I work in addiction medicine, and occasionally when I converse with my patients, I am struck at how disengaged they appear. As I offer what I think is my wise and sage advice, I feel like they often just hear white noise.
As a physician assistant (PA) who has been practicing for more than 20 years, a big part of my focus has been on health literacy, a subject that is completely different from literacy: Literacy is the ability to read and understand written/spoken language, whereas health literacy is the ability to understand what providers are talking about. Even with my strong commitment to making my communication meaningful and relevant to my patients, no matter their level of education, I often fail.
When I myself engage with clinicians, I frequently leave my appointments thinking: “Did they say 2 ear drops every 4 hours, or 3 drops every 2 hours? Is the medication to be taken with food? Should I use the inhaler q4h or prn?”
When I go to the pharmacy to pick up my medications, the pharmacist rattles off a list of instructions, and I smile and take my medications home. I look at the instructions on the package, and I ask myself, “Is this what they said? This sounds different than their instructions.” I open Dyna-Med or Pharmacopeia and see whether I can find any clarification, and then I do what I think I’m supposed to, only to find out later that it was not correct.
If this happens to us, as health professionals, imagine what it’s like for our patients as they sit politely and listen to our bizarre sequence of questions and commands: “Let me ask you about your medical history. Is your mother still alive? Stick your tongue out. Have you been to jail? Open your mouth. Pull your shirt up so I can push on your stomach. How long is it been between bowel movements?”
A patient who thought they were coming to see me to help them with their addiction is asked rapid-fire questions that seem very, very irrelevant to them. When I see their eyes glaze over, I can tell I’m failing my patients.
In particular, when treating patients with opioid-use disorder, I often encounter patients in opioid withdrawal. In this population setting, communication is extremely important, and there is little room for error. When I miss the mark, I jeopardize my patient’s chance for success in treatment. It’s as simple as that.
There’s a strong body of evidence suggesting that almost all patients, regardless of their socioeconomic standing or literacy skills, leave their medical visits with at least 1 misunderstanding. The Agency for Healthcare Research and Quality has done some great work about these issues, including framing them in a universal precautions light and encouraging medical providers to assume that all patients are at risk for leaving their office visits with some misunderstanding and confusion about next steps in treatment or what their diagnosis means.1 The agency has a wonderful resource list that includes some very informative and well-done videos showing how the standard medical provider language can leave patients very much in the dark. They offer ways to ensure that both patients and providers are on the same page.
I’ve found this resource to be very helpful in getting me to think more about the meaning of my words when I talk to patients. Maybe I would say, “I’d like to ask you about your family’s health,” instead of, “I’m going to ask you about your family’s medical history.”
We all try to communicate succinctly, but it’s easy to get lost in the weeds of our often-incomprehensible medical talk when we meet with patients. And when they don’t understand this secret medical language, just like when I myself don’t understand the secret language, it doesn’t mean that they’re stupid. It more likely means that we are failing them in finding ways to communicate effectively, and failing to verify their understanding in simple and reliable ways.
1. AHRQ Health Literacy Universal Precautions Toolkit. AHRQ website. https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/index.html. Updated July 2019. Accessed December 10, 2019.