• 30Aug

    Changing the way we communicate about patients

    Excerpts from a blog for the BMJ by Abraar Karan, an internal medicine resident at the Brigham and Women’s Hospital/ Harvard Medical School:

    The way doctors speak and write about patients not only reflects, but also impacts how we feel about them

    A 53 year old woman with right lower quadrant abdominal pain. A 36 year old acutely suicidal man off psych meds. A 21 year old opioid abuser in withdrawal. An 80 year old woman with chest pain. On a single shift, I regularly read through the “one-liners” of more than two dozen patients. To even keep track of who is who, I (along with most of my colleagues) end up remembering people by their presenting clinical symptom or main medical diagnosis. As much as we recognize this to be clinically necessary, what do we lose when we begin to think of patients in this way?

    The loss of compassion and the risk of dehumanization in medicine is a real one. Studies show that empathy systematically decreases over the course of residency, while burnout increases. As much as this is a product of challenging schedules and tough daily work, we contribute to this decline in many other ways as well—notably through our routes of communication. Examples of this include how we write our medical notes, how we present cases on morning rounds, and how we talk about patients with colleagues.

    The way we currently communicate reinforces a culture in which people become another case of “X” disease. Our manner of speaking and writing about patients not only reflects, but also impacts how we feel about them. It can contribute to a steady loss of empathy and even, I’d argue, a deterioration in patient health outcomes. Studies have already found that patients who are treated by physicians who score higher on measures of empathy have better outcomes. Similarly, when the physician has a negative attitude, patients have been shown to have worse outcomes. While the link between language, empathy, and outcomes has not been studied, I think that they are connected.

    Our complacency in referring to a patient as “the pancreatitis guy” or “the heart failure lady” can also become a precursor for other harmful transgressions of language. On the more egregious end of the spectrum, there are many documented cases of physicians speaking ill of their patients. Unfortunately, these are not rare anomalies. As physicians, we know that derogatory language is a daily occurrence in the hospital.

    There are many changes that we can make to improve how we communicate about patients. One of the easiest and most critical transformations is how we write our medical notes. One of the best doctors I ever worked with did exactly this, and is famous at the Brigham (our hospital) for doing it. He systematically starts every single note with the person’s social history. Who is this patient? It is not just a lady with abdominal pain. It is a mother of three, a retired teacher, and an active cyclist. That is the first thing we read about her, and so when I enter her room, I can’t help but see her this way rather than as a case of appendicitis.

    Another easy change is to make sure that each patient has a picture of them in their electronic medical record—preferably one of when they were in better health. It is a stark reminder that the patients we are seeing were once in good health, and it helps us to frame how their disease has affected them not only physically, but mentally, emotionally, and spiritually.

    As practitioners, we are being trained to sift through large amounts of data to present relevant information, interpret this quickly, and create safe and effective treatment plans. In many ways, our current medical culture treats the social history and other “soft” data without regard. But by restructuring how we integrate this information and making it a central part of how we write, speak, and engage, we will not only become more empathetic, but also provide better care for our patients.