Understanding Your Patient: Conquering the Communication Gap


The quality of healthcare balances on the edge of a growing rift in communication. Effective communication is the foundation of successful diagnosis and treatment and essential for ensuring superior patient care.

“The problem with communication ... is the illusion that it has been accomplished.”—George Bernard Shaw

The quality of healthcare balances on the edge of a growing rift in communication. Effective communication is the foundation of successful diagnosis and treatment and essential for ensuring superior patient care.

Healthcare professionals are responsible for communicating complex medical information to a wide range of people, yet the idea that communication has been successful is often an illusion. Sometimes a physician mistakenly assumes there is mutual understanding, and other times a patient is too embarrassed to admit feeling confusion and pretends to understand.

“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,” suggests Matthew Wynia, MD, MPH, director of the Institute of Ethics at the American Medical Association.

Low Health Literacy

In an attempt to bridge the communication gap, the medical community has turned its focus on addressing the low health literacy level that plagues the United States. According to the AMA, nearly 90 million people in this country cannot read or comprehend the type of information physicians commonly provide, such as instructions printed on a pill bottle or patient education materials for postoperative care at home.

There is no relationship between a low level of health literacy and intelligence. Often, the confusion results from language barriers, cultural differences, advanced age, or the patient's inattentiveness due to pain or discomfort. When you consider the vast and ever-increasing diversity among our country's population, the possibility of having patients whose health literacy is not up to par may be 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,” explains Joanne Schwartzberg, MD, Director of Aging and Community Health at the AMA. “So we know where we need to go, but we don't know how to get there.” US Census Bureau statistics show that 1 in 5 Americans speaks a language other than English at home, and 8% of the population has limited English proficiency, which the Census Bureau defines as the ability to speak, read, understand, or write English “less than very well.” This is projected to increase to 10% of the population by 2010. It is becoming more important than ever to find ways of breaking down language and cultural barriers to ensure that patient care is not compromised.

Dr. Wynia cites informed consent as an area where cultural misunderstandings can come into play. “People who grew up in America know about the litigious climate of American medicine,” Dr. 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 raised in another culture may see the physician as being incompetent, while others may consider it bad luck to discuss bad outcomes.

Where to Start

Dr. Schwartzberg says to make sure the patient is clear on what you are telling them. “Ensure the patient understands you 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,” she says. “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,” Dr. Schwartzberg adds. “Doctors are very skilled in talking about difficult issues with patients. The same kind of nonjudgmental ways they use to make people feel comfortable and bring up subjects that are very painful, they can use in terms of [fostering] patient understanding.” It is important that patients do not feel disgraced when they do not understand, and they need to feel comfortable asking questions.

Malpractice Concerns

The risk of facing a malpractice lawsuit is a significant enough reason on its own not to ignore this concern. “The responsibility to communicate successfully rests with the provider, not with the patient,” says Steven Levin, MD, who was 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.” Dr. Schwartzberg cites the Joint Commission as reporting that 65% to 80% of all medical errors concern communication failures. Some cases involve provider-to-provider communication and others concern interaction between provider and patient. “Malpractice lawyers have told us it's primarily communication issues,” Dr. Schwartzberg says.

Another potential for error concerns medication. “I think errors around prescriptions are the second most common reason for malpractice suits, and that's probably just the tip of the iceberg,” Dr. Schwartzberg says. She adds that close to 30% of hospitalizations of elderly patients result from an adverse event involving medication, either stemming from noncompliance, doses that are too high or too low, or drug interactions. Dr. Schwartzberg points out that “Patients older than 65 have an average of 7 or 8 different physicians who prescribe for them, 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.”

In an attempt to minimize the potential for these types of errors, an increasing number of physicians are adopting the “brown-bag method.” The physician asks that the patient to put every medication taken on a regular basis into a brown bag and bring it to the next appointment. At the appointment, the physician asks the patient to describe what each pill is for and when it is taken. This helps ensure that the doctor knows exactly what medications the patient is using and how they are being used.

Dr. Wynia reminds physicians that “If you fail to provide effective communication you're going to end up having mistakes and those mistakes could be really costly.” While it is difficult to determine whether your efforts have resulted in averting any really bad outcomes, it is worth remembering that it only takes one debilitating malpractice suit to devastate a physician's career.

The impact poor communication has on the medical community may not always make headlines, but it is a looming giant and has greater consequences than most people realize. As the demographic of our population shifts upward in age and as we continue to grow more diverse, doctors need to remain vigilant on this issue, to protect not only their patients but themselves.

Source: Surgical Rounds, 2/08

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