The Little Things
Meera Iyengar, MD Oct 30, 2020
Communication is essential to practicing medicine. It allows us to coordinate care with other members of the healthcare team, to ensure safe handovers, and to cultivate trusting relationships with our patients. An unassuming well-woman visit turned out to be the one of the most profound illustrations of its importance for me.
Mrs. X was a Spanish-speaking woman who came to clinic for a well woman exam. I called a hospital interpreter to help me take a medical history. Besides an asymptomatic fibroid and two C-sections, her history was unremarkable. I reported this to the attending, and we both went to the patient’s room to discuss the seemingly straightforward plan. Everything was going smoothly, and just as we were about to say goodbye, she asked,
“Doctor, do I have cancer?”
We paused. Why did the patient think she had cancer? Did we miss something in her history?
“Several years ago a doctor told me I have a mass in my uterus. It’s not causing me pain, but I am very worried that it is cancer. Do you think I have cancer?”
Then it dawned on us: the fibroid. The asymptomatic fibroid, which was completely benign, had been keeping this patient up at night for years.
My attending grabbed a stool and sat down. Pausing after every sentence for translation, he maintained eye contact and a warm demeanor while reassuring her that asymptomatic fibroids were benign. As he continued talking, the patient’s relief grew palpable to everyone in the room. At the end of the visit, the patient strode out with a beaming smile on her face.
This is just one of many examples where patience, understanding, time, and awareness are essential to fostering an environment in which patients feel comfortable effacing their vulnerabilities, asking questions to clear their doubts.
But the situation only begged further questions for me: Why had this not been addressed before? Had she tried voicing her concern in the past and no one listened?
I see at least two perspectives.
Healthcare workers attend to large volumes of patients, making it challenging to be both efficient and thorough. Some days are just busy: 25 patients on your service need to be seen during morning rounds, and you have a full day of clinic in the afternoon. Balancing efficiency and thoroughness seems impossible, and, at that point, efficiency often becomes the priority while thoroughness takes the backseat.
Patients, on the other hand, are coming to you as individuals. They entrust you with their lives and reveal their most sensitive vulnerabilities. Add in barriers of unfamiliar customs, a foreign language, and an unstable financial source to an already sensitive situation – coming to the doctor is a scary experience.
I do not think either side is to blame. The healthcare staff does their best to balance the high volume of patients and their own continuing education; patients naturally feel more at home around caregivers who speak their language and have a similar cultural background.
So how can we as healthcare workers improve this seemingly stagnant situation?
Improving larger forces at play (i.e. hospital systems, access to interpreters, reimbursement, administrative costs), optimizing our verbal communication skills, and educating ourselves about different cultures and ways of life are important and necessary steps.
But there are also the subtleties.
Given the diverse populations we as physicians serve, learning how to create a comfortable space conducive to open communication for all in spite of language and cultural barriers is extremely relevant.
The Mehrabian communication model illustrates that there are three aspects to communication: verbal, non-verbal (i.e. tone, intonation, volume), and visual (i.e. body language). Only 7% of what we communicate is conveyed by our literal words, whereas 38% is conveyed by nonverbal communication, and 55% by visual communication . Therefore, the manner with which we speak and the way we carry ourselves hold far more weight than the words themselves.
Maybe we don’t have time to extensively educate patients during that hectic morning before rounds, but we can pause for two seconds to look them in the eye and smile, or put a hand on their shoulder when asking how they did overnight. These small acts can garner trust so that, perhaps, when you or another physician down the road do have time to teach, they will be in a less anxious headspace to process that information and understand. Patient education is important; I would argue creating a safe space in which patients feel empowered to change is equally important. Great potential to improve relationships lies in the subtleties: being mindful of our body language, purposeful with our gestures. Unless we are vigilant, these seemingly insignificant actions and reactions contribute to a strained physician-patient relationship.
Circumstances may prevent us from delivering optimal care despite our deep desire to do so, which can be the most frustrating. It is important to not let our frustration of the system affect the quality of care we give to our patients in that moment.
We may not always speak the same language and understand their struggles, but all humans know love, no matter the culture, no matter the language. It’s hard to determine what exactly prompted Mrs. X to open up, but I can’t help but believe that it was due in part to the environment that her previous caregivers and we created. If we make a conscious effort to express this compassion and love each day, it will be a step forward in addressing barriers to care, giving patients a voice, and making them feel at home.
1. Mulder, P. (2012). Communication Model by Albert Mehrabian.
Originally published in the National Med-Peds Resident Association newsletter.