Say What?!

by Dr. Amit Singh

“Good morning Mr. Johnson*!” our chief resident bellowed as we all crowded around the bedside, a sea of endless short and long white coats. “I want to let you know we took a look at the X-ray this morning and it looks good. The angle looks sharp, no effusion!”

We looked at Mr. Johnson and I saw his completely blank stare. His breakfast tray was not far from him as he was just about to start eating. The resident “examined” him, and in a matter of one minute, our whirlwind of a team was out of the room as fast as we had entered.

As he watched us all, it was at that exact moment on my very first day of rounds, on my first clinical rotation as a medical student that I learned exactly how not to talk to patients.

Whether it’s your best friend, the barista taking your drink order, or your significant other, the hallmark of any good relationship rests on good communication. As a physician, communication is at the heart of everything we do. Forget all the pathophysiology, differential diagnoses, research, QI, and the like. If we can’t even just sit and talk to our patients about what’s going on in their bodies, then what’s it all for really?

We think of ourselves as agents of science, but our job requires us to be the best “people person” there is. When you walk in that exam room, you never know who is beyond the door. Explaining why “nothing” is the treatment of choice for bronchiolitis (and that it’s not “bronchitis”) to both the most experienced of parents and the most inexperienced teen mom, can be equally tricky.

Learning how to do it? Well, I didn’t finish medical school that long ago but I know there was no syllabus on communication. No one taught me how to interpret non-verbal cues, or how to understand when a patient chooses not to use an interpreter even when we know they should. No one taught me that now isn’t a good time to explain a diagnosis of Kawasaki Disease to a parent because their kid is freaking out from the IV that was just placed and didn’t sleep all night. And no one taught me how listening and watching are sometimes way more important than talking.

In the age of family-centeredness and patient satisfaction, we are expected to be masters of this communication thing. Moreover, like a great date, the conversation should go both ways, right? What about what we need to say? We have diagnoses to give, lab results to provide, consultants’ recommendations to lay out, daily plans to make. When do we get this chance to talk and do what we came here to do? Well…on rounds…bright and early at 7:30 am when the family is most receptive, duh!

So what can we do? When we have 14 inpatients to see in two-and-a-half hours, how can we guarantee that the conversations are worthwhile? That we are effectively communicating? Here are a few keys that I have learned along the way to effective patient communication:

1.    Simply just SIT DOWN. This is something research has proven, yet I still don’t see it happening enough. Wherever it is in the room, just sitting has made my experiences with any family, whether they are tired, angry, anxious, or happy, just go so much better. Even if it’s on the patient’s bed (with permission of course), leveling the playing field so that we are physically in the same plane is a motion which demonstrates that we have time to talk, that we are in the moment, and that we are mindful and present.

2.    Have a regular conversation with your patient and their family. Talk with them like you would anyone else, in plain language, and leave all assumptions in the hall. When I decided to be a pediatric hospitalist, I kept telling everyone I was going to be an “inpatient” doctor. My wife reminded me that no one knew what that meant. “Really? ‘Inpatient’ vs. ‘outpatient’, you didn’t know that?” I said. We do this all the time, make assumptions about how much Medicalese our patients speak…“We’ll switch your baby to IV plus PO today”…”His CRP is better”… ”Her tachycardia is improved”…“I am your attending and this is your resident.” We spend our whole training lives speaking this way only to have to not speak it at the bedside.

We must constantly remind ourselves that, if all the patients decided not to show up tomorrow, we’d be without purpose. Our job doesn’t even exist without them so we really better be able to talk to them. Being able to communicate with people means listening, being patient, observing cues, and explaining things without the use of jargon. We have to ensure that when they leave, they are armed with the knowledge they need to take care of themselves or their children in the healthiest way possible.

The word “doctor” comes from the Latin word doc?re which means “to teach”. That means before I do anything else, I am a teacher first and foremost. What else is a good teacher if not the most powerful communicator there is?

*name changed

 

Singh_Amit_HeadshotDr. Amit Singh is a Clinical Instructor and Pediatric Hospitalist at Stanford School of Medicine and Lucile Packard Children’s Hospital Stanford in Palo Alto, CA. He completed his residency training at the Children’s Hospital and Research Center Oakland (now USCF Benioff Children’s Hospital Oakland) in Oakland, CA. He then completed a two year PHM fellowship at the University of California San Diego at Rady Children’s Hospital. His main interests are in improving communication with patients and families and the interface of technology and pediatric hospital medicine. When is he not taking care of hospitalized children, you can find him eating his way through San Francisco where he lives or at home watching Seinfeld after a long day on service. You can follow Amit on Twitter: @Amitej03

4 Comments

  1. Suryakant T. Desai on March 24, 2015 at 4:43 pm

    Wow !!!
    Amit. you have written very well. What you have said is so true. It is the simple gestures in life and the time taken to talk to someone in need that make life purposeful and rewarding.

    Congratulations !!!!
    Dad Desai

  2. jas singh on March 25, 2015 at 5:36 pm

    wow, this is great. something all doctors should consider.

  3. Amrita on March 27, 2015 at 8:16 am

    Great article! Medical education doesn’t place enough emphasis on communication…

  4. Weijen Chang on March 28, 2015 at 11:36 pm

    Amit,
    Great article, and I completely agree. But as much as I love platitudes, the reality is that everything we are doing in medicine takes us away from the art and practice of communication: EMR, auto populating notes, endless electronic alerts, the onslaught of “quality” measures which require physicians to become slaves to the checklist. Now don’t get me wrong – I happen to espouse and promulgate many of the things I just mentioned. But there doesn’t seem to be any ongoing assessment of how our electronic leashes degrade our ability to communicate. I hope that in the near future, perhaps with the rising importance of “patient experience,” we can learn to balance the need for EMR excellence and actually having a conversation with our patients.

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