Language and Communication
How do I know what I have said until I know what you have heard?
Once, after being introduced to an audience of nurses to whom I spoke about the medical needs of recent Russian Jewish immigrants, I began my talk in Yiddish. “Don’t panic,” I said, switching to English after a few sen- tences and letting them in on my prank, “but think of what it would be like if you didn’t understand what was going on in your new country. Think also what you would feel like if you didn’t understand what your doctor was say- ing to you about a matter of great importance.” The body of my talk dealt with the immigrant’s adjustment to life in the United States and to the American system of medical care, but I used it as a metaphor: Any barrier to understanding gets in the way of productive discourse. Complete under- standing and “speaking the same language” facilitate important decisions and genuine collaboration. There is no comparison between a conversa- tion between a patient and physician allied with each other and one that is confrontational, patronizing, or full of jargon.
There are many superb transactions by which physicians communicate facts, opinions, consistency, reliability, accessibility, and commitment:
• “I can imagine what this must be like for you.”
• “We’ll do all we can to make this surgery turn out well.”
• “Come down to the office this morning.” (Not, “I’ll see if I can fit you in.”)
• “I don’t know the answer, but I do know that it’s nothing to be concerned about.”
• “I don’t know the answer, but I’ll find out and call you in the next two days.”
• “Here is what I think is wrong. . . .”
But there are barriers to communication. The concept of “language bar- rier” applies not only to the difference between the native language of the doctor and the patient but even between them when they share a language.
By reading between the lines, we enhance our understanding of what the patient means:
• When the husband of a deceased patient said to the physician, “You didn’t do enough,” he really was saying, “I wonder if I didn’t do enough.” The physician recognized this and used the criticism as an opportunity to address the hus- band’s guilt and to reassure him that he had done all he possibly could.
• When, many years after the death of her retarded son, his mother declared that “I should have done more to prevent his death,” the physician saw the opportu- nity to explore the meaning of her statement and gain further insight into her long-standing depression.
• The unexpected question from an 80-year-old patient, “What’s my choles- terol?” was her way of asking, “How much longer do I have? How’s my heart?”
• When a patient with widespread cancer asked, “How long do I have to live?” the physician realized she was not looking for a numerical answer. Rather she saw the opportunity to discuss the patient’s goals and values and to address other unasked but implied questions: “Will I have uncontrollable pain? What will the remaining time be like?”
Unless the physician and the patient have a common understanding of the illness, they will have difficulty working together:
• A 75-year-old patient refused to restart insulin despite a very high blood sugar concentration, because she felt her sugar was “not that high,” and she had also concluded that only those people who took insulin later lost their vision or needed leg amputations.
• A 50-year-old woman refused to take a cholesterol-lowering medicine because she feared its side-effects.
• A patient delayed prostate surgery for two years of unnecessary discomfort be- cause his first doctor did a poor job of presenting his proposal. “If my original urologist had talked to me the way this last one did, I would have had surgery two years ago. He showed me the x-rays, he explained, he took the time.”
When the patient becomes silent, the physician often has to subdue the urge to fill the silence quickly with a comment, an assurance, or another question. But patients pause for various reasons: to deal with painful thoughts, to stifle tears or other signs of emotions, or to plan what they are going to say next. Often what a patient says immediately after a period of si- lence has great significance, and to interrupt a silence is as inappropriate as interrupting a narration. Silence may provide an added dimension to what has been said. “In her silence,” one student observed, “you felt that it was even more painful [than she described it].” Silence may allow both the pa- tient and the physician time to reflect on what has been said—and left un- said. There is metaphoric silence also, the absence of timely information, the absence of appropriately shared feelings. Some things are better said than left alone.
Words can harm. The physician may describe a patient as “manipula-tive,” “hysterical,” “noncompliant,” or “a hypochondriac” and a family as “dysfunctional.” Used carelessly and pejoratively, they cloud precise think- ing. A single word cannot completely define patients or their families, until we know more about their stories, motivations, points of view, reasons for behavior, and values.
Physicians especially need to choose words carefully. Some years ago, my patient went to a nearby medical center for a second opinion about what he thought were episodes of hypoglycemia. After having been interviewed by the resident-in-training and going through several days of tests, he saw the senior physician. When he finished retelling his story at this long-antici- pated meeting, the doctor said, “Mr. R, I have never heard a story like yours before.” What the doctor meant was, “You don’t have hypoglycemia. Your story doesn’t sound like it,” but any reasonable patient could have thought, “If you’ve never heard a story like this before, I think I’d like to see someone who has. That’s why I’m here, at great inconvenience and expense.” What physicians say may mean something entirely different than intended to the listener, because it is unclear, because the listener is tense, or because the listener does not understand the physician’s language, even though they are both speaking English. As one student put it, “How do I know what I have said until I know what you have heard?”
