Get Unwired
Electronic communication has its place in
medicine, but when it
comes to diagnosis and treatment, there is no substitute for a
face-to-face exchange.
comes to diagnosis and treatment, there is no substitute for a
face-to-face exchange.
“What do you mean we don’t
communicate? Just yesterday I faxed you a reply to the recorded
message you left me on your answering machine.” This is
the caption of a cartoon showing a husband and wife having
breakfast, noses stuck in newspapers. This is also a fairly
accurate glimpse of what communication has become for many busy
people who are trying to balance work, family and
recreation—including physicians.
The ability to
communicate quickly and efficiently with little or no
interpersonal contact is enticing. Faxes, voice mail, text
messaging, and e-mail all make instant communication possible
across thousands of miles and even across oceans. I have
considered this subject with several questions in mind: 1) Are
doctors relying too much on impersonal forms of communication?
2) How is this affecting their practices and patient care? 3)
When is it appropriate to use electronic means of
communication? These are all important questions that you
probably have considered at one time or another.
Studies are beginning to
come out that assess the impact of “information
overload” and how electronic communication affects our
lives and businesses. In a series of recent clinical studies, Dr.
Glenn Wilson, a psychiatrist at King’s College London
University, monitored the IQ of workers throughout the day. In
those individuals who tried to juggle messages and work, their
IQ’s fell by 10 points—the equivalent to missing a
whole night’s sleep. Even smoking marijuana had less of
an impact (with only a four-point drop). Another study of 1,100
Britons conducted by TNS Research and commissioned by Hewlett
Packard, found the following:
• Half of all workers respond to an
e-mail within an hour of receiving it.
• The constant interruptions
increased workers’ levels of fatigue and reduced
productivity.
• Nearly two out of three people
checked messages when they were away from their office at home
or on vacation.
The medium for the message
Ken Cohn, a surgical oncologist and the
author of Better Communication for Better Care:
Mastering Physician-Administrator Collaboration, believes that e-mail has its place in a
medical practice. “E-mail creates a document that is much
easier to trace, print, and file and thus minimizes the chance
that important patient details will fall through the cracks
because a post-it note was inadvertently thrown out,” he
says. Cohn recommends that e-mail be used for “routine
details, agendas of meetings, and sharing of information as
attachments among team members.” However, when it comes
to exchanging information with patients, Cohn has this
perspective, “In all areas of medicine, good judgment
comes from unexpectedly undesirable outcomes. Face-to face
communication is essential for providing negative feedback and
for controlling sensitive information that might be
misinterpreted if quoted out of context. Once one presses the
send option, one abdicates control of the flow of
information.”
David Maxwell, the director
of research at VitalSmarts,
says he doesn’t believe that electronic communication in
health care is overutilized. Instead, he describes two kinds of
communication. The first is routine communication, which he
says can be very effectively done electronically. “An
example would be the challenge of two drugs that sound similar
or, when you write them, appear similar [and might be confused
with each other]. In this case, a physician order entry system
or some other type of electronic communication could prevent
those problems.”
The second type of
communication is the subject of two books by Kerry Patterson:
Crucial Conversations: Tools For
Talking When Stakes are High,
and Crucial Confrontations: Tools for
Resolving Broken Promises,
Violated Expectations, and Bad Behavior. Maxwell elaborates:
“Crucial conversations are ones that are high
stakes, emotional, and involve differences of opinion. Our
experience is that people actively avoid those
conversations.” Because people don’t like to engage
in crucial conversations, they often use e-mail or other
impersonal ways to communicate. Interestingly, Maxwell’s
research has found that the topic of the conversation does not
predict how well it will go. Instead, in crucial conversations,
Maxwell says, “You can talk about any sort of threatening
content as long as you find a way to make it
‘safe.’ When a person gets upset or defensive about
what you are saying it is because they are questioning your
intent. It is not about the content.”
In order to have
“safe” crucial conversations, Maxwell advises,
there must be two elements of safety. The first is
“mutual purpose.” It is essential that the person
you are engaging in conversation believes that your goals are
the same. The second is “mutual respect.” Maxwell
says that when someone doesn’t feel respected he will go
into one of two modes: silence or violence. In the
violent mode, he will become obviously angry. In the silent
mode, he will withdraw.
Maxwell cautions that
the first sign that a conversation is going badly is when it
goes to silence or violence. He says, “We’re good
at noticing violence but lousy at noticing silence. The patient
probably overvalues your time. This may lead to them not
voicing the concerns that they have.”
Tools for talking
David
Woods is the president of
Healthcare Media International, Inc. and the author of Communication for Doctors. Woods writes that communication is the number
one issue in medical malpractice, and that communication issues
can involve many people: “Not only issues involving
communication between physician and patient, but physicians
with other treating or consulting physicians, physicians with
other health-care providers, physicians with office staff or
hospital staff, and between patient and physician office staff,
to name a few.” Woods goes on to advise readers that
“communication issues may also lead to allegations of
failure to follow up or failure to diagnose in a timely
manner.”
In one chapter, Woods
suggests 30 ways to make your practice more
“patient-friendly.” Some of the highlights from
this chapter include:
1. People like people who speak
first. Don’t wait for your patients to introduce
themselves—take the initiative.
2. Give written information for even
the simplest advice. This is a major patient satisfier and it
means fewer questions later.
3. Instead of asking, “Do you
have any questions?” try “What questions can I
answer for you?”
4. Patients want to feel that their
health-care providers spend enough time with them. You can
create the impression that a meaningful amount of time was
spent by giving undivided attention to your patient during the
first 60 seconds of your encounter. It’s not as easy as
it sounds.
5. Think about how you felt on your
first day of practice and let your patients see your
enthusiasm. People love people who love what they do.
Though Woods
doesn’t use the term “crucial conversations,”
he describes skills for “answering questions patients
don’t ask.”
He suggests:
He suggests:
1. Never underestimate a
patient’s intelligence. Even relatively uneducated
patients want to be fully informed about their health and any
treatment prescribed.
2. Explain what you are doing and
why you are doing it.
3. Discuss the diagnosis and the
treatment regimen carefully and then encourage the patient to
ask questions. If the patient fails to ask appropriate
questions, ask questions yourself. (e.g., Do you understand
what diabetes is now that we have discussed it?)
Communication, whether
it is electronic or face-to-face is an extremely important
aspect of medical care. The time has past where doctors should
“look wise, say nothing, and grunt” (this according
to the great clinician Sir William Osler). Instead, it is our
job as physicians to begin the dialogue and steer it in a
manner so that all of the information that a patient (or
another health-care provider) needs is given. As an article in
the British Medical Journal (325: 697-700) noted, “good
doctors communicate effectively with patients—they
identify patients’ problems more accurately, and patients
are more satisfied with the care they receive.” Good
communication is good medicine. g
Julie
Silver, MD is an
Assistant Professor at Harvard Medical School and the author of
several books including Chronic Pain and the Family. She is also directing the new Harvard CME
course, “Publishing Books, Memoirs and Other Creative
Non-Fiction” (for more information go to http:
//cme.med.harvard.edu/.)
