by Ken Murray
Once, when I was a young doctor, I saw an elderly lady in urgent care who complained of severe constipation. She’d already seen several doctors but with no luck. I confidently put her on some stuff that would really clean her out, and I referred her to a great colleague. When I ran into this doctor later, I asked how things had gone. “Great!” he said. “Only one problem. When she said constipation, she meant diarrhea.”
Welcome to the world of medical miscommunication. We hear a lot about health insurance and rocketing health costs and shortages of primary care physicians. But so many of the problems between patients and medical providers today just come from poor communication. When I look over patient surveys, the most common complaints I see are things like “My doctor doesn’t listen to what I’m telling him,” or “I told her about what happened, but she was too busy writing to listen to what I was saying.”
Remember, physicians can do only three things: carry out procedures, prescribe medications, and give advice. They have years of training in procedures and generally do those well. They also do pretty well in medication, even if some tend to go overboard. But giving advice is another story. Everyone struggles to communicate properly, but, in medicine, lack of time, jargon, fear, language, and even status make the problem unusually severe. You wouldn’t believe how many people are taking medications without any idea of why they’re taking them. You also wouldn’t believe how often people say yes to a procedure without any idea of what they’re saying yes to.
Is there anything that patients can do about it? Yes, and it’s not too hard. You’ll be getting much better medical care if you do five very simple things:
1. Cut through the jargon by asking questions
Every profession, from medicine to plumbing, has its own jargon. Doctors talk in technical terms all the time, but patients often are too shy to ask what they mean. Don’t be too shy! It’s your doctor’s job to help you understand.
At the same time, don’t trot out technical terms of your own. Patients often use medical terms incorrectly, and doctors take them at face value. It doesn’t do any good for you to tell your doctor you have meningitis when what you really mean is you have laryngitis.
Finally, make sure both of you are asking a lot of questions. If my colleague hadn’t asked the lady with diarrhea about her symptoms, he would’ve treated her for constipation, as I did. Asking for clarification is much easier than fixing a mistake.
2. Before you go in, write down your questions and ailments for the doctor—and bring an extra copy for you to write notes, for yourself.
Have you ever gone to the doctor and then come home realizing you forgot to bring up something that’s been wrong? The way to prevent that problem is to write down everything you want to discuss with your doctor before you go into the office.
Provide as much detail as possible. Include the history of your medical issue and what sort of other treatment you’ve sought for it. At the doctor’s office, give one copy to the receptionist as soon as you arrive, so that your doctor can review it even before your appointment begins. This will also go into your medical record. You won’t forget to ask the necessary questions—and, just as important, your clinician won’t forget to answer them. And you can use your own copy to write down the answers to your questions.
Writing stuff down in advance also helps prevent you from displays of stoic bravado once your doctor walks into the room. Recently, I accompanied a friend of mine to her orthopedist. She’d broken her foot not long ago and was still in a lot of pain. “How’s the foot?” the orthopedist asked. “Good,” she answered. My jaw dropped at this about-face. Not surprisingly, the orthopedist didn’t suggest any new approaches to her healing, and my friend remained in pain. If she’d recorded her pre-appointment thoughts in writing, she’d have had her own words in front of her to remind her of her real feelings—and her doctor would have had a copy of them, too.
3. Create your own health record—it’s easier than you think
We talk a lot about Electronic Health Record technology, which has a lot of promise, but for now most of us are a lot better off just creating our own health record. Simply get a paper or plastic folder and put your health documents in it.
Here are the documents you’ll need: your laboratory tests, biopsies, x-rays, imaging studies, and anything that has been identified as abnormal. (And don’t worry about asking your doctor for a copy of these records. It’s your body, and we are generally happy when someone takes an interest!) If you’ve been hospitalized, get a copy of your discharge summary, surgical report, and pathology reports. (The rest you can skip. Don’t waste your money.) Make sure someone close to you knows where you keep it.
When you go for a medical visit, take your health folder with with you. If your doctor asks about an old blood test or an x-ray, you’ll have the records right there. You won’t have to repeat lots of tests that you’ve already had. If your practitioner mentions some abnormal test result on your visit, ask for a copy while you are there, before you forget.
How much agony can this save? I once saw a patient who was a long-time smoker with a deep cough and an ominous shadow on his latest chest x-ray. I asked when he’d last had a chest x-ray. “Oh, 20 years ago, back at the VA,” he answered. What followed was a paper chase of many weeks, while the man and his family made arrangements for what they thought would be the final weeks of his life. When we finally were able to get the film, it revealed an identical mass from 20 years ago. It wasn’t cancer.
