Raising the Bar for Communication in Clinical Care

By K. Casey Lion, MD, MPH, acting assistant professor of pediatrics, University of Washington/Seattle Children’s Hospital

I was motivated by the best of intentions. Our patient’s family spoke only Spanish, and as an intern who spoke Spanish fairly well, I fell into interpreting for the team on rounds. Our patient, Antonio,* was a 6-year-old receiving IV antibiotics for osteomyelitis, awaiting normalization of his inflammatory markers. Although occasionally I felt that a professional interpreter would probably do a better job, we never had one available, and I was really happy to be able to help both my team and Antonio’s family to communicate.  It was only after he developed slurred speech that we began to really consider the headaches he had been mentioning for over a week. The CT scan confirmed that he had developed a brain abscess, requiring surgical drainage and an even longer hospital stay.  While I will never know for sure what part my interpretations played in the delayed diagnosis, what I do know is that we consistently provided Antonio and his family with a lower standard of communication than other families receive, and that similar scenarios are happening every day around the country.

Communication is the most important diagnostic and therapeutic tool we have as physicians, yet it is the one we seem to hold the least sacred, the one we are most likely to compromise in the face of logistical or temporal constraints.  As we discuss in our article in the October issue of Academic Medicine, even residents who rate their Spanish language skills as less than proficient routinely use those skills with patients and families. We also found that residents were often inaccurate in assessing their own proficiency.

For other skill-based activities in medicine, we require trainees to demonstrate skill proficiency before they can act unsupervised; so why don’t we require the same for language skills? And more importantly, why are we willing to compromise on communication when we are so uncompromising in most other aspects of clinical care? We would never rely on an untrained colleague to read an echocardiogram because it was too much trouble to track down the cardiologist—so why do we think it’s ok to get by with an untrained interpreter or broken English, just because getting a professional interpreter is inconvenient or slow? We do inconvenient things in the course of providing medical care all the time, when they are the right thing to do. And using professional interpretation is no different.

So how do we change the current state of affairs? As Darcy Thompson and colleagues’ article describes, many residents do not receive any formal training on interpreter use, and that lack of training is associated with low self-efficacy for using interpreters. Since self-efficacy is in turn associated with successful action, implementing formal training during residency may improve resident interpreter use. Testing provider language proficiency, and enforcing policies prohibiting use of non-proficient language skills for clinical care is another important step hospitals and training programs should take. And as individual providers, we must consider not only how our communication decisions impact our patients, but also what we are modelling for our colleagues and trainees, and how that will impact their patients.

We are all responsible for the current culture, in which cutting corners in how we gather and share information with our patients is considered acceptable, or at least inevitable. We need to recognize the absolutely critical role that effective, bidirectional communication plays in the practice of medicine, and start treating it with the respect and vigilance it deserves.

*Name has been changed to protect the patient’s identity.

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  1. Kemi Tomobi
    September 4, 2013 at 10:10 PM

    Regardless of mistakes made,  I learned that the first step is to apologize to the patient and family.  It is hard to be superhuman, so be strong and competent in what you can do to make sure that each patient gets the best quality care, and improve patient safety, and the culture of patient safety.

    Communication is key, and is one of the 6 ACGME competencies.  Likely it is the most neglected in medical education, as compared to achieving other milestones in the core competencies.

     Communication can be verbal or nonverbal. They should be used hand in hand, and together should convey the same message.  It is one thing when someone communicates something verbally in writing or orally and for the accompanying nonverbal communication to be opposite, thus creating confusion;  it is another thing entirely in cross cultural communication, including situations where there needs to be communication between the native speaker of one language and the native speaker of a different language. 

    It is great to have opportunities to learn another language, especially Medical Spanish, as there are several patients who do not understand native English, and usually need an interpreter.  When discussing medical care, an interpreter who is familiar with medical vocabulary in the native language is preferred.  When an interpreter is present, a physician should realize that he or she is STILL communicating with the patient.  The interpreter is just the liaison.  Therefore, eye contact should not be made with the interpreter, but the patient, at all times – especially while the physician is speaking, and when the patient is responding.  Physician should be facing the patient.  This is a sign that both verbal and nonverbal communication should be in sync.  I do hope that there will be more medical interpreters available in the future, and that if physicians and physicians in training are to be credentialed to speak another language, that every opportunity is made to enhance cross-cultural communication skills.

    Communication is not just crucial in cross-cultural situations; it is necessary in multidisciplinary teams and work; it is crucial between providers, and patients will say that the communication between different units is not cohesive, thus presenting a confusing picture to a patient concerning treatment plans,  thus any formal or informal opportunities for trainees to improve their communication skills will make them better, empathetic physicians in the long run.

    On behalf of the upcoming celebrations of Hispanic Heritage Month, I am glad to have read this post, and I trust that our Hispanic patient population will be glad that someone wrote such a post.


  2. wsumed
    September 6, 2013 at 2:14 PM

    Reblogged this on WSU MED.

  3. Raising the Bar for Communication in Clinical Care | Wing Of Zock
    September 12, 2013 at 8:01 AM

    […] posted on September 4, […]

  4. James E. Lewis, Ph.D>
    September 13, 2013 at 7:45 PM

    This post raises an important issue about communicating with patients but, for me, it raises another issue regarding the candid and frank, even soul baring, statements that bloggers often make in their posts. For example, is a clause like “lower standard of communication than other families receive” potentially attractive to someone who might wish to sue a physician and an institution for malpractice or other forms of liability? Or do bloggers need to be more careful, perhaps even generic, in relating commentaries about events, problematic or otherwise, where patient care is involved?
    I don’t know the answer and hope those who may have an answer will engage in discussion of this question. It doesn’t take reading many health-related blog posts to come up with a fairly long list of examples of statements that someone might pursue. Not many years ago, lawyers were known to ride hospital elevators listening to conversations among physicians, nurses, and others hoping to hear something that might lead to filing a lawsuit. In the 1980s and 1990s, institutions commonly posted warning signs in their elevators as reminders about patient confidentiality. Perhaps HIPPA has sunk in enough that such signs are no longer necessary. I have not done any systematic search of hospital elevator walls recently, but, within the past 6 months, I did find at a large community hospital boxes of hundreds of patient records sitting unattended in a public corridor while an office re-location was underway. No one that I pointed this situation out to was particularly interested until I asked one if he/she knew how to spell “HIPPA? Security arrived about 15 minutes later.
    My generic question is simple: Are blogs unintentionally becoming hunting grounds for those seeking excuses to file lawsuits against health professionals and institutions? Even the frivolous ones waste time, money, and generate unnecessary angst and bad publicity. Remember the words of Andrew Grove: “Only the (non-delusional) paranoid survive.” Parenthesis added.

    James E. Lewis, Ph.D.

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