Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, M.D.
9 January 2002

THE IMPORTANCE OF PATIENT COMMUNICATION

     For anyone who watches television, it’s hard to have missed the recent advertisement for digital telephones.  I was very amused by the one about the football coach who wants, “A replacement for O’Neil.”  It is intimated that his assistant heard the coach ask for, “The Captain and Tenille.”  The remainder of the ad shows the football team out dancing as the Captain and Tenille do their song and dance.  I laughed when I first saw this but it provides and example of the crazy things that happen because of miscommunication.

       As ridiculous as the above example is, medical miscommunication leads to problems that bad and worse.  Doctor-patient communications are highly privileged.  A doctor may not divulge information communicated from a patient except in that very rare situation, where the information maybe dangerous to another individual.  Such an example would be if a patient were having thoughts of harming or killing another individual, the doctor is required to take steps to protect the other individual.  However, confessions  or information about past events already completed, even if they harmed another person, remained privileg information on a doctor’s record.  Thus communications with a person’s physician are as privileged as communications with one’s priest, or a lawyer.  It is thus very important that patient’s communicate their concerns and history to allow the physician to act in the best way possible for the patient’s welfare.

    Rule #1:  The best medical outcome occurs with a complete history.  A tragic example for this rule is the story of a gentleman who came to the clinic because of abdominal pain.  The pain had been present for several weeks, was made worse by eating and the gentleman had lost several pounds in the previous weeks.  Two brothers and the gentleman’s father had previously had cancer of the colon.  The patient was terrified that he might have a similar problem but felt that the healthcare provider seeing him “would know what to do”.  Therefore, the gentleman didn’t even mention the family history of cancer and in fact said, that he thought his problem was a little indigestion that would get better with an antacid.  The clinic visit occurred in a hurried situation and a complete history was not obtained.  The gentleman was given the antacid that he requested and did not seek further medical attention until a month later when his bowel perforated and he required emergency surgery.  The healthcare provider was professionally embarrassed by the mistake of missing a problem that could have been dealt with more effectively earlier.  Unfortunately, the patient’s tendency to deny a problem because of his fear lead to the healthcare provider missing a diagnosis.  Taking a complete history and getting all the details is a critical part of healthcare.

       Rule #2:  The best medical result occurs when the patient’s concerns and interpretation of their situation is known.  Here the example is quite similar to the one above.  A gentleman came to the clinic with a complaint of lower chest pain that occurred when he laid down at night. The pain tended to come on at times when he had eaten more or had late afternoon or evening coffee.  The patient was not a smoker.  He did not have high blood pressure.  He was not diabetic and his cholesterol was known to be in the low normal range.  The patient very clearly had an example of acid from his stomach backing into the esophagus and causing a burn that was painful.  The patient was given an appropriate medication to decrease acid secretion in his stomach and this would have solved the problem.  Unfortunately, the healthcare provider was made aware that the patient was terribly concerned that they had heart disease and was going to have a heart attack.  The patient didn’t indicate his concern feeling that the healthcare provider should consider this possibility and do various tests to evaluate it.  The healthcare provider did consider the possibility but then appropriately ruled out heart disease as the cause for the gentleman’s symptoms although it was not discussed with the gentleman.  Since the doctor did not test for heart disease, the patient felt that there workup was inadequate and the doctor was making a mistake.  Not wanting to insult their doctor, the patient said nothing but instead went to another physician with the same story.  When the patient got to the second doctor, he indicated that he thought he was having a heart attack and an unnecessary expensive, time consuming, evaluation was done.  Had the patient’s concerns been appropriately elicited and communicated to the doctor, unnecessary anxiety and workup could have been avoided.

       Rule #3:  Trying to hide bad medical news from your loved one is rarely useful, rarely effective and most often detrimental to the medical situation.  The example here is of a lady, 66 years of age who was involved in relatively minor automobile accident in which the steering wheel struck her abdomen.  She had abdominal pain for several weeks after that and then the problem seemed clear.  However, the pain recurred about 3 months after the accident and then seemed to get worse.  The patient’s daughter accompanied her mother to the clinic where a subsequent diagnosis of inoperable pancreatic cancer was eventually made.  The daughter was so concerned that her mother “just couldn’t stand to know her diagnosis” resulted in a 4 month charade with the daughter pretending that the pain was related to the automobile accident 6 months before.  Soon the mother ceased to communicate her concern and needs because nobody acted upon them and her abdominal pain persisted.  Confidence and communication between doctor, patient and family deteriorated.  Prior to the patient’s death, she did find out that she had cancer and was very resentful and insulted that both the physician and the family had not had the courage to tell her the truth.

       Rule #4:  When life changing medical information is told to the patient be very, very sure of the truth before offering that information.  Seeking a second opinion is a wise choice for the physician.

       The example here is that of my mother and father.  They had been courting for some length of time when my father had a physical examination related to a job application.  The examining physician heard a heart murmur that in fact was meaningless.  However, the physician misinterpreted the murmur and told my father that he only had 6 months to live at 21 years of age.  As dad said that he was young and foolish.  Now convinced that he was going to die in 6 months, he wrote my mother an insulting goodbye letter and moved to Arizona to live out his last 6 months.  Fate was kind and 3 years later when they happened to meet again by happenstance, the story had a happy ending.  The rule here is easy.  Healthcare providers should not give life changing medical information unless it is very, very well grounded though patients don’t accept life changing medical information without a thorough explanation.  A wise physician will himself seek a second opinion in such situations before the patient requests it.

       I cannot emphasize how critically important communication is.  Suffice to say that there are more bad medical outcomes related to miscommunication than there are to medical mistakes. Being given the wrong dose of the medication is relatively rare.  Not receiving the communication that a person is allergic to a medication is much more common.