Avoiding the Slippery Slope to the Attorney’s Doorstep

by Mark Gorney, M.D., F.A.C.S., Medical Director, Board of Governors

From time to time, we reprint pertinent articles from past issues of The Doctor’s Advocate. The following article, which provides a fundamental refresher on communicating with patients, was first published in the fourth quarter of 1999. We think it would be useful under today’s circumstances to publish it as a reminder.

You have heard it before: The common denominators of all malpractice claims are surprise, disappointment, and anger. Regardless of the underlying complaint, these three elements are always among the primary emotions that drive a patient to the attorney’s office.

The universal vaccine for this malady is accurate communication. Once the symptoms appear, the antidote is rapid intervention and adequate doses of TLC—an inexpensive and readily available medication. Sometimes, however, it is unavailable to those who can’t—or won’t—be the necessary catalyst to make it work. That catalyst is the physician’s nature—in the person’s genetic makeup. It is a combination of your central nervous system, your environment, and what you learned at your mother’s knee.

You have heard about surgeons who are superbly trained and infinitely competent at what they do, but who are poor physicians because their image is cold, aloof, or even arrogant. Conversely, there are those whose skill or medical expertise may be less than ideal, but whose waiting rooms are always packed because they have a warm personality and a caring manner—a combination of traits that makes patients feel the doctor is really listening.

Hearing and listening are distinctly different. Hearing is a neuroacoustic phenomenon in which physical stimuli become sound in our brain. Listening, on the other hand, is evaluating what is heard and acting on the information heard. Listening can be a powerful claims prevention tool.

Expression

Because clear communication requires appropriate expression, misunderstandings are just as likely to arise from ineffective speaking—or from no response—as from poor listening. After listening to a patient, you must respond. Psychological literature abounds with studies on communication patterns and the critical difference that effective speaking has on creating rapport between speaker and listener. The following techniques help improve verbal communication.

• Tempo of Speech and Tone of Voice
  Some of us tend to speak rapidly or to economize on words. To ensure that patients understand you, speak slowly and clearly. Often, the stress that physicians experience in their daily practices is reflected unconsciously in their tone of voice. For example, the phrase “You should have called me” can be said in a regretful, solicitous manner or in an impatient, accusatory way. The effects these two styles have on a patient can differ dramatically.
  
  
• Pause for Digestion and Feedback
  When your message is complex, pause frequently—even if your listeners do not seem confused. A break in speech allows patients to digest what you are saying or to ask for clarification. Also, invite questions repeatedly. The resulting dialogue will reinforce patients’ feeling that they are participating in their health care. There is nothing wrong with asking “Do you understand?” as often as you think necessary. Most patients will interpret your question for what it is—a sincere interest in their welfare. One of the best ways to make sure explanations or instructions are understood is to ask patients to repeat what they have just been told. Any notion that you are insulting their intelligence can be dispelled by explaining that you want to ensure their well-being. You might want to give the example that “50” and “15” may sound very similar, but the numbers can literally spell the difference between life and death when they represent milligrams prescribed for a potent drug.
  
  
• Tailor Your Language
  One of the most common complaints in patient attitude surveys is physicians’ use of complex terminology or medical jargon. There is a substantial choice of words available for communicating with patients according to their intellect and education level. For instance, rather than tell a patient that you need to perform a “fecal analysis,” it might be better to substitute the word “stool.” In some cases, you may need to use even more basic descriptive terminology. The goal is to make sure you are understood.
  
  Similarly, while physicians define the stomach as a definite organ with a specific function, a patient’s complaint of a “stomachache” might refer to an indefinite area anywhere from the ribs to the pubis.
  
  
• Repetition
  Various studies have shown that the average patient retains only 35 percent of what he or she is told. To improve retention, summarize the essential points of your message at the end of the consultation or examination. Repetition strongly reinforces what you have said.
  
  
• Request Written Questions
  A visit to the doctor can cause anxiety that makes patients forget important questions or information until after they have left your office. The French call this esprit d’escalier or the “spirit of the staircase,” where many people remember what they forgot to ask. Assure patients that this behavior is normal. Encourage them to write down any questions they have and to bring a list on their next visit. If your patient already has a list, do not—by word or body language—express impatience about answering the questions. In the event of an unfavorable outcome, your conversation about that list may prove extremely useful to your defense.
  
  
• Body Language
  Body language is as important in speaking as it is in listening. While much has been written on the subject of body language, relatively little has been said about its role in the doctor-patient relationship. Starting with the first friendly handshake, nonverbal communication is important to establish and maintain patient confidence; it becomes absolutely critical if things start to go wrong. In fact, poor body language during highly charged situations can easily trigger a breakdown in doctor-patient rapport.
  
  In speaking, as in listening, eye contact is critical—it is the essential expression of understanding. Maintaining eye contact with patients will hold their attention. Patients’ facial expressions and frequent nods will indicate how effectively you are getting your message across.
  
  
• Permitting Your Emotions or Frustrations to Affect the Patient
  The anxieties of sick or injured people often act as a lens that magnifies the physician’s body language. A frown or a simple “hmmm” by you may exacerbate that anxiety. In some cases, patients’ visits to attorneys have been triggered by an innocent sigh, a raised eyebrow, or a look of skepticism when evaluating a colleague’s results. Many claims are triggered by unfavorable comments—spoken or implied—by the subsequent treating physician. And, never talk to a patient while standing with your hand on the doorknob.
  
  
• Biting the Hand That Protects You
  We frequently hear personal accounts of physicians’ attitudes from those with whom they interact. These attitudes range from indifference to outright rudeness. We understand better than anyone the kinds of stress a claim (or even the threat of one) produces in a doctor. Nonetheless, this is a gentle reminder that The Doctors Company is part of the solution, not part of the problem. Just as a reassuring smile, a comforting touch, and a confident, caring attitude are indispensable ingredients for a solid doctor-patient relationship, the patience, cooperation, and confidence of your insurer’s representatives are the key to your defense when the patient rapport you established goes sour.

Nowhere is the old adage “An ounce of prevention is worth a pound of cure” more appropriate than in the doctor-patient relationship.