A terribly overweight woman goes to the doctor to find the perfect diet. “I want you to eat regularly for two days then skip a day. Do that for two weeks and when you come back you will have lost five pounds.” When she returned, she shocked the doctor by losing twenty pounds. “Why, that’s amazing. Did you follow my instructions?” The woman nodded. “I did, but I thought I would drop dead by the third day.” “From hunger?” asked the doctor. “No, from the skipping.”

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The playwright George Bernard Shaw once said, “The greatest problem with communication is the illusion that it has been accomplished.” In communicating healthcare information the task is all that much more of a challenge.

As one of the pillars of bedside manner, the benefit of communication cannot be overemphasized. With proper communication of expectations and instructions your patients benefit by being more compliant and thereby achieving better outcomes. You will prevent many costly, stressful, time-consuming failures that often lead to lawsuits.

Two areas of professional practice require strong communications skills: treatment plans (including description of treatment, other options, expected outcome, and postoperative sequelae), and financial considerations.

COMMUNICATING THE TREATMENT PLAN

When a patient understands their treatment plan, they have more realistic expectations of outcome, are better able to respond to adverse consequences, and they will trust and respect you even if things go wrong.

A PICTURE IS WORTH A THOUSAND WORDS

There is no better way to communicate a procedure than by employing a visual aid. You don’t have to take courses in art unless your sketching skills are as bad as your handwriting. Assuming you can draw a reasonable diagram of the planned procedure, you’ll be fine.

Always sit next to the patient so they can see your illustration as it comes to life. Allow them to ask questions as the need arises. At various intervals during lengthy explanations, you should ask the patient if they understand. Waiting until you are finished to answer their questions may be confusing, especially for the elderly.

Be sure to make notes alongside the drawing using key words regarding your discussion. Your notes should cover options for other forms of treatment (including the choice to doing nothing), chance for success and failure i.e. prognosis, a general explanation of the treatment procedure, postoperative considerations and cost. Make sure your explanation is understandable. Once you complete your presentation, you can give the patient a copy of the diagram.

You should be explaining things to the patient anyway, and the time it takes to make a drawing that is included in your records is well worth the effort. The diagram becomes proof that you provided a verbal informed consent. It is there to show the patient when controversy arises, such as complications, flare up or failure to achieve the expected outcome. This picture makes a great exhibit in court. While some patients don’t understand no matter how hard you try, the picture shows you tried. Remember, if the jury can understand your explanation and they like your picture, they will be sympathetic to your cause.

Patients often find they can’t remember or explain anything you told them when they get home. With a drawing, they have half a chance. More importantly, they appreciate your personal interest in explaining the problem and procedure in a clear and understandable manner. To provide a formal consent form based on legal advice with all sorts of disclaimers and highly complex descriptions is all right for your records, but it can’t compare to an uncomplicated picture that is made personally for each patient.

Drawings are of great benefit when a patient claims they didn’t understand something. In crucial instances, you will be able to calm the most aggressive of patients by producing your diagram and pointing out how you discussed the fact that the procedure may not be successful, or the fee, or the consequences of treatment.

Never rush patients when they ask questions, especially if they need to see you after you’ve performed a treatment and they have adverse consequences. No matter how far behind schedule you’re running, rushing patients experiencing complications leads to bad will and potential lawsuits.

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A Dental Specialist Says

You present differently to a CPA versus a nurse versus an engineer versus a hotel worker. What the patient wants to know is:  Do you understand the problem? Are you qualified to fix it? Can you fix it? Have you done this before? Do other people have this type of problem and will you fix it with the least amount of pain and minimal complications? It’s my job to communicate the answers to these questions. Communication and trust require eye contact. I look directly into my patient’s eyes when I speak with them.

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A major flaw in communication is to assume every patient is as knowledgeable as you are. Something as simple as a technical word you take for granted can destroy an entire explanation: “The tissue is inflamed, resulting in a productive cough.”

‘Tissue’ is Kleenex to many, and ‘productive’ means getting the job done. While you may be smiling at the absurdity of this example, it is not at all absurd, and you will understand this when you are a good communicator. Tissue is skin or gum or whatever organ you may be treating. By watching for body language you may pick up on moments when patients don’t understand and you can slow down or explain over again when necessary.

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There was this couple whose husband experienced the loss of libido. Upon returning from the doctor he entered the house wearing a tuxedo. His wife asked anxiously if he had seen the doctor about his problem. “Of course!” he replied.

“Well, why are you all dressed up in a tuxedo?” she queried.

“The doctor said I’m impotent, so if I’m impotent, I figured I should look impotent.”

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There are many words that should be stricken from your vocabulary when speaking with patients. Here are some examples and proper ways to say the same thing.

Avoid using the term "incision." Instead tell your patients "I will make a small opening"

I&D means nothing to most patients, however, they understand, "We are going to release the pressure."

Going under the knife? Can you sound any more barbaric? Try, "You need a surgical procedure."

