How Doctors, And Parents, Talk

Many doctors, including me, go “harumph” when parents bring their child to the Emergency Department with non-emergencies, like rashes or insect bites.  Non-emergencies are what doctors’ offices are for.  However, often when I talk to the parents, they relay a hidden fear that they feel couldn’t wait for their doctor.  ”My father-in-law had the flesh-eating bacteria and almost died!”, they’ll say.  ”Does my child have it too?”

This illustrates the importance of good communication between doctors and parents. When doctors go into exam rooms with bad attitudes, glance at the rash, grumble about parents wasting their time, and zip out, they don’t get a chance to hear why the family’s there and allay their fears.

Doctors make about 85% of diagnoses by the history of the patient’s illness alone. This is also why communication is important- doctors need to be good listeners to make accurate and helpful diagnoses. Taking histories is a special skill doctors learn in medical school, polish in residency, and hone throughout their careers. I’m sure I take better histories now than I did, say, 10 years ago.

However, doctors are often pressed for time, particularly in ERs, and feel they can’t take lots of time to listen.  Here’s the data- a patient or parent, given about 90-120 seconds, will tell the doctor most everything she needs to know to make the correct diagnosis. Not a real time sink!  However, data also shows that most doctors interrupt the patient’s story after about 15 seconds, start asking yes-or-no questions, and shut down the patient’s narrative.

Specialists are another group besides ER doctors, that may not listen to a patient’s whole story. Since they have patients referred to them from other doctors, some feel that the patient’s story has already been told, is in the record, and doesn’t need repeating.  However, the best specialists take their own histories from the beginning. Who knows what new clue the patient will reveal in the retelling, that may make the diagnosis the referring doctor missed?

Specialists often get patients with complex stories referred to them.  After all, if the diagnosis was easy, the generalist would have made it already, right?  But one complex issue generalists often see is abdominal pain.  The abdomen is full of different organs, hidden deep inside, and each organ has several ways to go wrong. Many times a certain organ’s symptoms mimic it’s neighbors.  The ovary on the right side hurts when it develops a cyst, but that hurts a lot like when the adjacent appendix gets infected, or nearby bowel gets full of gas.

As we mentioned above, specialists should often have patients repeat their complicated stories to reveal clues the referring doctor missed. But all doctors should take careful, thorough histories with belly pain. Sometimes after I’ve taken the history of a teenager’s abdominal pain, done the exam, and discussed it with her and her family, I’ll return later with new questions.  I’ll be writing in the chart and think- “did I ask about urinary symptoms?”  I’ll pop out of my chair and revisit that with the patient. After tests come back, they might suggest another possible diagnosis, and I’ll go ask about that. And every once in a while, say on my third or fourth trip into the patient’s room, they’ll give me the crucial clue, like “Well, she is seeing a GYN doctor for her ovarian cysts.” Why didn’t you tell me that two hours ago???

Effective communication is a two-way street.  Doctors need to listen to the patients’ stories, and parents and patients need to be prepared to tell the story too. If the doctor interrupts because he’s interested in some point that’s brought up, be sure to continue the story after briefly answering his question.  If the doctor seems not to be listening, call him on it.  It’s okay to say, “Are you listening?” if he seems distracted.  Also, its okay to tell the doctor if you think he’s missing something.  You can say something non-confrontational like, “I’m worried my baby might have diabetes.  What do you think?”

Finally, it’s best to choose a doctor who’s a listener, before your child gets sick and it’s crucial.  A doctor receptive to your story is important to figure things out.  As the father of modern medicine, William Osler, said over 100 years ago, “Listen to your patient.  He is telling you the diagnosis.”

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