The average person speaks about 16 000 words in one day. Sixteen thousand words spoken over 24 hours to your pets, your neighbour, your partner, maybe even yourself. Learning this made me wonder; how many words do I generate and receive during a day in clinic, interacting with patients, their families, colleagues, and everyone in between. Ultimately, the actual number doesn’t really matter; but it’s interesting to intentionally look at and dissect the content and quantity of communication that goes on, every day. It seems like this communication can happen in a rote way; most conversations between physicians and patients land somewhere within the bounds of the scripts we learned in medical school. Sometimes we may rely too much on these guides for conversations about symptoms, side effects, and treatments with our patients. And when that happens, when patients don’t hear what it is we’re trying to convey to them and vice versa, we are no longer engaged in a therapeutic alliance with them, and we may in fact be causing harm.
When patients don’t hear what it is we’re trying to convey to them and vice versa, we are no longer engaged in a therapeutic alliance with them
Dr. Arthur J. Barsky, a psychiatrist out of Boston, wrote about the exchange of information that happens between an MD and their patient, in his opinion piece, The Iatrogenic Potential of Words. One point that resonated with me, was about the nuances of informed consent. He discusses the compromise that is made between a physician’s legal duty to disclose all appropriate risks and benefits of an interventions, and a physician’s ethical promise to do no harm. This applies especially in the case of reporting non-specific side effects such as fatigue, poor concentration, dizziness, etc. The mind is powerful, and just as the placebo effect can work in favour of good patient outcomes; the nocebo effect can work against them. We have RCT data that confirms that patients who are told about adverse effects of a non-active comparison agent, will experience these to the same degree as those patients receiving the active trial agent. Legally, we must disclose all significant effects of the interventions we propose to patients, that much is clear. But Barsky argues that we can achieve contextualized informed consent whereby patients are advised that non-specific symptoms are not discussed so as to avoid making them more likely. Taking the time to explain the nocebo effect and asking patients for their permission to disclose risk in this way, could remedy this problem, especially for those patients who are more anxiety prone. We can alleviate or facilitate the impact of our words on people, for example, by expressing how many people do not experience undesirable effect X of a therapy. The way we frame information matters.
At the moment, I’m working in palliative care with patients at various stages of the dying process; their care is adjusted on a minute to minute and hour to hour basis to match their wants and needs in that moment. Working with them, I’ve experienced what feels like a totally different way of communicating in a clinical setting. I’ve learned how important it is to really know the people we’re taking care of, and to remind ourselves that no person is built the same. In a patient’s discussion with us, they may need or want more or less information. While managing active medical issues, I’ve also had the privilege of trying to understand my patients’ existential and spiritual difficulties. I’ve learned about where they were born, who their parents were, the paths they took to unique careers and hobbies. I’ve explored ideas of contentment, fulfillment, and suffering. The idea that the information shared with our patients can modulate perception of their physical and emotional symptoms has become so apparent to me over the course of my rotation. Given the significance of language to our patients, I would encourage you to take a minute and reflect on the impact of your words, and those of your patients, on how you practice medicine.
This article was written by Madison Le Gallee, a resident at McGill University and member of the Mindful Medical Learner Team.
References
Barsky AJ. The Iatrogenic Potential of the Physician’s Words. JAMA. 2017;318(24):2425–2426. doi:10.1001/jama.2017.16216
The Mindful Medical Learner 