Lost in Clinical Translation: What happens when doctors can’t communicate clearly?

FEBRUARY 8, 2014, 2:30 PM  1 Comment

Lost in Clinical Translation

By THERESA BROWN

A classic “Far Side” cartoon shows a man talking forcefully to his dog. The man says: “Okay, Ginger! I’ve had it! You stay out of the garbage!” But the dog hears only: “Blah blah Ginger blah blah blah blah blah blah blah blah Ginger …”

As a nurse, I often worry that patients’ comprehension of doctors and nurses is equally limited — except what the patient hears from us is: “Blah blah blah Heart Attack blah blah blah Cancer.”

I first witnessed one of these lost-in-translation moments as a nursing student. My patient, a single woman, a flight attendant in her early 30s, had developed chest pain and severe shortness of breath during the final leg of a flight. She thought she was having a heart attack, but it turned out to be a pulmonary embolism: a blood clot in the lungs. Treatment required several days in the hospital. Already far from home and alone, she was very worried that a clotting problem would mean she could no longer fly.

When the medical team came to her room, they discussed her situation in detail: the problem itself, the necessary course of anti-coagulation treatment and the required blood tests that went with it. To me, just at the start of my nursing education, the explanations were clear and easy to follow, and I felt hopeful they would give my patient some comfort.

After the rounding team left, though, she turned a stricken face to me and deadpanned, “Well, that was clear as mud, wasn’t it?”

I sat down and clarified as best I could. But until then, I hadn’t realized what a huge comprehension gap often exists between what we in health care say to patients and what those patients actually understand.

A growing body of literature suggests that these clinical miscommunications matter, because the success of physician-patient interaction has a real effect on patients’ health.

In a 2005 article in the Journal of the American Medical Association, Eric B. Larson and Xin Yao, researchers at the University of Washington, claim that treatment outcomes are better when doctors show more empathy and take the time to make sure patients understand what’s going on.

I saw the importance of caring communication during a friend’s recent heart attack scare. He had a lingering case of bronchitis, and one morning found himself struggling for air. He had pain in his shoulders, back and neck and a feeling of increasing constriction in his chest.

Concerned, his wife took him to the emergency room, where his breathing became even more labored. In the triage area he began sweating profusely and then collapsed. A rapid response team rushed in, put him on oxygen, started an IV, got an EKG. His wife thought she was watching, helplessly, as her husband of more than 20 years died in front of her.

Minutes passed and the code team revived him, but no one told her that he’d passed out because of a protective effect of his autonomic nervous system, not because his life was threatened. No one fully explained that to him, either.

At that point his wife called me, and knowing how confusing modern health care can be, I went to the hospital to help. I caught up with them in the cardiac catheterization lab, where the miscommunications continued. The cardiac cath showed that his arteries were clear — but the diagnosis, explained in technical terms, meant nothing to his wife. It took over 12 hours to learn that his echocardiogram revealed all cardiac structures to be normal. (Also, no one told the wife that her husband would stay overnight in the I.C.U. because protocol required it, not because he actually needed intensive care.)

Although my friend received exemplary care, neither he nor his wife felt that they had. Instead, similar to my patient in nursing school, they felt they had been hijacked to a foreign land. The hospital staff members were obviously dedicated to restoring patients’ health, but they and the work itself came across as alien, obtrusive and impossible to understand. Also, my friend’s problem was correctly diagnosed days later when he went to his primary care physician. Acid reflux was causing his pain; the cure was a prescription for Prilosec.

Interestingly, patients in hospitals report more satisfying interactions with physicians when doctors sit down during rounds instead of standing, according to a 2012 article co-written by the researcher Kelli J. Swayden, a nurse practitioner, in the journal Patient Education and Counseling. Sitting gives the message “I have time,” whereas doctors who stand communicate urgency and impatience.

I don’t mean to blame doctors and nurses; it can be very hard to force yourself to slow down and tune in to a patient’s wavelength when you have other patients and countless pressing tasks to get to.

And that’s especially true today, when hospitals are focused, machinelike, on volume and flow. Bedside manner does not increase efficiency, and it certainly can’t be charged for. Still: My friends had gone from blueberry pancakes at breakfast to worrying that the husband might die, and the closest anyone got to assuaging that fear was the doctor who said, “Well, we’ve ruled out everything that will kill you right away.”

And that’s not good enough, because going to the hospital is an exercise in trust. Ill health is frightening, the treatments we offer can be scary, and stress and anxiety make people poor listeners. Our high-tech scans and fast-paced care save lives, but we need to make time for the human issues that pull at every patient’s heart.

Theresa Brown is an oncology nurse and the author of “Critical Care: A New Nurse Faces Death, Life, and Everything in Between.”