4. Get instructions in writing
Practitioners give verbal instructions to their patients about what to do with their medications or how to exercise, etc., but often these instructions don’t survive the trip to the street. They’re quickly forgotten or misremembered. They’re also misunderstood. One study found that three out of four ER patients fail to comprehend the instructions given to them by doctors. (I’ve seen this myself when people have come up with their own terrible ideas for what to apply to stitches—things like paint thinner, even perfume.) So try to get any instructions from the doctor in writing. Many clinicians have printed instructions sitting in their offices for the asking
5. Take notes
If your doctor doesn’t have printed instructions, write down your own instructions. Write down whatever else your doctor is saying, too. If you can’t do it in the examination room, do it immediately afterward in the waiting room. Now you won’t forget, and you won’t get it wrong. And take satisfaction in being one of the all-too-rare patients who take the lead in getting the right information to the right people. It’s the healthiest sort of communication you can have.
Ken Murray, MD is Clinical Assistant Professor of Family Medicine at USC.
*Photo courtesy of Chapendra.
Great guidelines for better communication from Dr. Murray. I hope both patients and doctors will read and heed:) It will help.
Great advice. My Internist of 25 years just retired as well as the orthopedic physician I saw. I was assigned to a newly minted Internist. A lad from India that I have had trouble communicating with during the 2 visits I have seen him. Both times I have left his office feeling uncertain and concerned. I know he is qualified but I also know he had an older patient that said she kept having, ‘Charlie Horses,’ in her leg. This young fellow questioned his office nurse about what this meant. Having overheard, I couldn’t help a quiet grin but made a mental note to myself not to use any American slang.
There appear to be a lot of young doctors from distant lands showing up in rural areas to practice medicine. We are lucky to have them. However, your advice is particularly important under these circumstances.
Hello,
This article should be circulated very, very widely. Many doctors are talking about doing what you suggested, but few patients actually do.
I have started writing down my parents’ medical history on a sheet of paper for them to take to the doctor. English for them is a second language, and medical thoughts are ever harder for them to express than native English speakers – and it’s hard enough even for them! (such as “charlie horse”) Additionally, none of their doctors are native English speakers. (Canada is incredibly multilingual)
I also organize thoughts in the way the doctor will ask them, just to make it easier for the MD (Name, Healthcare #, Main complaint, Secondary complaint, past history, normal and abnormal tests, etc) – that’s not something a “layperson” will do, but maybe we can distribute standard history forms for patients via the clinic’s website?
Anyway… Magic happens when my parents go to the doctor with this sheet of paper. Their concerns get addressed, and they never come back from the doctor with “Uh, he said something about my stomach? maybe it was my heart… I’m not sure… he recommended a medication, but I forget the name… My next appointment is sometime in June I think…”
Dad’s doctor has mentioned how impressed he is with this one single sheet of paper (which took me half an hour to write, and only because it took me this long to collect the information from my dad).
Bottom line: It saves time for both parties, ensures concerns are addressed, and allows the patient to write down information.
And yet myself, I have only seen a rare few patients come with prepared information. I have printed my answers on an elderly lady’s sheet of paper (she had at least ten questions that she never got answered because she kept forgetting to write down the answers). Her followup appointment was brief because now she knew exactly what the appointment was for, and was completely prepared for it.
I always insist that my patients bring written information (few actually do), but I think I will become more insistent. It makes a world of a difference.
Why? I have spend over 20 years in service industry. The customers came with many ideas what the problem was but with few right questions I had been able to determinate what the problem was. I was the specialist. Same applies to doctors, they have to learn how to ask questions and listen to answers. They have to become health knowledge professionals, no money counters.
Good idea with dentists, too. I found myself in need of a root canal a few years back. Thinking the tooth in question was marginal (meets its mate only at the edge) and not wanting the cost or pain, I told him to yank it instead. Turned out it was another, more substantial tooth he wanted to operate on! Oops . . .
To Dr. Natalia: The reverse would also be very helpful. A written sheet from the doctor, providing his diagnosis, his recommended treatment, and when to return for followup, would be very helpful. Too many patients leave their doctor’s offices clutching only a scrip, which of course is indecipherable to them
Thank you all for your comments!
We did a yearlong research study with parents of disabled kids. They told us that no one, Doctor, Nurse, Therapist, Pastor, Friend ever asked how the parents and/or other family members were doing. 2. No one ever asked the parents what they thought would help their child, what meds worked or did not work. In short, nobody listened to them.
In medicine the focus is the Disease which is separated from the Patient and the patient is separated from the person, who is separated from the family which is separated from their support system.
I did everything you said, and watched as a consultant ignored my notes, did not read the careful account I gave him, asked leading questions and jumped to fascinating conclusions (just one example: he linked my asthma to suggesting my other symptom was panic related, never bothering to ask what my asthma triggers are–humidity, non allergenic). I teach history and had be been so cavalier with evidence in my classes I’d have failed him.
