(from the November 2007 edition of PMD)
By Janine Anthes
The quality of health care balances on the edge of a growing rift in communication. In fact, when health is broken down to its essential parts, communication is the true foundation of successful diagnosis and treatment.
Every health care organization must communicate complex medical information to a wide range of people, yet successful communication is all too often an illusion between a physician and patient—sometimes created by a physician who assumes a mutual understanding took place, and sometimes by a patient who is too embarrassed to confess their confusion.
"Effective communication is at the heart of every health care interaction. Ineffective communication—for whatever reason—can lead to ineffective health care and bad outcomes, which means it’s always an issue," says Matthew Wynia, MD, MPH, director of the Institute of Ethics at the American Medical Association (AMA).
Low Health Literacy In an attempt to bridge the communication gap, the medical community has turned its focus on the low health literacy levels that plague our country. According to the AMA, about 90 million people in the United States can't read or understand the type of information commonly given to people by physicians (eg, instructions on a pill bottle, follow-up appointments, etc).
Low health literacy levels are by no means a determinant of intelligence. Oftentimes they are a result of language barriers, culture, age, or the patient's pain or discomfort. Considering the ever-growing diversity of our country, the possibility of a patient with low health literacy is greater than most physicians imagine.
"We've just gone through another national survey, and somewhere between 16% and 20% of the population has a really serious reading problem. They're saying below basic," says Joanne Schwartzberg, MD, AMA director of aging and community health. "So we know where we need to go, but we don’t know how to get there," Schwartzberg says.
Recent studies by the US Census Bureau show that one in five Americans speaks a language other than English at home, and 8.1% of the population has limited English proficiency— defined by the US Census as the ability to speak, read, understand or write English "less than very well." This number is projected to increase to 10% of the population by 2010. So it has become more important than ever to find ways to break down these language and cultural barriers so that the patient’s care is not compromised.
Wynia cites cultural misunderstanding when it comes to the concept of informed consent. "People who grew up in America know about the litigious climate of American medicine," Wynia says. "So physicians run this litany of, well you could have an infection, you could bleed, you could even die if that’s the extreme—and sign here." Someone with a different cultural background may see the physician as being incompetent— others may think that it's bad luck to talk about bad outcomes.
Where to Start
"What makes the difference is: Did the patient understand you? Ensure that the patient understood by speaking simply and directly and by using what we are calling a 'teach back.' Ask the patient to summarize the key points that you've discussed. Make sure the patient understood them," Schwartzberg says.
Another huge concern is medication. "Patients older than 65 have an average of 7 or 8 different physicians who prescribe for them," Schwartzberg says. "And if you have 5 chronic illnesses and you're over 65, you may have as many as 14 different doctors prescribing during one year—and they don’t know about each other. So the potential for error is great."
The brown-bag method aims to reduce that chance of error. It is when a physician asks the patient to put every medication they take on a regular basis into a brown bag and bring it to their next appointment. The physician can then ask the patient to describe what each pill is and when they take it—this helps ensure that the physician knows exactly what their patient is taking, and how they are taking it.
"The extent of the shame and embarrassment of these patients is another thing you want physicians to understand. These are very sensitive, very difficult issues," Schwartzberg says. "Doctors are very skilled in talking about difficult issues with patients, they've trained themselves, they're used to breaking bad news to patients, they're used to doing interviews to get sexual histories, etc. But the same kind of nonjudgmental ways that they use to make people feel comfortable and bring up subjects that are very painful—they can use it in terms of patient understanding." It's important that the patient does not feel like it's a disgrace that they didn't understand, and they need to feel comfortable and shame-free to ask questions.
Unfortunately, malpractice if nothing else is a significant reason not to ignore this topic. "The responsibility to communicate successfully rests with the provider, not with the patient," says Steven Levin, MD, named 2007 Family Physician of the Year by the American Academy of Family Physicians. "It's not a legal excuse that the patient didn’t understand."
According to Schwartzberg, data by the Joint Commission shows that between 65% and 80% of all medical errors are around communication failures. Some of that is provider-toprovider communication and some of it is provider to patient. "Malpractice lawyers have told us it's primarily communication issues," Schwartzberg says.
"I think errors around prescriptions are the second most common reason for malpractice suits," Schwartzberg says. "And that's probably just the tip of the iceberg. I know in the elderly close to 30% of hospitalizations are around some kind of medication adverse event, either noncompliance, too much, too little, or interactions between drugs." This is why more and more physicians are adopting the brown-bag method—especially when it comes to their older patients.
"If you fail to provide effective communication you're going to end up having mistakes and those mistakes could be really costly," Wynia says. It's hard to know when you've avoided one of those mistakes—it's difficult to track whether your efforts avoid a really bad outcome that doesn't happen— but it only takes one debilitating malpractice suit to devastate a physician's career. "The issue of communication is a more pervasive set of issues that we constantly have to be thinking about," Wynia says. The impact poor communication has on the medical community may not always make headlines, but it is a looming giant that has greater consequences than most people realize. And as our country continues to age and grow in diversity, physicians need to be aware of this threat, to not only protect their patients, but also themselves.