Purulent drainage is pus to the layman. Use their language.

Who knows what a patient might think when you tell them you are laying a flap? It is much more comprehensible to tell them you are going to “pull back” the gum, skin or whatever you are operating upon.

Curetting is clean out, enucleating is removing, and an exploratory operation sounds much better if it is described simply as you "are going to look around."

The term “prognosis” is used all the time. Stop using it with your patients. "The chance of this working out" is much easier to understand. Yes, there are patients who have no idea what prognosis means, and they are too embarrassed to ask.

Sure, you didn’t go to medical school to speak like an idiot, but you have to communicate to your patients in a clear, non-threatening manner if you want to have the best bedside manner.

It is a great idea to get a small digital recorder and listen to at least a dozen of your presentations of treatment plans or explaining procedures. You may be surprised at how you sound to your patients.

Despite your best efforts, there are some patients who will never fully understand your explanation of a complex procedure. To offer the best possible service and chance of success, you should always have written instructions for each procedure you perform.

Written instructions are a wonderful way to enhance the way you communicate with your patients. While some patients don’t understand anything you tell them, never read your instructions, and are not very compliant because of their lack of understanding and lack of interest, there are those who appreciate the written word.

WRITTEN COMMUNICATIONS – THE HANDOUTS

Written handouts are a simple way to communicate more effectively with your patients, and they require no personality or social skills on your part, as do oral communications.

Besides enhancing your bedside manner by utilizing good communication skills, written handouts, diagrams used in explaining procedures, and signed consent forms will help keep you out of the courtroom. Most plaintiffs’ attorneys won’t take a case when they see great documentation and the damages are not significant. Even if you end up in court, it is very difficult for the plaintiff to convince a jury of laymen that you didn’t explain anything when it’s all there in black and white.

At minimum, every practitioner should have a written informed consent carefully constructed with the advice of a professional organization or an attorney versed in such matters, a pamphlet describing what you do in lay terms and what to expect from treatment, and a post treatment instruction sheet that includes what to expect and how to handle after hours emergencies.

The post treatment instructions are especially important. Rather than calling you in the middle of the night, your patients can read the directions if they experience complications after they leave your office.

If your procedures require multiple visits, make sure you give the patient the post treatment instruction sheet after each visit. While you may think patients save your instruction sheet in a scrapbook of important documents to be passed on to their heirs, they usually throw them away. By handing patients a sheet of instructions after each visit, they will have help when they need it.

People generally remember first and last impressions. To become the great doctor everyone wants to see, always leave your patients on a positive note. When you dismiss your patients, always give them reassurance: “If there’s anything you don’t understand or need help with later, don’t hesitate to give us a call.” This reassurance is the ultimate form of communication in that it tells your patients they can get answers to anything they didn’t understand. Knowing you are there for them goes a long way toward having a meaningful doctor-patient relationship.

Patients getting a second opinion will almost always choose the doctor who explains things better. If you’re the first opinion and have great communication skills, most patients won’t even consider getting a second opinion.

COMMUNICATING FINANCIAL ISSUES

 Financial considerations are one of the biggest reasons patients get upset with their doctors. If you want a distinguished reputation, besides being compassionate in handling fiscal matters as described in the chapter on compassion, you must communicate fees and expectations for payment.

Most patients expect insurance companies to pay for services and when unexpected co-payments arise they often get upset. Just because your forms state that patients are responsible for any unpaid fees, patients may claim they didn’t see, read, or understand the notice.

A well-trained front desk is the key to avoid misunderstandings. They should present financial expectations at the initial call after setting up the appointment. Your staff should have the means to check insurance coverage by phone or Internet connection. They should emphasize that any co-payment they quote is only an estimate based on the “information you provided.”

Many patients believe doctors are wealthy and cannot understand how healing arts professionals could possibly ask them to pay the meager ten-dollar co-payment. They usually have little understanding of reimbursement schedules requiring doctors to treat patients for minimal fees that at times don’t pay for overhead costs. Well-scripted employees can respond to the cynical patient commenting on why the doctor “really needs my ten dollars.”

“Mr. Jones, in order to participate with your insurance company and provide you and your family with the best of care, Dr. Smith accepts greatly reduced fees. Your insurance company determines the co-payment, not the doctor, and that helps to supplement the reduced fees. Between insurance company payments and your co-payment, it doesn’t leave much profit for many of the procedures Dr. Smith performs. I do hope you can understand we are trying to keep payment by the patient as low as possible by participating with these insurance plans. That’s why we have to collect these modest co-payments.”

No matter how wonderful your bedside manner, if the patient can’t afford the bill, thinks they were charged more than they were told upon initial contact, or feels their financial responsibility wasn’t explained appropriately, they will not come back to see you. Quite often, they will badmouth you to validate their perception of injustice.