Here are some other examples of what is said and what is heard:
• When a physician told a 27-year-old man, a heavy drinker, that “your liver tests are abnormal,” the patient concluded that he had irreversible and fatal liver dis- ease. The physician needed to explain that the abnormalities were reversible, and he needed to say it more than once.
• When the physician told a patient, “You have arthritis,” she heard, “I’m falling apart. I’m going to become disabled with a crippling disease.” She needed a de- tailed explanation that the “arthritis” to which he referred was the type that would not become disabling.
• When a patient asked the cardiologist, “Will the Lanoxin [that he was taking for a disorder of his heart rhythm] hurt my heart?” she replied, “It’s hardly thera- peutic.” What she meant was, “It’s not at a dangerous level.” The patient’s inter- pretation: “If it’s not therapeutic, then why am I taking it?”
• “You have hypertension” was a statement of trivial importance to the physi- cian, because high blood pressure is so common. To one patient, it meant immi- nent stroke, a lifetime of medicine with adverse effects, and the transition from perfect health to a flawed body.
• The urologist told a patient with prostate cancer, previously treated with sur- gery, that his prostate-specific antigen (PSA) blood test level, used to follow the progress of the disease, had increased slightly and should be repeated in six months rather than a year. The physician was only expressing the need for more diligent surveillance. The effect on the patient was profound: Concerned that his tumor was progressing, he became anxious and depressed.
“Lack of clarity equals bad news,” a friend observed after he had listened to a cardiologist present a jargon-filled description of his father’s coronary angiogram. Physicians who stumble with complex explanations are often struggling with their own difficulty in delivering bad news. Even if they are not, it is too easy for patients to misinterpret and infer the worst. A patient once told me, “What the doctor tells me has a profound effect on my mind.” Even the way we address patients carries weight. Greeting an adult pa- tient for the first time with “Hi, Harry” initiates a different quality of trans- action than “How do you do, Mr. Swenson.” The first greeting lacks the respect and deference due any person. Many will prefer to be addressed more informally by their first name, but it is their call, not the physician’s.
Any patient’s question becomes an opportunity to engage in discussion and explore issues. Good physicians read between the lines and ask them- selves, “What does my patient’s question mean?” To the patient, they say, “I want to be certain I understand. Tell me what you mean when you say… .” Patients survive bad language and communication, but why cause addi- tional pain? Reflecting on his heart attack, Arthur Frank wrote: “The more extreme the situation, the more time and help I need to say anything. . . . You cannot be told that you have had a heart attack without having a great deal to express and needing to express it. The problem is finding someone who will help you work out the terms of that expression.”1
Sometimes the disparity in understanding is not so obvious, often sig- naled by an inappropriately angry response to advice. This conversa-tion—between a physician and the son of an elderly nursing home patient after his mother had become more confused—illustrates:
Physician: There’s a possibility that she may have fallen, struck her head, and developed a subdural hematoma, a blood clot pressing on her brain.
Son: I don’t think she has a blood clot. Physician: That’s a decision for me.
The son took offense. What he meant was, “I want to keep my prerogatives, since I know my mother best of all.” What the physician meant was, “You need not have the burden of deciding if she has a blood clot; that’s what you have a doctor for.” The physician was wise enough to recognize this dis- crepancy in interpretation immediately, and they were able to come to an accommodation: Even if there was a strong likelihood for the hematoma, they decided together, nothing would be done therapeutically, and so no further tests would be done. When patients or families become angry, phy- sicians need to ask, “What does my patient’s anger mean?” Patients may be angry for various reasons. Misunderstanding is at the top of the list, which includes depression, a prior unpleasant transaction with a physician, frus- tration with the “system,” frustration with an illness that is not going well, and unrevealed psychological issues.
WHAT DO WE LEARN?
Here are some lessons I have learned over the years about language and communication.
Sit. Do not minimize the importance of body language. Sitting when one talks with a patient is an important gesture. No matter if the conversation is less than a minute, patients see this as a commitment to them and them alone, a statement that “you are all I have on my mind now.” Less than a minute sitting seems like five minutes standing. Five minutes standing seems as if “the doctor’s got one foot out the door.”
