Abraar Karan: Changing the way we communicate about patients

The way we communicate can reinforce a culture in which people become another case of “X” disease

abraarA 53 year old woman with right lower quadrant abdominal pain. A 36 year old acutely suicidal man off psych meds. A 21 year old opioid abuser in withdrawal. An 80 year old woman with chest pain. On a single shift, I regularly read through the “one-liners” of more than two dozen patients. To even keep track of who is who, I (along with most of my colleagues) end up remembering people by their presenting clinical symptom or main medical diagnosis. As much as we recognize this to be clinically necessary, what do we lose when we begin to think of patients in this way?

The loss of compassion and the risk of dehumanization in medicine is a real one. Studies show that empathy systematically decreases over the course of residency, while burnout increases. As much as this is a product of challenging schedules and tough daily work, we contribute to this decline in many other ways as well—notably through our routes of communication. Examples of this include how we write our medical notes, how we present cases on morning rounds, and how we talk about patients with colleagues.

The way we currently communicate reinforces a culture in which people become another case of “X” disease. Our manner of speaking and writing about patients not only reflects, but also impacts how we feel about them. It can contribute to a steady loss of empathy and even, I’d argue, a deterioration in patient health outcomes. Studies have already found that patients who are treated by physicians who score higher on measures of empathy have better outcomes. Similarly, when the physician has a negative attitude, patients have been shown to have worse outcomes. While the link between language, empathy, and outcomes has not been studied, I think that they are connected.

Our complacency in referring to a patient as “the pancreatitis guy” or “the heart failure lady” can also become a precursor for other harmful transgressions of language. On the more egregious end of the spectrum, there are many documented cases of physicians speaking ill of their patients. Unfortunately, these are not rare anomalies. As physicians, we know that derogatory language is a daily occurrence in the hospital.

There are many changes that we can make to improve how we communicate about patients. One of the easiest and most critical transformations is how we write our medical notes. One of the best doctors I ever worked with did exactly this, and is famous at the Brigham (our hospital) for doing it. He systematically starts every single note with the person’s social history. Who is this patient? It is not just a lady with abdominal pain. It is a mother of three, a retired teacher, and an active cyclist. That is the first thing we read about her, and so when I enter her room, I can’t help but see her this way rather than as a case of appendicitis.

This matters because patients deserve to be treated as people—a statement that’s so obvious it shouldn’t need to be said, but which physician behaviour doesn’t always reflect. You wouldn’t expect to know the most sensitive and vulnerable aspects of someone before even knowing their most basic background, yet we do this in medicine all the time. This is also important because in many clinical presentations, it provides critical information that helps deduce how they got sick, and why they may get sick again in the same way if we don’t restructure something essential in their life. For instance, if I didn’t know that the 22 year old opioid addict had just been kicked out of his house and is on the street without transportation to get to his suboxone clinic, I will not have truly solved what brought him to the hospital in the first place.

Another easy change is to make sure that each patient has a picture of them in their electronic medical record—preferably one of when they were in better health. It is a stark reminder that the patients we are seeing were once in good health, and it helps us to frame how their disease has affected them not only physically, but mentally, emotionally, and spiritually. Ask any doctor how eye opening it is to see the picture of the patient who is intubated and sedated in the ICU when they were smiling and healthy just a few months earlier. Family members often bring these pictures in, but we should proactively ensure that they are in the medical chart with the permission of the patient or family member. Every doctor should be reminded of this.

Lastly, changing the way we speak about patients can make a big difference. And while finding out on rounds that, say, “Mrs. A is a gardener and an avid football fan” may not change her clinical management, it will undoubtedly change the way we frame her in our mind. It will allow us to connect with her not only around that which brings her stress, such as her illness, but around those things that bring her joy.

As practitioners, we are being trained to sift through large amounts of data to present relevant information, interpret this quickly, and create safe and effective treatment plans. In many ways, our current medical culture treats the social history and other “soft” data without regard. But by restructuring how we integrate this information and making it a central part of how we write, speak, and engage, we will not only become more empathetic, but also provide better care for our patients.

Abraar Karan is an internal medicine resident at the Brigham and Women’s Hospital/ Harvard Medical School. Twitter @AbraarKaran

Competing interests: None declared.

The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.