If your practice deals with emergency care, you may not have the luxury of obtaining preauthorization, in which case you may want to estimate patient financial responsibility and have the patient sign a statement indicating that until the insurance coverage can be verified, they will be responsible for any unpaid charges.

If you withhold care for financial reasons, make sure you offer a less expensive alternative. Patients will not perceive you as compassionate (or worthy of being called a doctor), if money is your only consideration for providing service.

Some patients perceive any discussion of money as unprofessional. Try to avoid placing undue emphasis on financial matters. On initial contact by phone, bring up fees and financial arrangements after attending to all of the patient’s questions concerning treatment and making an appointment. Fees should always be discussed but not at the first moment of contact.

Even in cases where the patient has no co-payments, they may be jealous and have disdain for doctors when they see how much they are paid for various procedures. The days of appreciating the skills of a great doctor are being replaced by a world of envious people wanting to consume more than they contribute. This attitude is all the more reason for healthcare professionals to be clear about financial matters.

COMMUNICATING WITH YOUR STAFF

Communicating with your staff is just as important as communicating with your patients. And how your staff communicates with the patients is equally important. Besides assuring that they assist you in the appropriate manner while performing technical procedures, they can help explain routine things and answer common questions with your prepared, fully scripted responses.

Make sure your staff understands every procedure you perform, but don’t let them explain or respond to complex or controversial questions. The last thing you need is a patient making claims that your nurse told them something for which you could be liable.

Your staff should never give medical advice. This happens in many offices in spite of the potential risks. Every time a staff member tells a patient what to do regarding postoperative care, it could be perceived of as medical advice. That is why it is important that you clearly instruct your staff with appropriate scripting anytime you have them give patient instructions.

Your staff should not be instructing patients on issues like dosage of medication unless you have a standing protocol that doesn’t necessitate that they ask you in each case. For example, if patients call with continued swelling that may require doubling the dosage of an antibiotic or anti-inflammatory agent, and you routinely make that recommendation, you may allow your staff to make that recommendation without asking you. Of course make sure they get the appropriate information about the patient’s condition and document the conversation in the patient chart. You must be able to justify the recommendation when a savvy personal injury attorney tells a jury that you should have spoken with the patient and should have never let your staff make the recommendation.

There are so many instances where we let staff communicate instructions to the patient that we take for granted. Having a secretary tell the patient to use hot compresses or ice or any other recommendation must be grounded in sound practice. This requires more instruction than allowing staff to make the recommendation they heard you make a hundred times unless that recommendation is the only appropriate option.

You don’t want to have to defend yourself in a case where your secretary told a patient to place a hot compress on an abdominal pain that turns into a burst appendix, just because they heard you make that recommendation for some other ailment.

Every area of practice has certain routine recommendations that are offered to the patient on the phone every day. While it is best for you to make all the decisions, practically speaking, you do have to delegate certain duties. Make sure you have documented that you trained each staff member regarding any recommendations you have them make. This is best written into a staff manual. Naturally, any recommendation made by your staff should be documented in the patient chart with your initials.

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An Endodontist Says:

When patients call with postoperative pain, I have my secretary ask a few key questions:

“Is there any swelling? Do you feel feverish? Does it hurt to close your teeth together without any food in your mouth?”

 As long as they respond “no” to those questions, I have my secretary use the following script:

“I want you to rinse your mouth with hot saltwater for five minutes each hour. You can take the pain medicine prescribed if the Advil or Tylenol doesn’t help.  If there is no change in twenty-four hours I’d like you to call back and let me know.”

 This way, I know there is consistency in communicating the appropriate instructions to the patient. If they are swelling or have any fever, or if they can’t bite down, I want them to come in to see me.

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Each realm of treatment requires that you prepare scripts as described above and make sure anything that can be confusing is not left for the front desk to handle.

If the patient insists on speaking with the doctor, your policy should provide for them to speak with the doctor. While you can't be expected to stop everything to speak with patients when it is not practical, you should set up a system that encourages the patient to work out their problem with the front desk. Perhaps a policy like this may help:

Dr. Jones is with patients and can't come to the phone this moment. If you would like to tell me your problem, I may be able to help you, or relay your message to Dr. Jones so we can see you today if necessary."

If the patient is insistent, proceed:

"I'll be happy to have Dr. Jones call you back when he is finished with patients or sooner if he gets a break. That usually is at the end of his appointment hours, so if I can help you regarding any emergency concerns, it would be best to tell me now. That way we can get you in today if necessary. Otherwise I will have him call you as soon as possible. If he calls you after hours, he won’t be able to see you today, so please let me help you now.”

This script offers the patient two chances to work with the front desk staff. It let's them know you won't necessarily be calling them back until after hours. It tells them that emergency questions should be mentioned at that moment if they expect to come in to see the doctor that day. And it is not refusing their request to speak with the doctor.

There are some doctors who take patient calls as they come through. While that is not an easy task, it sure makes the patients on the phone happy, while the ones being treated may not be overjoyed by multiple interruptions. You decide.