Talk with patients as equals. Do not talk down. Do not shout. Here is one of my favorite stories. Early in my career, I assumed that all old people were hearing impaired, and so I introduced myself to an 89-year-old woman by shouting, “I’m Dr. Savett!” She responded in kind, “Good for you!”
Set the context. In order to explain things to patients, provide a context and start where the patient is. I often begin with a general statement such as “All in all, I think your health is good.” Then I continue with the details of the diagnosis and other issues of concern. When necessary, I enlarge the context. For example, each time she came to the office, a 45-year-old attor-ney dwelled on her obesity, her unresponsiveness to diet, and her poor im- age of herself. We enlarged the context by talking about her successful roles as mother, wife, and competent legal advocate.
Make no assumptions about the patient’s level of knowledge. Even if the pa-tient is a professional colleague, state the assumptions, clarify them if nec- essary, be certain of agreement, and try to understand all the participants in the drama. Ask, “What have you been told so far?”
Explore the patient’s beliefs and values. My new patient, a 95-year-old Or-thodox Jew, had a seizure just before he was brought to the hospital. Though the emergency had passed, he was still unconscious, and I was con- cerned that we might be faced with more acute problems and have to make urgent judgments about treatment and especially about resuscitation. I spoke with his daughter about “comfort, pain, and dignity” and suggested hospitalization and forgoing resuscitation. She insisted that we “do every- thing” including resuscitation. In their tradition, she taught me, the soul is that which should be preserved, and the body, the container of the soul, should therefore be preserved as long as possible, for in those additional moments, important insights may occur and relationships may be healed.
That discussion reinforced lessons about dealing with all patients, the need to inquire about beliefs and values and be aware that words mean dif- ferent things to different people. To me, the “dignity” of hospitalization that I proposed meant a comforting bedside scene; to the family, it meant the intrusion of repeated trips to the hospital to visit, a far less attractive choice than nursing him at home with family always present. To me, “pain” meant the pain of resuscitation; to them, it meant the pain of premature loss.
In helping patients to make a difficult decision, I often ask them to con-sider two questions: “Is it, the treatment, worth it?” and “Am I, the patient, worth it?” If both of your answers to those questions are “yes,” I tell them, then the other decisions will flow from that. And if both answers are not “yes,” we need to explore their values.
Recognize that a long conversation is often better than a short one. In the midst of a patient’s long hospitalization for liver disease, a nonmalignant ovarian tumor, and many surgical complications, I talked for an hour with her and her husband. During this time, I reviewed the entire hospitaliza- tion, how we had gotten to where we were (she was still seriously ill), in- quired about prior crises they had faced and their strengths during those times, expressed hope for a quick recovery, assured them of my commit- ment to do all I could, and recognized the uncertainties. We could not have addressed all these issues in a brief time, nor could a few short conversations have explored them in depth.
Recognize that a confrontation is often an indication for a longer conversation. A face-to-face conversation is better than a phone call. When the physician sees a patient rather than simply talking on the phone, the transaction car- ries more weight. The patient perceives: She cares enough to see me, to take the time, and to look me over. Not only does the patient hear the phy- sician’s voice, but he sees her face and body language, all of which enhance the value of her decisions and instructions.
Authorize the patient to speak freely. “I want you to know that there is nothing we can’t talk about. And if you don’t understand what I have said or if you disagree, you should let me know.” Acknowledge that “you wouldn’t be human if you weren’t apprehensive.” Ask, “What about this surgery frightens you the most?”
Negotiate. I propose a theory of the illness or a remedy, and then the pa-tient and I refine it. I ask, “Does this sound reasonable to you?” and allow the conversation to evolve. I never forget that patients are expert and have first-hand knowledge about their symptoms, reaction to certain drugs, and the impact of life’s events on their health. A 40-year-old bachelor described chest pain that I thought was similar to pain he had had for over twenty years. He was out of work, and he was concerned that he had heart trouble. After carefully listening to him and examining him, I said, “I think your pain is likely not related to your heart, especially in view of what’s going on in your life.” His response was, “But this pain is different—the location is different.” As we talked further, it became clear to me that this pain re- quired further investigation, including evaluation for heart disease. That is why I reason out loud, in order that together we can decide if the decisions are appropriate.
