When I recently learned that a friend of mine, Miro Kazakoff, teaches Managerial Communication at the MIT Sloan School of Management, I thought, “Wow, what an interesting job” and “Why do they teach communication in business school but not medical school?” Miro was kind enough to take me through a crash course in communications, which I then tested out in my own clinic. Here’s what I learned.
First, some basics of memory. People in general will take about 3 pieces of information away from a conversation. The serial position effect tells us that they will most likely remember things at the beginning or end of the conversation. As Miro put it, “You may think the patient needs to know 10 things, but if they only have the ability to absorb three points, the question for you is: Will you pick the 3 things you want them to remember, or will you give the patient 10 things and let them decide which three are most important?” If you pick the 3 things ahead of time, you can emphasize them at the beginning and end of the conversation to maximize the patient’s ability to remember them.
Miro also clued me in to the two main approaches to structuring communication, direct and indirect. In the indirect approach, the evidence for your argument is laid out, building a case for the eventual conclusion. This is what we do in our office notes (subjective/objective/assessment/plan) and in our scientific literature (introduction/methods/results/conclusion). Naturally, most of us probably use this in our patient conversations as well, without giving it much thought. But in the direct approach, you start with the conclusion and lay out the evidence as needed. The direct approach puts the most important information first, where it is more likely to be remembered (thank you, serial position effect). It is patient-centered, as it allows the patient to control the roll-out of supporting information according to what they think is important. It better respects the time and decision-making abilities of the patient.
To test this out, imagine a new patient in your office with a distal radius fracture that needs an ORIF. Here is how I would typically have that conversation, before my lesson in communications. “You have a distal radius fracture. The x-rays show that this fracture is displaced beyond where we think is acceptable. Because of this displacement, I would recommend fixing the fracture with a plate and screws in the operating room. Surgery takes about an hour, and you can come and go the same day.”
To use the direct method requires the surgeon first to think about what the most important information is from the patient’s perspective. When Miro and I thought about this, we realized the most important information to the patient may actually be that most patients with distal radius fractures return to full function. I hadn’t even mentioned this in my first mock conversation!
Our revised conversation went like this. “You have a distal radius fracture. We have a pathway to get you back to full function. To do that, you will need an operation. After the operation, you can expect it will take 3 months of healing and rehabilitation to get back to full function. Let me walk you first through surgery, then through the risks, then through the rehab period.”
The next day, I put my newfound knowledge about communication to work in my pediatric hand clinic. Here’s how it went for the first 3 patients:
Patient 1: Physeal check for a boy who had a Salter-Harris II distal radius fracture 9 months ago. I completely forgot everything I learned and launched into a long, complicated discussion of the x-rays and why he needed an MRI to check the physis. The patient thought I was telling him he needed surgery and got scared. I caught myself in time for a concise wrap-up, giving the family 3 things to remember at the end of the visit.
Patient 2: College student with a bony mallet injury, now healed with a 5 degree extension lag. I started with the patient-centered conclusion. “Your finger has a small droop, but you have full function, and I would expect that to continue in the future. This is pretty typical for how patients end up after this injury.” This worked well – the patient then told me the main reason he came in was because his mom was worried his finger looked a little different than the other side, but he thought it was fine. In just a few seconds we addressed his main concern. I was surprised how receptive he was to my starting with the conclusion.
Patient 3: Girl with a volar plate avulsion fracture. My PA saw her first, so we took a minute before going back into the room to determine our conclusion. She was worried the injury would ruin her upcoming volleyball season, so I started with that. “This injury is really more like a bad sprain. You will be able to play volleyball within a few weeks, and there should be no long-term issues with your finger. Here’s how we are going to get you there…” I paid special attention to the serial position effect in this case, and repeated my conclusion and a few instructions at the end of the visit. “To recap, you should be able to play volleyball within a few weeks. Wear the finger splint for only a week, then switch to the buddy taping like we showed you for the next week.” It felt a little silly to repeat the conclusion that was obvious to me, but as Miro put it, “If you are repeating something that is important to the patient, why is that patronizing or silly?” The family seemed relieved and happy.
Outside of our technical skill in the operating room, communication is probably the most important skill for a surgeon. Understanding a little more about how people learn and retain information can help us improve that skill. From my brief experience, spending a little time and thought on my communication plan made office visits more effective in a shorter amount of time – a goal worth pursuing!
Great advice! So easy to lapse into our routines of endless explanation!