Communication and Patient Safety

She said I said what?
Sometimes, even when we try to explain things very carefully the message does not really get through. I have often sensed this happening during a conversation, and usually it is due to a patient’s or family member’s lack of comprehension of what I have said, despite my well-intentioned efforts. Some patients want simple solutions and explanations and when these cannot be provided they are less attuned to comprehension and understanding of the uncertainties and more complex explanations.
Clinicians deal with a multitude of patients daily, all of them and each one of their family members, has different capabilities to listen, to understand and then to explain to others the advice given. Probably the most important questions to ask are “Do you understand what I have said? Do you have any questions?”
What makes this even more difficult and therefore dangerous, is that even if we ask these questions our patients may not reveal to us their lack of understanding because they may be embarrassed to do so, and that is really, really challenging.
Case Study: Patient-centric dys-communication
A mother with three children, below the age of four, brought all of her children to the clinic on a day that her youngest, Sally, an 18 month old, was being seen because of recurrent respiratory infections. The little girl had never had a serious infection and remained happy and playful. Sally had been developing normally but seemed to have a new respiratory infection every 4-6 weeks, including three ear infections in the past six months. All three children spent several hours each day with five other youngsters in a day care setting that her mother ran as a small business in her home.
I performed a thorough examination and then ordered some laboratory studies including a throat swab, blood count and some screening immune function tests. When the results came back all normal for age I shared this reassuring information with the mother and advised her that though the infections were a concern, the frequency was within the normal range for infants of this age, especially infants with older siblings and who spend time in day care, and that her growth and development were normal and reassuring.
I explained, “In my opinion Sally is a normal little girl, and I am comfortable that at this time no further investigations are necessary or likely to be helpful. I know her infections have been a challenge for you and your husband, but with normal growth and development you should be reassured that Sally is not likely to have a serious medical problem. As summer is coming, and Sally is getting older, let’s see what happens over the next few months. You might also consider an alternative day care arrangement, if you can afford that, because day care is often the source of recurrent infections in young children.”
Two days later, I was called by my supervisor who advised me that a patient complaint had been submitted by Sally’s parents. “Mr. Smith (who had not been present at the office visits) alleges that you told his wife that there was nothing wrong with Sally and that you refused to do more tests. Also, he alleges that you told Mrs. Smith to stop her home care business because she was harming her child, that you said you did not know what was going on and had run out of tests to do.”
Frankly, I thought that perhaps I had slipped into a parallel universe. I found it hard to believe that Mrs. Smith had so failed to understand the message I was conveying. In fact she seemed comfortable with my explanation, smiled and thanked me when she left the office. All I can imagine is that when she shared my message with her husband the content became distorted, resulting in his getting angry. The lesson for me was to never underestimate the potential for dys-communication.
What we think we know, we may not really know, and what we know we said, may not have been heard and/or interpreted correctly; and what we don’t know, but think we do know, may result in complaints and even harm…confused yet?


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