Understanding doctors can be challenging

Few simple questions are as difficult to answer as the perennial "What did the doctor say?"

The words are so natural as to be virtually automatic. They spring from our lips, almost of their own accord, whenever a loved one returns from a doctor's visit. Whether we recognize it or not, the answer has the potential to make us face our own mortality.

But why should the answer to this question be difficult? The usual suspects — inadequate patient education, differences in cultural perceptions, problems of health literacy — all overlook an important fact: Medicine is a foreign language. It is not foreign because of "big words" — its multisyllabic arcana can always be translated into simpler terms. Rather, the hedging, equivocation and other linguistic devices that doctors reflexively use obscures the plain meaning of their words.

Linguistic Hedging

Let's illustrate this point with a simple exercise using the elementary school mnemonic "Every Good Boy Deserves Fun."

Teachers use this tool to help students learn the letters of the musical staff: EGBDF. Linguistic hedging might soften the restrictive word "every" into a more inclusive word, such as "eligible." Similarly, the value-laden word "good" might morph into the less judgmental word "grateful." By continuing that trend, we might arrive at something like "eligible grateful boys derive fun." While preserving the utility of EGBDF, we have completely lost the thrust of its meaning.

By repeating the exercise with the technique of equivocation, we might qualify the phrase "every good boy" as "every good boy, who would not be otherwise disqualified." And by extending the process to its predictably absurd conclusion, we might arrive at "eligible grateful boys, who would not be otherwise disqualified, derive, whether by direct or indirect means, the equivalent of something that might be considered akin to the concept of fun."

Ghastly as such a construction may be, it approximates the language that doctors commonly use. A quote from a clinical practice guideline that we cited in a comment published in JAMA provides a good example:

"Decision-making about possible tapering of . . . medication should be accompanied by a discussion with the patient (if clinically feasible) as well as with the patient's surrogate decision-maker (if relevant) with input from family or others involved with the patient."

The layers of equivocation in this statement are many, varied and perversely artful. 1: The guideline does not recommend an action, rather it recommends decision-making. 2: That decision does not address the tapering of medication, it addresses its possible tapering. 3: It recommends that the decision be made in conjunction with a discussion with the patient (as if there were an ethical alternative). 4: It states that that discussion need only be carried out if clinically feasible (as if there were any alternative). 5: It advises that the patient's surrogate decision-maker be a party to the decision (ditto). 6: It states that that the decision-maker should only be involved if relevant, as if one would do something that were intentionally irrelevant. And 7: It recommends soliciting input from family or others involved with the patient (thus extending the scope to the universe of anyone who might seek to quibble with the recommendation).

How might one characterize such wording? Byzantine? Rococo? Feckless? While each might be a fair descriptor, such recommendations represent doctors' best efforts. They are derived from clinical practice guidelines created by experts. Through a tedious and exacting process, these experts draft language that they refine under the auspices of a professional society over months until they deem it worthy of publication.

How, then, are these recommendations conveyed to the patient? Scientifically, we don't know. Studies have been few and small in size. Most important, perhaps, they suffer from a medical version of the Hawthorne effect: When doctors know they are being observed, they behave differently. In the wild, their communication skills are likely to be poorer than those noted in clinical studies. By experience, we know that effective communication is difficult when a physician and patient meet. The discomfort caused by a physician's questions can lead to a communication gap.

I Don't Understand

But can a patient be faulted for not knowing what the doctor said? At a minimum, the patient is being honest when he or she answers the loved one's question by saying, "I don't know," and that can be a solid step toward remediation.

When patients do not understand their medical issue, they may search for a second opinion, which may not be any clearer. It might, instead, introduce a conflicting recommendation causing more confusion, frustration and what is called "analysis paralysis." The patient might feel compelled to choose between doing nothing and following the least-threatening option in what becomes tantamount to a leap of faith. Both options are bad.

A good option would be a technique known as teach-back, in which the physician asks the patient to describe the assessment and treatment plan. The doctor corrects the misunderstood or missing elements, and the patient repeats the process until the doctor and patient are in sync. The process is simple and has been proven to be effective.

Getting a physician to engage in a repetitive process such as teach-back may be difficult, particularly as it usually occurs at the end of a hurried 15-minute appointment. It may also be difficult for patients to admit that they do not understand. But an "I don't understand" might be just the remedy for an "I don't know."

Klasco is an assistant professor of emergency medicine at the University of Colorado School of Medicine. Glinert is a professor of linguistics at Dartmouth College.