Thirteen Communication Rules For Doctors And Patients
By Herb Denenberg, The Bulletin
Published: Thursday, December 11, 2008
I started to write a column about patients communicating with their doctors, but soon discovered the same principles apply to virtually all other forms of communications such as lawyer-client and employer-employee. For example, I’ve attended many continuing legal education courses for lawyers in which lawyer-client relationships are discussed in detail. One important aspect of that relationship that is stressed is the necessity of returning client phone calls promptly. I suspect that would be true of any professional or other relationship.
I started thinking about this topic because I have the honor of speaking to a group of first-year medical students at the Medical School of the University of Pennsylvania about that subject and how I’ve reacted to medical care. I was asked by Dr. Jerry Johnson, Division Chief of Geriatric Medicine at the Medical School, to talk about my reactions to doctors and hospitals, in general, and also specifically at the Medical Center of the University of Pennsylvania. I was selected in part because I’m a senior citizen and the class wanted the perspectives of one. I was anxious to get involved with this project, as I know about the work of Dr. Bruce Kinosian of the Division of Geriatric Medicine, who works with Dr. Charlene Compher, a group that makes the best nutritional advising team I’ve ever encountered.
I decided to bring my thoughts within the framework of communications between doctors and patients, and what each group can do to make them effective. They are stated as a series of 13 rules.
Rule One: The doctors should realize they can’t communicate effectively if they don’t return the patient’s phone calls promptly or can’t set up an appointment within a reasonable period.
I know of cardiologists that take a couple of days, even more, to get back to a patient who has expressed a concern of some urgency. If the doctor can’t return the call, he should at least have a physician assistant, a nurse, or someone else in the office establish contact with the patient to respond to the question or at least tell the patient when to expect a response.
This seems to be a problem with other professions. One of the leading complaints about lawyers is that they don’t return calls promptly. So you might make an addition to Thomas Jefferson’s famous statement: Lawyers agree to nothing, challenge everything, talk by the hour, but don’t return clients’ calls.
On appointments, I know of people who have called doctors needing a fairly prompt visit but to be told they might have to wait a month or two to get an appointment. This kind of response is done with no attempt to figure out the urgency of the visit, if any. There should be some attempt to ask about the urgency of the matter and then take appropriate action. Maybe if the doctor knew the nature of the visit, it would be expedited. Or maybe the patient would be told to perhaps see another doctor or even go to an emergency room. The patients may not be assertive enough in these situations, and where their problem requires faster attention they should request the situation be explained to the doctor, for his recommendation as to appointment scheduling.
Rule Two: You can’t communicate if you don’t listen. I’ve seen advice coming from doctors and lawyers who have studied communications between members of professions and their customers that they only listen for a minute or two before they shut-out the patient’s communications. The advice is even given to patients to get in your main complaint at the top of the conversation or it may never get communicated. This short window for listening denies the doctor the full knowledge of the patient’s problem and also may prematurely pigeonhole the diagnosis before all the facts are in.
This seems like an easily avoided obstacle to good communications but it isn’t. I’ve seen the problem in other contexts. I spent about 25 years interviewing people on camera for television news reports and investigations. I know how easy it is and how common it is for the one asking the question to start thinking of the next question, or of a follow-up question, or of what has already been said, or of something else altogether, and being distracted from what is being said.
This came home to me dramatically when I was reading a book by a well-known memory expert. He gave an expensive course on improving memory, and once received a call from a woman who thought she was losing her memory and wanted to take the course. But she wanted to know if it would help her, so she asked the expert what kind of things he teaches.
He asked when she has memory problems. She said when introduced to people she never seems to be able to remember their names. So he said one of the key lessons is that if you want to remember you have to sharply focus on what you want to remember and pay attention to it. He said when you’re introduced to someone, instead of concentrating on their name, people often think of what they want to say next, or what kind of impression they are making, or what is going on across the room or something else. They do everything but listen and pay attention to the person’s name and comments.
A few days later the expert got a call back from the woman who previously had thought her memory was impaired. She said her memory was O.K. and that she won’t need the course because now that she pays attention to the names of people being introduced to her, she remembers their names.
Rule Three: Oral communications, which predominate in the doctor-patient relationship, are inherently sloppy, ambiguous, and hard to remember. The patient is under stress and may have trouble remembering what was said even if it is crystal clear. But often it is not.
You can often fluff over important distinctions with oral communications and not even realize you’ve left questions and ambiguities in your trail. Anyone who has even studied for an exam and taken it, often discovers that you find when you try to write the answer down your oral recitations and reviews have left all kinds of undetected holes in your knowledge. I agree with those who say you don’t know something until you can explain it in writing.
