December 2006 | Back to Table of Contents

Perspective

Making Your Point but Missing the Patient

Are you talking at, to, or with your patients?

By Gregory A. Plotnikoff, M.D., M.T.S.

Adedicated, hard-working—and stressed—pediatric oncologist had to deliver bad news to an equally stressed out single mother. He approached the situation with the utmost of care, expressing feelings and breaking the news as gently as he could. Following the Golden Rule, he treated the woman in the way that he would want to be treated.

However, the mother would have none of it. The harder the doctor tried to convey his concern, the more furious the woman became. “Dr. X is not being honest with me! He is hiding something. Why won’t he be straight with me?” she cried.

The exasperated woman went so far as to file a formal complaint against the physician. And in the end, the physician was both puzzled and hurt by the woman’s reaction to his efforts to provide what he considered to be superb care. What went wrong?

One-Way Ticket

This story illustrates a phenomenon that I call “munication.” Although not a real word, munication describes a very real and very important problem: communication minus the mutuality suggested by the prefix com, which means together.

Munication is not a misunderstanding that occurs as the result of one person’s use of sophisticated vocabulary or unfamiliar concepts. Rather, it is the dis-understanding that occurs as a result of one person not honoring the preferred communication style of another.

It wasn’t until I moved to Japan five years ago that I recognized this. But I have encountered it frequently as I struggle to teach and give Grand Rounds in Japanese. After an incredible amount of study, I can finally prepare and deliver a talk that conveys what I consider to be relevant information and opinions. I can get my point across, but the information transfer is purely one-way. I can talk at, and I can talk to, but I cannot talk with the Japanese. Missing is any exchange and any confirmation of understanding.

Such experiences in Japan have reminded me of the opening story in which the physician and patient’s mother failed to communicate despite speaking the same language. The physician could talk at, talk to, but not talk with the mother. Even though the physician strived to treat the woman as he would like to be treated, there was no bilateral exchange, no communication. He made his point but missed his patient. He did not conform to her preferred style of communication.

In the book, Health Care Communication Using Personality Type (Routledge, 2000), authors Susan Brock and Judy Allen document that patients, as well as physicians, have four distinct, and usually unconscious, communication preferences. Knowledge of these, and of one’s own preference, is the foundation for successful communication.

Brock and Allen interviewed a number of patients about how they would like to receive bad news. They categorized the patients’ answers into distinctive categories based on the Myers-Briggs Personality Testing Instrument. Here, I have reworked their original descriptions and incorporated what I have learned from my experience about the way people prefer to communicate: Type I - Logical facts (I just want the straightforward facts, no fuzzy prelude); Type II - Personal facts (I need clear information delivered by someone who relates to me as a person); Type III - Logical options (I want to know that the doctor is competent and what options there are, and I want to be consulted as an equal); and Type IV - Personal options (I want to be seen as a whole person, not a disease, and to have my personal values taken into account). Each of the four categories correlates with preferred patterns of taking in and processing clinical information, for personal or impersonal word choices, and for specific or abstract reasoning. Thus each represents a preferred vocabulary and strategy for communication (see box).

Honoring Preferences

Knowing that patients have different communication styles means that we physicians need to choose our words and the way we say them carefully, keeping the patient—and not ourselves—in mind.

Words are potent. With each choice we make, we send implicit messages. For example, consider how you would convey information about sodium levels to a patient. One way is with a statement such as “Your sodium level is 148. Normal is below 145.” The message is specific, precise, and focused on what has been measured. It is scientific and impersonal. This is ideal for a patient who is a Type 1 communicator, whose priority is getting logical facts. However, those who prefer a more personal style would likely find the message unappealing. They might describe the statement as “dry” and even “cold.” Likewise, another physician might say, “Your sodium level is significantly higher than I want to see now.” Some patients might like such a delivery because it uses the personal pronoun you, conveys values, and interprets the situation. But for others, the message might seem frustratingly vague or even deceptive.

And these are just two brief, simple sentences. Imagine 15 or 30 minutes of conversation, and it’s easy to see that there is potential for a significant disruption of the physician-patient relationship. In the case of the conflict between the pediatric oncologist and single mother, the physician’s way of delivering bad news was to express comfort and care. This approach clearly clashed with the mother’s need for straightforward facts. The unfortunate result was her belief that Dr. X was not being honest with her and was hiding something. Although counter-intuitive, the truth is that following the Golden Rule may not work when communicating clinical information.

The challenge, of course, is for physicians to match their communication style to the patient’s preference. These five steps offer guidance.

1. Recognize that each person has a preferred way of communicating.
2. Identify your own preferred communication style.
3. Listen for clues to a preference through the patient’s word choices and reasoning. Is it impersonal or poetic? Specific or abstract?
4. Monitor your own use of language. Is it impersonal or personal? Specific or abstract?
5. Rework your approach to match the patient’s preferred style.

Clearly, even when using simple vocabulary and common concepts in a shared language, significant communication failures can occur. Avoiding these and achieving mutual communication requires us to recognize our own communication preferences and those of our patients. This approach should help us minimize the possibility of physician-patient conflicts, optimize patient comfort, and maximize our clinical efficiency and effectiveness. At the very least, it is likely to boost our scores on patient-satisfaction surveys and enhance the sense of satisfaction we get from clinical practice. MM

Gregory Plotnikoff is an associate professor at Keio University Medical School in Tokyo, Japan, and at the University of Minnesota Medical School.