Monday, February 10, 2014

Speaking and Hearing

Doctors and nurses often don’t speak English. They speak “medicine.” When I was a young medical student at Columbia University, Dr. Lewis Rowland was the new Chairman of Neurology. Even then, he was already a giant in the field, but he was, at that point, a young giant. In my eyes his greatness was as much a function of his ability to understand the need to communicate clearly as it was his knowledge of and research in neurology. When a medical student would present to Dr. Rowland -- which was always an occasion of great anxiety -- the student’s knowledge of neurology and the diagnosis of neurological diseases would be tested, but so would his or her ability to speak English. The minute a student stated “the patient had upper extremity weakness,” Dr. Rowland would stop the student and say in a questioning tone, “upper extremity?” He would then, with great flair, state, “Oh, you mean arms!” He would never let a student or a resident get away with speaking medicalese when English was available.  

Yet even when a doctor or a nurse makes an attempt to avoid medical jargon and speak English, the fear and emotions that are part of every medical encounter makes hearing what is said extremely difficult. In a recent New York Times blog post entitled “Lost in Clinical Translation,” Theresa Brown -- who is an oncology nurse and an author --talks about the need to pay more attention to both what doctors and nurses say and what patients hear. She starts her post with the following analogy:

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.”
Her choice of the word “translation” in her title is especially meaningful for me. I have often said that in medical school I did not learn how to practice medicine; I only learned the language of medicine. As someone with a great love of the English language, I was struck at how different the way medical professionals communicate is from the way the rest of the world communicates. The intent is often good, and that is to be precise when plain English may not be precise enough.  That is not only limited to the medical world. It seems within every discipline and within every culture, there is a language all its own. When I decided to go back to school to study business and work toward an MBA degree, it was because I was already involved in discussions having to do with healthcare costs and management systems, and I was frustrated because I did not know the language. I felt I needed the formal coursework to learn to translate from medical to business.

In our society, when we speak of healthcare, if we are speaking from a point of view of legislation, the language is government. When we speak from a point of view of costs, the language is economics. When we speak from a point of view of technology, it is “techno-speak.” And so we speak multiple languages, even when we think we are all speaking about the same thing: healthcare. For me, that is all just noise, as the real language of healthcare is the conversation that occurs between a person in need and a health professional, even if that professional is a professional office worker in a doctor’s office. That, for me, is what being patient-centered is really all about.

But whatever the language, and no matter how well it is translated, it’s also important to remember that what is said may not be heard. Ms. Brown’s blog article points out that challenge. She described a situation early in her nursing education when a patient who was in the hospital for a pulmonary embolism (medical speak for a blood clot that travels to the lungs and damages part of the lung, making it difficult to breath) is seen by the medical team who explain her condition to her. She writes:

“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?’”
Taking time to communicate clearly – and even more importantly, to ensure that the communication is heard and interpreted in the way it was intended – is part of the art of medicine, whether that art is practiced by a doctor, a nurse, a therapist, or even a clerk at the front desk. I fear we will not focus enough on this communication as we move toward efficiency as the goal of a cost-conscious health system.  Without taking that time, and leaving the understanding between the medical professional and the patient wanting, the efficiency that results is a false efficiency – and costs will actually go up.

As we, as a country, struggle with medical costs, we should start by recognizing that by paying for more medical personnel who slow down and speak in plain English – to make sure that patients are hearing what was said – will save more money than we will through technology and efficient networks.
It also supports the model we have developed at Accolade. At Accolade, our clients have their own Accolade Health Assistant® who is skilled at purposeful, understandable communication and relationship-building in order to foster the type of two-way communication that is critical to good, truly efficient care. The clients also often have a Clinical Health Assistant, a nurse, who works with the Health Assistant to offer the medical knowledge (and translation) that is also critical to good, efficient care. With that team approach, the resources for proper, care and two-way communications are in place. The result is better care and lower costs.

The lesson learned for health care more broadly from our experience is the lesson of communication and trust as modalities every bit as important, and perhaps even more important, than the pure science that is integral to good medicine.