About Natalia’s excellent advice:
I have a fairly complicated medical history (especially for a person who really isn’t all that sick) involving not just one, but three unrelated rare diseases.
I’m a medically savvy person with no communication difficulties in English, but when I encounter a new physician, I usually take along a one- or two-page letter that describes the highlights. I give it to the medical assistant so that the physician can read it before even entering the exam room. Every time I’ve done this, the physician has thanked me (often repeatedly).
I’ve found three significant benefits:
1. Limiting myself to two pages helps me prioritize. I use bold-face type to highlight the names of medical conditions and medications for ease of scanning.
2. Providing a summary of “everything” is efficient for all of us. I don’t forget important details, and we don’t waste time discussing trivia or leave the appointment feeling we missed the forest for the trees.
3. Before even seeing me, the physician decides that I’m a “good patient”.
I recommend this to anyone, even people whose medical history is far less complex. And after you write it the first time, it only takes a couple of minutes to read it over and update it before seeing someone new.
One thing I would add is if you’re suffering from chronic pain or kidney failure or are really overwhelmed physically or emotionally, bring a family member or friend along to your appointment. It’s hard to take in all the info and instructions when you feel bad or are confused.
When I changed GPs I brought in a decades’s worth of blood work, a list of everything big to small that was bugging me and a notebook to write down her thoughts. She was pleasantly surprised that anyone could be so organized. Whenever I see her (rarely) it’s always a very pleasant visit because we both communicate well and ask each other questions. And write down the answers!
Some additional things to think about: 1. find out how much time the doctor is allowed for appointments. Some HMOs and other health care plans force docs to allot only 15 minutes per patient. Brutal! 2. Bring your own friend/advocate with you. Go over your questions with them and allow them to either ask questions or remind you to ask questions. Even with organization and a list, you forget. 3. Taking notes can be intimidating to some docs. Think very tall, white male cardiologists or surgeons who stand over you while you huddle in your flimsy gown on that cold, crinkly paper covering the exam table. Use one of those old yellow legal pads, write big, turn the pages of your notes slowly and always use first names if they call you by yours. Turnabout is fair play!
(And don’t worry about asking your doctor for a copy of these records. It’s your body, and we are generally happy when someone takes an interest!)
Many doctors and dentists refuse to release x-rays. Please suggest tips on prying these records about OUR bodies from your colleagues!
This all sounds great but I can tell you, as a patient who has tried VERY hard to do this with a succession of doctors, that it often simply doesn’t work. (Per comments from Dr. Gary Sweeten, and Farah, above…many docs are simply not interested in what the patient has to say.) I acknowledge that SOMEtimes it’s not entirely their fault…the fifteen or twenty-minute appointment is a great system for a kid with strep or a broken finger, but it’s TERRIBLE for an older patient managing several chronic problems.
In such a case, doctors simply do not have time to follow this wonderful model for communication. As long as virtually all primary care is based on this very short appointment time, then people who need more time simply by virtue of the material to be covered will continue to receive poor or inadequate care, due to the nature of this limitation, no matter how well they and the physician can theoretically communicate. If we don’t fix this huge flaw in primary care, then all the notes and communication skills in the world won’t help such patients get adequate care.
Not to mention that in one study I read about, the average time that went by before the doctor interrupted the patient at an appointment was sixteen seconds. A very very poor model for communication, no matter who is involved.
Having spend more than 30 years as a non-medical research scientist in a large university hospital, I feel compelled to comment:
- While the percentage of uninterested, lazy or plainly incompetent physicians may be smaller compared to professions like plumbers or politicians, it is clearly above zero.
- A “list” (or whatever can be done by the patient) is not a magical tool transforming a “bad” doctor into a “good” one, and thus of limited value.
- The only real choice a patient has is to change the doctor if there is any doubt about his or her competence, and the patient should act accordingly if his or her problems are more severe than a common cold.
- Though I do have a few ideas on how to evaluate a doctor´s competence in my case, I am clearly not qualified to offer any general recommendations, but I am very much interested in contributions from others – patients and doctors alike (and of Dr Murray in particular.)
I help staff and build hospitals nursing homes for a living I took a Director of Surgery out to play in a golf tournament we needed a forth he has a young intern from china who was a scratch golfer so filled out the foursome. After spending mu usual tour of duty on the beachs of the course the young man would call to me ‘take a half sandwhich’ i would reply i am not hungry..clear communications anybody?
Dear Ken,
I was once your patient and your friend back in the old Studio City Days. As you were/are a brilliant Physician and interesting person, I have enjoyed reading your articles. They are most enlightening. I would very much like to touch base with you and catch up. My private email should be listed but not published for the world to see.
Hope to hear from you and happy that you are apparently doing well!
Cheers,
Roxanne