Saturday, January 27, 2007

Stop me if I say something you don't understand

I used to work with a physician who dictated office notes in front of his patients. After explaining his findings, he would ask the patient to listen while he dictated his findings. “Stop me if I say something you don’t understand or think is inaccurate,” he would say. When he finished, he would ask the patient (again) if there was something she did not understand. This process assured three opportunities for patient understanding – after the exam, during dictation, and after dictation.

As a medical student, the doctor had lived with his wife’s parents and often heard his mother-in-law discussing her interactions with the medical community. She was clear about what she did and did not like, and he incorporated into his own practice the lessons he learned from her medical interactions.

This physician heard the voice of the “consumer” in his mother-in-law’s stories. She became a stand-in for his future patients, a role model of the “health care consumer,” long before that term entered the health care world. Today we understand that communications are important, not just for patient satisfaction, but for reasons of patient safety.

When patients feel comfortable asking questions, volunteering information, and voicing concerns, they are more likely to understand and cooperate with their treatment. They are also more likely to speak up if something seems wrong, and this can be an important warning sign. Effective communications with patients can reduce the opportunity for mistakes, such as medication errors, identification mix-ups, and wrong-side procedures.

Two of my relatives were hospitalized in the last two months, and their experiences reminded me how different is the hospital world a patient experiences from the hospital world we see every day as caregivers.[1] What is obvious or routine to us may be invisible or incomprehensible to patients. They don’t understand our language. They don’t share our mental map that readily understands the relationships among attending and consulting doctors, charge nurses and discharge planners, therapists, and service staff.

Even knowledgeable people experience the hospital differently when they become patients. A surgeon once told me about his experience as a patient. “I was on a gurney,” he said, describing his trip to the OR. “As the transporter waited for an elevator, I was surrounded by equipment, IV poles, mobile x-ray units, food carts. I suddenly realized I was no longer a patient. I was a piece of cargo competing for elevator space.” The hospital world that was known to this experienced surgeon became a different place when he was a patient – he felt both isolated (“surrounded by equipment”) and alienated (“a piece of cargo”).

My recent experiences at two out-of-town hospitals reminded me how important it is to make patients feel secure and comfortable in our world. Recognizing the puzzlement in a patient’s eyes is a signal for us to explain what we just said – again – in different words. Recognizing that a smiling face does not always mean the patient understands what was just said should prompt us to take a moment to use new words or ask the question in a different way. These are basic skills in human communications, and in the hospital world they not only help patients feel more secure, they help us keep patients safe as well.

[1] My recent experience at the other hospitals prompted me to adapt this letter from one I wrote several years ago in a somewhat different form (January 3, 2004).

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