Pumps,Wires and Pipes: Translating Medicine for our Patients

“The patient will never care how much you know, until they know how much you care.”

S. Terry Canale, MD (1)

Although simple in theory, talking to patients is far from easy. While the basic definition of communication is the conveying of information (2), in the world of medicine, communication is a complex interplay that builds trust, underlies the patient-physician relationship and remains a timeless, intrinsic aspect of clinical excellence (3). Despite years of medical training to become a cardiologist, I had surprisingly little mentoring on how to best speak and connect with patients. I was fortunate, though, to experience two transformative patient encounters that taught me the crucial role communication has in earning trust and delivering the highest level of care.

“No way, I don't want it”. My jaw dropped when Mrs. M, a middle-aged otherwise healthy woman refused a heart catheterization, the procedure I had just recommended, after presenting to the emergency room with severe chest pain, a concerning electrocardiogram and a rising troponin, the blood test used to detect heart muscle damage. She was in the throes of an anterior ST elevation myocardial infarction, fearfully known as the Widowmaker heart attack, and I was the consulting cardiologist. I stood in her room in a large academic medical center, armed with all the tools needed to save her but really just feeling helplessly confused. Of course, I did not want to pressure her into a procedure that carried risk but her decision seemed clearly inconsistent with her medical values and goals. Rather, she seemed afraid and overwhelmed by the moment. She had already seen an army of short and long whitecoats hurriedly buzz in and out of her hospital room spewing foreign medical jargon. She was simply confused and did not trust us. In that humbling moment, I realized that our ability to leverage the power of modern medicine and be effective healers ultimately depends on navigating our relationships with patients through communication, trust and empathy. I had to change my approach. I slowed down and softened my tone. I sat down, made full eye contact, and explained the disease, the test results and the procedure again but with even simpler and clearer terms. I was patient, attentive and I listened. Whether it was my words or the genuine effort I made to help her understand, she eventually agreed to the procedure. Shortly thereafter, the heart catheterization revealed a clot completely blocking blood flow in her left anterior descending coronary artery, indeed the dreaded Widowmaker. A small metal stent was placed to open the artery and restore blood flow. Fortunately, all went well and when I saw her in recovery, she softly wept and thanked us. Years have passed and I have long since lost contact with Mrs. M but that day and its lesson have stayed with me. In order to care for our patients, we must first earn their trust through simple, honest and effective communication.

This responsibility to communicate and connect with patients is increasingly strained by the pressures of modern healthcare. The sheer amount of data and required charting necessitates that much of the analysis and complex decision making happens outside the room, allowing less time for valued bedside interaction (4,5). Patients have unprecedented access to confusing medical information and misinformation and providers must clarify this daunting body of knowledge in a way that allows patients to meaningfully engage in their own care (6). While there is no panacea to these fundamental tensions, we can at least make the most of the time that we do spend in the room by returning to traditional doctoring with simple and effective bedside communication, gradually improving our skills with each patient encounter.

The most important lesson I learned in residency was surprisingly in the very first month. I had admitted a 71 year old woman with rectal bleeding the night before and charged ahead of my team to deliver the good news. “Mrs. S, the GI doctors just told me that your colonoscopy is negative. They biopsied some unconcerning polyps but you are going home.” But Mrs. S didn't seem happy to receive the news, that is, until my senior resident explained this result “was exactly what we had hoped for – there was no cancer”. Afterwards, he pulled me aside and his words have stayed with me ever since, “I don't want you to talk like that to a patient again. Everyone learns how to take care of patients, not everyone learns how to talk to patients.” For the last 13 years, I have used this simple and impactful personal anecdote to illustrate a crucial but neglected understanding. Physicians are, in a way, bilingual translators who must speak two very different languages. To our colleagues, we must quickly convey immense amounts of patient data and analysis using complex terms in a structured way. To our patients, however, we must speak a very different language that distills the complexities of their clinical situation in an accessible, compassionate way while respecting their cultural identity and level of understanding. While medical school and beyond prepares us to speak the language of medicine, we are woefully underprepared to step into the role of translator. But the benefits of cultivating this ability are abundant as successful communication can build trust, empower and satisfy patients, serve as the foundation of informed consent, lower malpractice risk and reduce medical errors (3,7,8). But most importantly, helping someone understand their own health so they can navigate decisions that reflect their values and goals is an honor and ethical obligation.

While there is no universal formula, I have found certain practices very helpful in making the most out of the time I spend with my patients. First, upon entering the room, I always introduce myself, my specialty and my role in a patient's care to help orient both of us. Second, I try to maintain a subjective-objective-assessment-plan (SOAP)-style structure throughout the visit, intermittently charting as I ask questions, examine them and review their latest data. But when I discuss the assessment and plan for each major problem, I fully disengage from the computer, give my undivided attention and sit at eye level. Third, which is the hardest, I switch to the language of patients. I express myself slowly and clearly using simple, common words and phrases, avoiding the medical lexicon that instinctively pops into my head. Metaphors can be incredibly helpful. For example in cardiology, the terms heart pump, electrical wires and plumbing pipes are incredibly useful when discussing ventricular function, arrhythmias and coronary artery disease respectively. Professional models, diagrams, digital applications and videos can be highly effective as well and in my experience, often reduce, not lengthen, visit times (9).

The practice of medicine has and will continue to change. Even in the years since I met Mrs. M and Mrs. S, medical knowledge, health technology and clinical workflow have all dramatically evolved. But ultimately, delivering high quality care rests on the trust dynamic engendered through our ability to successfully connect and communicate with those that we care for. Perhaps this ability, more than any other, is what will endure through the coming changes to our profession and continue to reflect our deepest responsibility as healers.