“The biggest communication problem is we don’t listen to understand; we listen to reply.” — Stephen R. Covey (1932-2012)
Editor-In-Chief, Chester “Trip” Buckenmaier III, MD, COL (ret.), MC, USA
As we begin 2022 in federal medicine, I cannot help reflecting on the unprecedented transformational change our society has undergone in such a short period due to the pandemic. Assumptions regarding the workplace, school, social and religious gatherings have undergone a tectonic shift. Could you have imagined worrying about the vaccination status of a family member coming to an event like a wedding or Thanksgiving just two years ago?
Even before the pandemic, communication norms were changing fast. Years ago, I witnessed my daughters trying and failing to set up a social event with friends by texting. When I suggested a simple phone call would quickly solve their social coordination problem, I was greeted with stares of dismay and concern for offering such an “uncool” option to communicate. For better or worse, how we interact with friends and family has fundamentally changed. Admittedly, I cannot deny the tremendous advantages electronic forms of communication have played in my work and social life during the physical isolation of the pandemic. Then again, I am old enough to recognize the downsides of meeting and communicating over a computer or phone for business or family matters. Electronic communication, as yet, cannot replace the nonverbal body language cues so vital to the successful transfer of meaning in more intimate face-to-face discussions with another human or group of humans. I believe George Bernard Shaw’s famous quote concerning “the problem in communication is the illusion that it has taken place” is even more poignant in modern society.
I further believe the challenges confronting society regarding effective communication are magnified in the healthcare system. As an anesthesiology professor, I continue to interact with residents in clinical settings on a routine basis. With rare exceptions, most new residents are uncomfortable with face-to-face communication with fellow staff or patients. They often become so focused on the procedure they are about to perform (under my guidance) on the patient that they forget to inquire why the patient is even there for the procedure. They are often perplexed on why I insist, for example, on understanding and asking the woman in Room 3 with the cut hand; how did she cut her hand? In time, I hope the residents begin to see that the period invested in understanding the patients and their specific situation pays incredible dividends in the success and ease of the procedure we are performing. The communication focused on the patient about their career, family, military branch or whatever establishes a human relationship. This results in the patient becoming a partner and willing participant in the procedure we are about to perform on them. The residents are likely tired of me saying that our focus should not be what we can do to the patient; rather, our primary focus should be what we can learn about the patient. I believe this skill was more easily acquired when I was a resident because I did not start with the handicap of communication by electronic devices.
My wife and I also have noted growing concerns among friends and family regarding the paucity of clear and meaningful communication when interacting with their healthcare providers. Folks often call us when they are confused after their appointments. We take the time to explain their doctor visit, medical laboratory values and imaging studies. As a profession, healthcare in the United States generally seems so focused on what can be done to the patient (of course, that is where the billing is most straightforward) that the patient’s actual reason for interacting with the health system in the first place is almost lost.
In a recent interaction by my father-in-law during an emergency room visit, he complained of extreme pain in his shoulder. The pain was the primary complaint, but also noted was general weakness, so much so, he could barely walk. The clinician focused his complete attention on the shoulder, ignoring (or more likely wholly unaware) that the 80-year-old patient had played in a golf tournament the week before and now could barely get out of a chair. The shoulder pain was only a symptom of a much more severe problem. It took three return ambulance trips back to the emergency room and the intervention of my wife, before a clinician was forced to look a bit closer at the patient’s history and communicate with him on everything that was affecting his everyday life. This discussion led to blood work that revealed positive blood cultures and septic arthritis. Obviously, my father-in-law’s story is far more detailed than I have space in this editorial. In short, the system focused on what could be done to the patient to get to a quick (seemingly inexpensive) disposition. Although this approach satisfied the insurance algorithms, the superficial care he received resulted in more expense as he had to return multiple times as his condition deteriorated. Had anyone initially taken time to fully communicate with my father-in-law concerning what was going on in his life (called a history and physical), I believe considerable resources could have been saved. Once my wife forced the system to pause long enough to listen, the diagnosis was forthcoming, and the needed care was evident. Following this drama (my father-in-law is doing much better), my wife commented that another 80-year-old without a health professional daughter likely would have had a far less pleasant outcome, given this same set of circumstances.
I have often commented that I feel blessed to work in federal medicine, where the pressure of monetary concerns is less acutely felt in my management of patients. I recognize that our system is not perfect. Still, I would argue it is perhaps one of the better examples of what good healthcare could become in this country. Obviously, for this to happen, we will have to stop looking at healthcare as a profitable business venture and see it as the human right it must be in any free society. This concept is undoubtedly beyond this editorial’s scope and any single federal provider’s capability to change today. That said, we can change how we interact with our patients to provide a positive example to our colleagues and hopefully the nation in time. We can spend more time listening and communicating with our patients and less time doing things to them. If we can learn to value communication with the patient over procedures, this would genuinely change healthcare for the better. I am hopeful we in federal medicine can embrace this concept of improved communication and provide leadership in this regard for the nation in the New Year.