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Poor communication=unrealistic expectations

April 2009

One of my favorite Far Side cartoons is that of a dog with his owner, leaving their home in a car. The dog, in the rear seat, barks to his canine friend in a neighbor’s yard, “Ha ha ha, Biff. Guess what? After we go to the drug store and the post office, I’m going to the vet to get tutored.”

I expect that most of us have never had a patient confuse a tutoring appointment with a rarely indicated neutering. But it does serve to demonstrate the point: poor communication leads to unrealistic expectations.

Medicine is an elite club. We speak our own language and we are generally pretty smart people. To state the obvious, when we’re dealing with a vastly diverse population of patients, communication can get complicated. As we have all seen countless times, what we as physicians believe is inherently evident is not always so obvious to our patients.

It should also come as no surprise that the “best” physicians as judged by our patients are usually those who are the most adept communicators. Clinical skill and knowledge, although no doubt important, are probably nowhere as significant to patients as our ability to comfort, communicate and empathize. (That’s especially true for hospitalists, maybe less so for neurosurgeons.) Studies show that our risk of litigation correlates most directly to communication, not to outcome.

But because this is an April Fool’s edition of my column, I can’t resist recalling some of the funnier instances in which a doctor’s communication unintentionally led to unrealistic expectations. The following anecdotes are, in my opinion, completely benign. I’m purposely avoiding any humor that comes at the expense of people who have lost mental faculties or demonstrated truly ridiculous or reckless behavior– stories best not publicly repeated.

With that note, here are some of my favorites:

● While in medical school, I had a patient who reported having trouble swallowing her pills, which included a statin. Her ingenious solution: rolling them in butter first!

● While a resident in the late ‘90s, I had a male clinic patient present with gonorrhea. Pleased to have made the diagnosis, I had my attending–who was, incidentally, an attractive woman–confirm my suspicion. After she left, my patient earnestly asked me about the marital status of said physician. “Spoken for,” I assured him.

● Yet another patient, a sweet elderly woman, was asked to record the consistency of her stool prior to her next appointment. We certainly could not fault her for compliance when she showed up on the next visit with 60 Polaroids.

● A urology colleague passed on this story: He had just diagnosed a patient with benign prostatic hyperplasia on a rectal exam and was concerned about prostate cancer. He recommended that the patient have a prostate biopsy.

On follow-up, the patient earnestly reported that he’d consulted the Internet and wanted to request the “high tech” test that any 21st-century urologist should employ before moving to biopsy. The test? A “digital exam.”

Of course, it’s not always patients who cause us to chuckle. One of my transcribed H&Ps for a patient in heart failure came back reading, “We will follow the eyes and nose closely.” I was so tempted to write that as an order. I had to smirk when I noted the transcribed PSH: significant for “CABBAGE.”

Although I have been out of medical education for many years, I do remember being the inadvertent source of about as much humor as I witnessed. As a resident,

I once asked an intern to “prep” a patient for a central line. I walked in to find the patient comfortably propped up with two plush hospital pillows under her head. And here’s a story that illustrates one of the casualties of being married to a doctor:

When my wife showed up for the first ultrasound of her recent pregnancy, the receptionist referred to her as “AMA.” Confused and a little taken aback, as she was pretty sure pregnant women were supposed to have ultrasounds, she said, “But I’m not here against medical advice!”

This, I suppose, is what happens when you regularly hear your husband grouse that he had yet “another darn patient leave AMA!” Not that the term “advanced maternal age” made her any happier.

And here is my favorite story from last summer of confusion at a hospital. A hospital in Hawaii had apparently not adequately conveyed who or what could be included in visiting hours.

“A hospital … restated its rules on pets after a man took a horse up in a lift in a bid to cheer up a sick relative with his favorite steed. Man and beast were stopped by security guards only after reaching the third floor, after apparently passing through the lobby unchallenged.” The best part of the story: “It turned out the friend brought the wrong horse.”

Laughter truly is the best medicine. Happy April’s Fools!