When a doctor tells a patient something, neither the doctor nor patient may realize how ambiguous a simple communication can be. A doctor may say take the medicine three times a day. I get questions from readers all the time on what that means:
• Does it mean take the medicine exactly every eight hours, meaning three times in 24 hours, with the same intervals between each dose?
• Does it mean take it once on getting up, once on going to sleep, and once right in the middle of your day?
• How important is it to be right on the button in taking the medicine when you’re supposed to? Can you be an hour off? Two hours?
• Does the kind of medicine involved make a difference, and if so, what kind of difference?
There are all kinds of ambiguities in most other prescription orders. What does take before or after a meal mean? How soon before and how soon after? What does take with water mean? Does it mean a sip or a glass of water? For years, many aspirin labels simply said, “take with water.” That was bad advice and now they say take with a full glass of water. What does it mean when it says take once a day? Is there an optimum time?
Simply putting instructions in writing doesn’t solve the problem. You have to edit and re-edit to make sure your meaning is clearly stated. From my own personal experience, I’ve never received one of those instruction sheets given after a procedure that I thought was clear enough to follow without asking some additional questions.
Rule Four: Doctors and hospitals should be especially attentive to criticism sent their way. I’ve found in my own personal experience that important criticism and life-saving suggestions are often ignored.
On more than one occasion, I’ve had to threaten a hospital with a television or newspaper expose, unless a serious problem was corrected.
For example, I knew of a major teaching hospital that had negligently delayed for several months in advising a patient that a lab report indicated a medical condition requiring urgent care. The hospital did nothing to correct the problem. I called and told the hospital unless the matter is investigated and corrective action taken within 24 hours, I would be forced to do something they would not like (meaning a television expose).
The hospital called back promptly and said a doctor had been disciplined for not reporting lab results promptly to the patient. In addition, the investigation showed that the lab protocols failed to require that the particular deficiency in question be marked as a critical value, and that deficiency had now been corrected. The hospital should have been eager to correct a problem with potential for disaster for the patient and the hospital, yet it was like pulling tiger teeth to get it to act.
I would think that hospitals and doctors would go out of their way to correct deficiencies to improve customer satisfaction and to help minimize the chances of malpractice claims. But it seems they only go out of their way to avoid or ignore criticism.
Rule Five: Another obstacle to communication involves various members of the health-care team attending to the patient, but without identifying themselves. The situation is so bad that in the year 2005 South Carolina passed a law requiring all physicians in hospitals wear identification badges describing their rank. Ideally, every member of the health-care team that deals with patients should not only wear a badge describing their position, but also introduce themselves to the patient and explain their relationship to the treating team.
A patient at a major teaching hospital told me how a doctor walked into her room in the middle of the night and said she was going to have to have a blood transfusion. She said, “Who said so?” He replied he was a resident and he said so. Needless to say, she ejected him from the room and from her care. This suggests what should be standard practice but isn’t — a resident or someone in a similar position should not only identify their position but also make it clear on whose authority they speak. And if I’m ever to get a blood transfusion, I don’t want that decision made by a resident or intern on his own.
Rule Six: My pet peeve is a serious abuse that is all too common: Doctors ordering drugs, additions to IV infusions, X-rays or other procedures or tests without even telling the patient. The patient should know what he is being subjected to, just as a matter of making decisions on his own care, and as a matter of safety and convenience. When someone walks in and says, “We’re here to take you down for your X-ray,” the patient should know if one was actually ordered. When a doctor decides to give a patient a drug, the patient should know what to expect, so as to better know when there has been some sort of error. Every aspect of the patient-doctor relationship is seriously damaged when patients are kept in the dark in this fashion. In addition, failing to inform a patient may in some cases be failure of informed consent and the budding of a medical malpractice lawsuit.
Rule Seven: You’re never going to have effective communication if the doctor gives the patient the impression he has to hurry to the end of the visit and cut-off the conversation. Everyone knows doctors are under pressure from insurers and HMOs to see more patients, and that may be taking a huge toll in achieving good communications.
There at least should be some backup safety valves such as saying, “If you have more questions, give me or my physician assistant a call or send me an e-mail.”
I’ve found e-mail is one of the most effective and easiest ways to communicate with a doctor. And you have medical heaven when the doctor frequently checks e-mail and promptly responds. Of course, many patients aren’t computer literate, and one doctor told me this is especially true of older patients. However, I would say those older patients are the ones that need the miraculous reach of the computer to function most effectively. They should be encouraged to use the computer at least for e-mail and searching for information.
