Say what? Do patients really hear what doctors tell them?

by Carolyn Thomas  ♥ @HeartSisters

During my heart attack, I was taken immediately from the E.R. to the O.R. for emergency treatment for a blocked left anterior descending coronary artery.  But, overwhelmed and terrified, I knew nothing of what was about to happen to me, even though I have a vague memory of the cardiologist explaining something to me before I was taken upstairs.

I could see his lips moving and I could hear sounds coming out of his mouth, but he could have been speaking Swahili.  I don’t think I was capable of comprehension at the time. Everything I know about surviving what’s known as the “widowmaker“ heart attack, I learned much, much later.

I’m not alone. This study suggested that most heart patients believe that their cardiac interventions have far greater benefits than they actually do.

The research, published in the journal Annals of Internal Medicine, found that over 80% of heart patients studied who had undergone angioplasty with stents implanted believed that the procedure would cut their odds of having a future heart attack.

But about the same proportion of the cardiologists who had either referred these patients for angioplasty or performed the procedure reported to researchers that they had definitely told their patients that stents would do nothing more than simply relieve symptoms.

The Boston Globe called this a “yawning disconnect between what doctors say and what patients hear”.

This disconnect extends to other types of medical treatment as well, resulting in patient confusion and even overuse of some procedures. Cancer patients, for example, often believe that chemotherapy will destroy a tumour, counting on a cure that medical evidence does not promise at all.

Dr. Henry H. Ting from Mayo Clinic told a HealthDay interviewer that he was not surprised by the study findings. He pointed to a previous Mayo Clinic study that had found 80% of patients signed consent forms they had not read, and did not actually know the benefits or risks of the treatment they were having.

Dr. Ting, who conducts research on informed consent, said the problem of patient understanding is common in many areas of medicine.

”   We [doctors] don’t do a good job of knowledge transfer in a way that patients and family members can understand. Graphs and charts are not going to work for many of our patients.”

Other experts also blame flaws in the informed consent process for this communication gap. Dr. Alicia Fernandez of the University of California San Francisco told Cardiovascular Business News:

”    It’s important to incorporate decision aids or educational material so that patients at least get a brochure outlining the risks, the expected benefits and others that are not expected benefits.”

One reason for patients’ misunderstanding is the common belief cited in the recent study that if a treatment is offered, it must have curative benefits.

Nevertheless, almost three-quarters of all the patients studied still believed that if they didn’t undergo angioplasty, they would suffer a heart attack within the next five years.

Where are they getting this idea?

Study authors admit that they were not present during “informed consent” discussions between patient and doctor, and so had to rely instead on what cardiologists told them they had said to patients.

Only patients who are in mid-heart attack or in danger of having an imminent heart attack can expect angioplasty or stents to reduce risk of future heart attacks and death, according to research cited in the study.

But cardiologist Dr. Marc J. Schweiger of Tufts University School of Medicine (the senior author of this study) told The Boston Globe:

“This is not a cardiology issue; this is a medical issue.

“I suspect if you looked at any procedure you would find the same results. Doctors think they explain [them] to patients, yet patients for variety of reasons are misinformed.”

Dr. Richard Frankel, a Regenstrief Institute research scientist at the Indiana University School of Medicine, offers this observation on the classic doctor/patient miscommunication problem:

   “We don’t assume when a pilot and an air traffic controller converse that they have understood each other until there is an affirmation of understanding. That acknowledgement is lacking in most patient-physician encounters.”

Dr. Frankel, who studies ways to improve the doctor-patient relationship, is currently investigating how behavioural changes by both doctors and patients impact medical care. He adds:

“From previous work, including a well-regarded study from the University of Washington, we know that doctors ask patients whether they understand what was just discussed less than 2% of the time.

“Doctors should be trained to routinely check for understanding to ensure that there is neither miscommunication nor mismatch between what the patient wants and what doctors assume the patient wants.”

Patients are not to blame for that miscommunication about cardiac stents, says Dr. Michael Pignone, a medical editor for the Boston-based Foundation for Informed Medical Decision Making.

This makes sense to me.

For starters, when two people who are on equal footing are communicating calmly using a similar knowledge base, we might expect a reasonable level of mutual comprehension.  Two auto mechanics can talk shop together trusting that they absolutely understand each other. Ditto for two oceanographers. Two graphic designers. Two accountants.

But just try putting one of those two people in a drafty hospital gown, lying confused and vulnerable on an E.R. gurney while suffering distressing physical symptoms. Put the other person in a starched white coat, standing overhead coolly rattling off a jargon-filled explanation of what may or may not happen next. It’s a tragic recipe for miscommunication.

Should it be up to the person in the drafty gown to ensure that doctor-patient communication is accurate or effective during an emotionally overwhelming medical event?

Doctor-patient communication has been the life’s work of the University of Toronto’s Dr. Wendy Levinson. Her landmark research comparing doctors who had never been sued for medical malpractice with doctors who had been sued at least twice offers valuable insights on why doctors get sued.

When comparing the respective bedside manner of each group, Dr. Levinson reported no difference in the amount or quality of information doctors gave their patients. For example, the never-sued doctors didn’t provide more details about medication or the patient’s condition.

The difference was entirely in HOW they talked to their patients.  

Dr. Levinson adds that, although her colleagues are often more focused on their medicine than on their communication skills, she knows consumers can certainly relate to the need to enhance doctor-patient communication.

“At cocktail parties, when I tell other doctors what I do, they’re not really interested. But if I tell patients, they ALL have a story to tell.”

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See also:

–the Fierce Practice Management report called Most Heart Patients Confused About Stent Benefits.

-the Cardiovascular Business article called Doc, Patient Perceptions Differ on PCI, Consent Needs Overhaul

-the Heart Sisters article called Your Health Care Decisions: Don’t Worry Your Pretty Little Head Over Them

© Carolyn Thomas – Heart Sisters  – www.myheartsisters.org

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♥  This article was also published as a guest post on the websites KevinMD.com and The Prepared Patient.

♥  I wrote much more about doctor-patient communication in my book, “A Woman’s Guide to Living With Heart Disease” (Johns Hopkins University Press). You can ask for this book at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon. Or if you order it directly from Johns Hopkins University Press (use their code HTWN), you will save 30% off the list price.