This article was adapted from his editorial in AJM, Volume 124, Issue 5, in May 2011. — The Editor[divider] [note color="#f1f9fc" position="left" width=400 align="alignleft"][caption id="attachment_11941" align="alignleft" width="158"][/caption]
Joseph S. Alpert, MD, is Professor of Medicine and director of coronary care at The University of Arizona College of Medicine in Tucson, Arizona, and Editor-in-Chief of The American Journal of Medicine, published by Elsevier. He came to Arizona in 1992 from the University of Massachusetts in Worcester, where he was professor of medicine, director of the Division of Cardiovascular Medicine, and vice chairman of medicine.[/note]
Effective communication in clinical practice and teaching is, in my opinion, one of the most important skills that physicians in academic and community practice should strive to acquire. During my many years in medicine, I have often witnessed serious failures in communication between physicians and patients and among physicians speaking to each other.
The most common failure is the result of inattentive or inaccurate listening. When an individual fails to comprehend what is being said either explicitly or implicitly, misunderstandings may result that require prolonged discussion and negotiation before resolution is achieved. We can all agree that confusion often results when careful listening is not exercised. So how does one learn to listen effectively? This essay lists examples of communication failures along with guidelines I try to follow to improve my own communication skills in what I say or write.
1. Put down that iPhone and really listen!
Effective listening requires a conscious effort in order to understand what the speaker is trying to communicate. This kind of listening requires complete and focused attention; it will not occur if the listener is distracted by other thoughts or by a smart phone or BlackBerry. When I am trying to talk to someone and they are scanning through messages on their handheld device, it irritates me because I feel that they are not focusing their attention on what is being said. In addition to being downright discourteous, listening is not occurring. The simple guideline to follow here is to focus one’s attention actively and consciously on what is being said.
2. Drop the jargon
A second obstacle to understanding occurs when individuals use technical jargon during a conversation with someone who is not conversant with the terms. This failure frequently occurs when physicians or other health-care professionals attempt to clarify for a patient the cause of their illness and how it will be evaluated and treated. When technical terms or abbreviations such as “cath” or “PCI” are used in such a conversation, the patient often requires additional, detailed discussions. Physicians and their associates should eliminate jargon and abbreviations and use straightforward language.
3. PowerPoints should not cause eye strain
A third failure of effective communication involves teaching exercises or scientific presentations that employ PowerPoint slides. Slides crammed full of information and written in small type make it impossible to comprehend the points being made. Extensive, multi-lined tables are particularly difficult to see and understand. The rule for effective communication here is “KISS” — that is, “Keep It Simple, Stupid!” I was taught by Dr. James E. Dalen, a master communicator and Professor Emeritus at my college, to restrict slide information to four or five lines with a large, readable font size.
[pullquote align="right"]It is still not enough for language to have clarity and content… it must also have a goal and an imperative. Otherwise from language we descend to chatter, from chatter to babble and from babble to confusion.” — Rene Daumal (1908-1944; French writer and poet)[/pullquote]
4. Make sure you understand the question
A fourth failure of communication occurs when questions are asked. It is essential that the respondent listen carefully to the question and even ask for clarification if the point of the question is not perfectly understood. Otherwise, the answer often completely misses the mark and answers an entirely different question than the one posed. Patients often complain that physicians fail to explain the clinical situation adequately. I have often heard patients say, “The doctor did not answer my questions.”
Communicating with a sick patient requires special skills and involves a number of factors beyond the mere statement of facts. The doctor needs to focus their gaze on the patient’s face, speak slowly, clearly, and logically, and, as just stated, avoid technical jargon and/or medical abbreviations. Although some physicians may not agree with this, I often touch the patient’s hand or arm gently when I wish to emphasize a particularly important element in my clinical explanation. If I have something very important to tell the patient, such as the need for an operation or an invasive diagnostic procedure, I sit in a chair or on the side of the bed so that my eyes and those of the patient are on the same level.
5. Just answer the question …
Finally, when communicating with physician colleagues who have requested a consultation involving my expertise, I try hard to focus my clinical response on the question posed by the referring doctor. For example, if I am consulted about the management of a specific arrhythmia, I restrict my answer to this particular question and do not offer additional, and perhaps unwanted, advice concerning other internal medical aspects of the patient’s condition. This approach is something I stress to young cardiology fellows during their first year of training. They have just spent three years in their internal medicine training and often want to give some advice to the referring physician concerning aspects of the patient’s illness other than the specific cardiovascular question that has been posed. I had to learn this lesson and also restrict my consultative answers when I was a first year trainee in cardiology. The clinical mantra that I teach now is: “Just answer the question that led to this consultation.”
I remember clearly the day when, as a newly-commissioned first-year cardiology fellow, I was presenting a patient with mitral stenosis to Dr. Dalen. My presentation was very thorough and ended with a number of suggestions for managing the patient’s chronic obstructive lung disease and diverticulosis. Dr. Dalen supplied me with the mantra just cited, and I have followed it faithfully since then.
In conclusion, the algorithm to follow involves focused and complete listening, simple and straightforward oral or written language stripped of jargon and abbreviations, and carefully fashioned responses to questions so the response answers the question that was posed.
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