One group of Pennsylvania doctors adopted a more radical solution to the time problem. They decided they needed much more time with patients than Blue Shield, HMOs and other insurance companies allowed in their compensation structure. So they started giving patients the time they need, and stopped accepting insurance as payment.
Rule Eight: The patient should know in advance the procedures of the doctor’s office or of the hospital. Some patients don’t want to be examined by a physician assistant. So they should be surprised by one walking in and indicating he wants to examine them. In addition, some patients in a hospital setting don’t want to be seen by a doctor accompanied by a band of residents or interns. The patient should be told in advance of what might happen, and be allowed to express preferences.
Rule Nine: Doctors should use all the techniques of making sure the patient understands what has been said and is prepared to do what the doctor has recommended. The doctor should frequently use the question, “Do you have any questions?” Another important technique is to ask the patient to repeat something in his own words. The patient can turn that technique around by asking the doctor, is this what you mean? and then repeating the advice in his own words.
It is often suggested that a patient take along a tape recorder so he has a complete record of what is said, and so many questions can be answered by listening to the recording. Another standard suggestion is to take a long a friend or relative so two can listen (and ask questions). And a patient may want to take notes on what is said.
I’d make another suggestion. When a doctor sends out in advance a medical history form, there should also be included a form with the question, “What is the purpose of your visit? Another question should be, “What questions do you have?”
Still another suggestion, is to include a section in hospital charts for patients to add their own comments and questions. The patient can approximate this procedure by preparing written questions to give the doctor in advance of a visit or at the beginning of a visit.
I’ve always been impressed with the value of a prepared list of questions for a doctor, since I witnessed the great Dr. Fred Kaplan, an orthopedic surgeon at the Medical Center of the University of Pennsylvania, make a correct diagnosis by reading the list of the questions prepared by the patients. About a half a dozen other specialists had come up with the wrong diagnosis, but Dr. Kaplan got it right even before talking to and examining the patient.
Rule Ten: Doctors should do everything to make themselves as reasonably accessible as possible. Three of the best doctors I’ve ever encountered do just that. Dr. Ed Theurkauf, a pulmonologist at Bryn Mawr Hospital, has been practicing for about 50 years, but still takes calls at any time, even if they come in at three o’clock in the morning. Dr. Bruce Kinosian, a geriatrician at the Medical Center of the University of Pennsylvania also takes calls at anytime, although I’ve never called him at three in the morning. And Dr. Anthony Coletta, a top surgeon at Bryn Mawr Hospital, promptly responds to e-mails.
No one can expect every doctor to meet that ideal of the above three doctors. But I submit most can do better than they are now. This whole issue does provide amusement for me. When I hear a television drug commercial says that if such and such happens, contact your doctor immediately. I laugh to myself and wonder how many of those writers of commercials have tried calling a doctor lately.
Rule Eleven: We hear a lot about patient-doctor communication failures. But a closely related and even more serious problem is doctor-doctor communications. From my observations, you can have five doctors working on the same patient, and they often ignore each other instead of coordinating with each other. The primary care physician is supposed to take the lead in doing that, but often doesn’t. And I’ve seen cases where the patient suggests that some specialist call another doctor to get an important bit of information only to be ignored.
Rule Twelve: One good way to foster effective communications is to take patients on time as scheduled by their appointments. This applies to office visits, scheduled procedures and tests, and all the rest. I tell my friends if they have a test or procedure scheduled at a certain major teaching hospital in Philadelphia to take along plenty of reading material for the almost endless wait that is usual. In fact, I say don’t take a single book, but rather take a 10-volume set. When you don’t take patients on time, the message you’re sending is “We don’t value you or your time.”
Rule Thirteen: This may a bit of a stretch, but doctors have forgotten an important way of communicating with the patient. That’s by actually giving me a physical. Dr. Theurkauf, mentioned above, once told me doctors are losing the ability and willingness to take the patient’s pulse, listen to his heart and do a complete exam. They are quick to order medical tests and procedures, but are losing this important aspect of medicine. A doctor once told me every physical should include an inspection of the feet, but my guess is this is rarely done.
Herb Denenberg is a former insurance commissioner of Pennsylvania, public utility commissioner of Pennsylvania, and professor at the Wharton School. In 1973, he was elected to the Institute of Medicine of the National Academy of Sciences. He is the author or co-author of seven books and hundreds of articles on insurance, health care, and other subjects. You can reach him at [email protected].