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When Patients Don’t Get It,
Whose Fault Is It?

By Richard P. Mills, MD, MPH

Abstruse. What a wonderful descriptive word. I hadn’t used or thought about it in years, until I was reading a scientific paper on a subject far removed from my reality. Abstruse, I thought, out of the blue. As I mouthed the word and internalized its meaning, there was a definite pejorative context, as though the author had interests that were not mainstream, as I had defined mainstream. The logic of the author’s argument, apparently well constructed, didn’t have any relevance to me. I made the tentative decision that it was definitely the author’s failure to communicate to me, a chance visitor to his or her arcane world. Or was it? Maybe it was my problem, not being intelligent or informed enough to grasp the full impact of the author’s message. Maybe it was my obtuseness blocking my understanding of the context, the importance, the urgency of the communication.

Whose fault was it, anyway?

The good news here is that the author probably didn’t care if I understood. He or she was writing to a group of initiates, each of them eager to explore the rainbow of opinion within the discipline. Chance visitors like me did not deserve to be brought up to speed. What right did I have, insisting that I be able to comprehend the communication?

I would have dropped this rumination entirely, if I had not started to think about my own arcane world, viewed from the perspective of my patient. Here I am, trying to describe the mysteries of glaucoma and its treatment to a patient starting from zero. To the patient, am I Dr. Abstruse, personified? At the first mention of “loss of vision” or “blindness” does the patient slam his or her ears shut with worry and begin processing only the nonverbal communication? The author of the scientific paper didn’t care if I understood, but I care deeply that my patient understands. Only then will the patient become a fully empowered member of the treatment team, with all that entails in positive outcomes.

We all think we are God’s gift to patient communication. After all, don’t we do it every day, all day? Patients seldom complain about our communication skills, so we assume we rate a 10. But where does your family rate your communication? Less than 10, I bet. For example, did you fail to mention a meeting you had to attend while your spouse had other plans for you? Or maybe you didn’t mention how proud you were of a child’s achievement, so he or she assumed you didn’t care. Is it realistic to think you communicate better with patients than with your own family? I think not.

So what can we do to communicate better? Listening better would be a good first step. Listening for the metamessage, for the patient’s deepest concerns. Listening for where they are coming from. (Patients most certainly do not all start at the same place.) If you know where a patient is starting, it’s a whole lot easier to plot a course to where you want them to go, though it might take several compass readings taken during a series of office visits to get there.

We are all guilty of truncating the listening when time is short, and isn’t it always? Maybe we’d be better off saving some time on the talking end instead! Getting in tune with the patient’s information needs. Resolving to be less abstruse with our communication, especially with our more obtuse patients.