I love the show Modern Family. If I can’t be home when it is on I make certain I record it. Last week’s episode really had me in stitches, in particular the banter about what Gloria says and how she says it with her accent. Jay her husband points out that she always says “it’s a doggy-dog world” when the saying actually is “it’s a dog eat dog world.” Then she reacts, “that is awful, why would you say that, why would you want dogs to eat each other.” It reminded me of all the times I interacted with patients when they would say something and I had no idea what they were trying to actually communicate.

The screaming mighty Jesus

When I was working in labor and delivery, one of our duties was to assess the patient when she came in thinking she was in labor. We would ask a series of questions to determine a patient’s stage of pregnancy, her pregnancy history, previous experiences with having babies, and her general overall health. So I would start with “why are you here?” One patient in particular said, “I have pain in my universe.” I paused and wondered, what she could possibly mean. So I asked her to point to her universe, and in fact she was trying to convey “I have pain in my uterus.” At some point someone told her about her uterus and she heard, “universe.”

I asked another patient, “how many children have you had,” she said, “3.” I asked, “How old are they?” She said “2 and 6.” I said, “I thought you had 3?” She said, “I did, one died.” It is important we ask how the one baby died so that if it was in childbirth we would know that she was at high risk. So I asked, “What did that child die from?” She said, “The screaming mighty Jesus.”  I pondered, how I was going to figure out what that was, so I asked a series of questions, only to discover that her child died from spinal meningitis. At least that was not a concern for this pregnancy.

The contraception got me pregnant

Often the conversations we have with patients are confusing at best. And I am sure that our instruction can be difficult to understand. How is the patient actually interpreting what we are saying?

When a mother who is not immune to rubella comes in to have a baby, right after delivery she would be given the vaccine. Vaccines for rubella cannot be given to someone while pregnanct, it can be too risky for the fetus. And if she were to get rubella while pregnant that is risky, too. So while we know for certain she is not pregnant (because she just delivered), the common practice was to vaccinate her to prevent any risk of infection with subsequent pregnancies.

Once the vaccination was given we would instruct them as follows; “Now you can’t get pregnant for the next six weeks.” This is for the protection of a potential fetus that could be exposed while the vaccination is being integrated into their immune system.

At the six week postpartum check up a patient who had been given the rubella vaccination came in and was pregnant. I asked her, “did you not understand that you could not get pregnant for six weeks?” She said, “that is what they told me in the hospital, they told me they gave me something so that I could not get pregnant, so we didn’t have to use any other forms of birth control. But I got pregnant anyway, it didn’t work very well.” She heard from the instruction given after the vaccine was administered that this vaccine keeps you from conceiving, not that she should keep from getting pregnant because of the risks to another fetus. The baby ended up being fine but this is an example where the message being delivered by the health care professional (HCP) was very different than the message heard from the patient.

We are taught after we give patient education instructions to ask the patient to tell us what we just said, so we know if they understood it. But sometimes they just repeat words, and then when they leave they are just as confused as ever. Or other times we get too busy to take this extra step. We are always surprised to hear when a patient stops taking a medication because of how they felt, or because they didn’t understand the side effects, and weren’t told they were to be expected. One of the struggles HCPs often deal with is effective treatment means that you have to stick with it, try to tolerate the side effects to get the benefits. But if the patient has never been told to expect a side effect it can be downright scary. And for some this is too much to take, and they stop the medication.

65 Roses

Sometimes we even encourage minor miscommunications.  When children are diagnosed with cystic fibrosis, one of the initial challenges is explaining the condition to them. Not only is it scary and confusing – it’s almost impossible for a two or three year old to actually pronounce. So, health care professionals around the country teach them that they have sixty-five roses – a much more pronounceable take on the chronic lung disease.

Conversation anthropology

How do we know if what the HCP are saying is understood by the patient? How do we know if what the patient hears is translated correctly? One way this can be revealed is a tool we have in Pink Tank called conversation revelation. We examine the point of view of the HCP about a condition or potential treatment option, then from the patient’s point of view and then we bring them together to observe the conversation.

This has revealed very important components of the HCP-patient interaction. We realize that the HCP’s own interpretations and understandings can result in ineffective treatment and outcomes. Not only is the HCP often not asking the right questions, they may be determining a course of action based on a preconceived notion of that patient. The patient may not understand what the HCP is asking and/or answer the question the way they think the HCP wants them to answer it. Breaking down the barriers to effective conversations can be a valuable tool in improving patient care.

In the case of Modern Family, Gloria’s own misunderstandings or communication style is based on the fact that English is not her native language. But all of the examples I have shared are not because of a language barrier, just from a different frame of reference. Whatever the reason, often conversations and instructions given by the HCP can be ineffective if the patient hears something different than what was intended, or just simply does not understand. Revealing these barriers to effective communication can provide the insight needed to improve patient care.