means you have cancer in the neck, Mrs. Jones.
Mrs. Jones: (Gasps.) Oh, no! How could that be? I’ve been in good health and I don’t have any history of cancer in my immediate family.
Dr. Smith: Well, sometimes these things just happen. I’ll refer you to a medical oncologist who will continue the evaluation to stage the cancer and treat you. She’ll conduct the follow-up exams, so I won’t need to see you back.
Mrs. Jones: But, what are my chances, Dr. Smith? And, what about the risk that my daughter will get it?
Dr. Smith: Now, no need to worry yourself about this. This is easily treated and the risk to your daughter is really quite low. Just go out for a nice dinner and a good night’s sleep. You will hear from the oncologist’s office to schedule an appointment with her. Have a nice day.
Mrs. Jones: What do you mean about not to worry? How can I keep from worrying?
Dr. Smith: Mrs. Jones, I’m sure you’ll do just fine—you’ll probably live to be 100!
In the car on the way home, Mrs. Jones says to her family, “Well, it doesn’t sound too bad if I’m going to live to be 100 years old, right?”
What are the five ways this patient interaction could have been done differently? See below for a discussion.
One of the hardest responsibilities physicians need to learn in medical training is how to effectively communicate with patients in a manner that respects their autonomy, engenders trust, and provides information that’s critical to the patient’s understanding of his or her disease and treatment. Experience in communicating with others begins in childhood and is often a product of the examples set in the home and in the educational system. There is a range of personal capabilities and comfortableness among healthcare providers in their ability to communicate effectively with patients: Some are very good at it, some are not so good, and the rest of us try to do our best. Fortunately, there’s always room for improvement, and that can be a professional goal.
As someone who has taught medical students and residents for 50 years, I find that young trainees most often make the communication mistake of using terminology that’s stilted, too sophisticated, and often poorly understood by the patient. I trained at a medical school that had a high population of rural patients, most of whom I could relate to because I came from that same background. Too often I’ve heard a resident physician explain to a patient, “You have a high nasal septal deviation that’s impinging on the middle turbinate and causing sphenopalatine neuralgia,” or some such description of the pathology in confusing terminology. And I have seen the blank look on the patient’s face as they turn to me to decipher the language of medicine for them. Words do matter, especially when the patient doesn’t understand them.
So, how do we teach trainees to consider the words they use and decide what form of explanation should be used to educate a patient? One of the best ways to teach is to emulate proper communication through your own discussions with patients when trainees are present. Sometimes, a physician has to probe a bit to garner an appreciation for a patient’s level of understanding and receptivity when presenting what can be confusing and overwhelmingly complex medical information. This is where experience is quite helpful. Listen to the patient and pose questions before engaging in conversation.
As my mind tends to work on the more “simple” side of communication, I think I’m as good as the next physician in simplifying my communications with patients. Once I get to know a patient, I like to tailor my communications in a manner that might resonate with his or her own life or work. For instance, it’s fairly easy to explain Eustachian tube dysfunction or the Venturi effect on nasal and sinus airflow due to a deviated septum to a plumber or airplane pilot—they’ll get it. Similarly, for patients who understand skin cancers or have had them, I can relate glottic (vocal fold) squamous cell carcinomas to skin cancers owing to the stratified squamous lining of the vocal folds, as well as the effect of “funneling” and concentrating cancer-producing particles in tobacco smoke through the narrow opening between the vocal folds. By using anatomical charts to identify those structures and showing the direct effects of smoking on them, the patient both hears and sees what I’m trying to communicate to her. Additionally, if a medical student or resident is present, they can watch and learn.