Tell stories. To get information or to make a point, I tell a story that may have some parallel to the dilemma. To a man whose wife had just died, I said, “One of my patients, a man your age, felt as if he was losing his mind when his wife died. What does your wife’s death mean to you?” The story authorized him to talk about his feelings, something he was not used to do- ing. To the son who is struggling with a decision to forgo resuscitation on his terminally ill father, I told the story of a similar moment in author Philip Roth’s life, when he whispered to his unconscious father, dying from a brain tumor, “Dad, I’m going to have to let you go.”2
Acknowledge reality. “You’ll be OK” may be an appropriate assessment, but it is inadequate in some situations. To the patient who was recovering from a heart attack and had real fears about the future, I said, “I know that what will reassure you the most is first getting two weeks and then two months of good health behind you.”
Recognize that not all questions have answers. Acknowledge uncertainty, but set time limits. A 50-year-old bus driver had pain in his abdomen for two months. His story suggested duodenal ulcer, and I treated him with antiulcer medication. “Let’s give it a try for two weeks. If it’s not better, then we need to do some more tests.” Most people can handle the uncertainty.
Deliver difficult news face to face and with compassion. “You’re carrying a pregnancy that has a birth defect incompatible with life,” a patient’s obste- trician told her. Just like that. She fired the obstetrician. Allow patients to absorb the bad news, reflect, and then talk about their feelings. Ask, “What’s this like for you?”
Write letters of condolence. Writing condolence letters is a ritual I de- scribed in the last chapter. I often write to the nurses who have been so closely involved in the patient’s care, for I recognize their loss also.
TEACHING ABOUT LANGUAGE AND COMMUNICATION
Developing a warm communication style takes practice. Watching vid- eotapes of interviews (including our own), role playing, and then critiquing the exercise work in a trusting environment. When what we say to a patient is misunderstood, the critical physician will ask, “Why didn’t this work? How can I say it better? What can I learn so that next time I’ll do it better?”
To teach undergraduates and pediatric residents about language and communication, I use a story about a 21-month-old boy who had been in good health until his father left home.3 When his mother began abusing al- cohol and neglecting him, he developed recurring middle ear infections and lost weight. His hometown physician sent him to the infectious dis- eases clinic at the nearby medical center. After a few appointments, he was hospitalized there for “failure to thrive, feeding problems, developmental delay, and recurrent otitis media (middle ear infections).” An extensive evaluation with multiple tests followed. Each time he ran a fever, he had more tests; none was conclusive. The intern assigned to his case recognized that he was continuing to decline and that there might be another ap- proach to his care. Especially since the tests were not helpful, there seemed to be no point in repeating them each time the child had a fever, and so each episode of fever was treated with antibiotics without further investi- gation. In addition, the intern, with the help of a compassionate volunteer, concentrated on his feeding and providing a safe, consistent environment. The child rallied. “[The intern] continued to treat [the toddler] as his per- sonal responsibility and to act as his physician [and] ‘advocate.’ ”
I ask each student to assume that he or she is the toddler’s physician, who wishes to share the uncertainties of the diagnosis and treatment with his mother in a way that is realistic yet does not promote panic. “What else do you want this conversation to accomplish?” I ask them. “What would you say?”
Here is what one group of students wanted this conversation to accom- plish. They wanted to establish their credentials, credibility, and reliabil- ity; get more information about the child; find out what is going on in the mother’s life and what this experience is like for her; discover her under- standing of the illness; review all the important information with the mother; talk about the diagnosis, treatment, prognosis, and uncertainties; ask about her wishes for her child; address the necessity for her to be more responsible; begin to explore referral to a social worker and child care classes; reinforce good behavior; establish a trusting alliance; and assure the mother that she does not have to handle this situation alone and will not be abandoned.
During the exercise, a number of things occurred. Some who played the doctor role presented all of this material in a thoughtful, compassionate, and understandable way. Others talked endlessly, without stopping to allow the mother to ask questions. They spoke in a patronizing tone and used medical jargon. (“The blood tests have not shown any definable illness. His white count is elevated. He may have an immunologic disease.”) Ulti- mately they all recognized that they should “speak her language,” be cer- tain that both she and the physician were using the same information, make no assumptions without validating them with her, say the important things more than once, and do it all in a way that was respectful, reassuring, and not officious. Of course, I ask the students, “What did you learn? In what way can the lessons from this story and these exercises influence your approach to learning and to patient care?”
When physicians share responsibilities for care with colleagues, they must speak a language that each understands. In conversations with physi- cians, patients deserve no less. A caption in the Minnesota Historical Soci- ety exhibit on “Minnesota Communities” concluded, “When you find someone who ‘speaks your language,’ you experience an immediate and lasting bond.”4