A provider says “grazing” and the patient thinks, “Does she think I’m a cow?”
Chair of the National Diabetes Education Program Dr. Linda Siminerio reflects on nearly 20 years of patient-provider interactions and shares personal anecdotes that convey the importance of context and curiosity in creating a positive dialogue with patients.
Q: What do you think interferes with effective patient-provider communication?
A: Providers have the best intentions in the world, but don't always realize how their patients are receiving their messages. In patient management and care, we frequently use terms that we think our patients understand. Patients often don't interpret our communications in the correct way or in the way that we think they would interpret it.
I had a patient who grew up on a farm and had never been out of this rural community, in which we conduct telemedicine sessions. She had challenges with her weight and managing her diabetes, many of her issues due to excessive snacking. When talking to the patient, our endocrinologist used a term that we, as providers, use frequently and asked, "Are you grazing? I think the problem is you are grazing between meals and that is what plays havoc on your blood sugars." While I understood what, my colleague meant, "you seem to be snacking a lot and not sitting down to eat a meal," that's not what the patient understood. The patient was just shocked. She looked at me and asked, "Does she think I'm a cow?" It totally disrupted the entire session because our patient became disenfranchised with her provider, who had the best intentions. For that particular patient, the word "grazing" prompted the image of a cow. She had not heard this word used in any other context. This was a perfect example of some of the challenges we can face with communications and issues around health literacy.
Q: What other factors may affect patient-provider communication?
A: Often times, our patients may be afraid to talk openly or ask questions of their provider. I had a patient who worked in construction. Our physician came out and said to me, "You know, Linda, this patient is just totally noncompliant. I've tried everything. He needs to take these insulin injections three times a day when he is going to be eating and has not been complying. No wonder his A1C is 9.5%".
I started talking with this patient and learned that no one ever went over the schedule to help him figure out how to work insulin injections into his daily routine. When we got into a conversation, I did a lot of listening. I found that he wanted to take the injections. He asked, "How do I take an injection when I'm out on the road in construction?" and "I am in front of my buddies and you want me to pull out a needle?" His questions were the start of an important conversation where I was able to be curious and remind this person that our job is to help him. I asked questions such as "What if we did injections at other times of the day when you are not out on the road?" He was willing to work with us to figure out a schedule that would meet his needs. Up to this point, he had been too afraid and too embarrassed to share his concerns because he thought his physician would think less of him, which is crazy, but understandable from his perspective. Listening is so clearly the most important first step in helping people to self-manage.
Q: Why is curiosity about the patient as a whole so important for providers?
A: The environment, their social dynamic, attitudes, and beliefs and culture—all of these things influence how people make decisions about their health care. I think the key to helping patients who may have particular barriers or disparities in their care, is to learn to listen. Instead of focusing solely on what you need to check off to make sure you've met all your quality check marks—just listen. Ask, "What's going on in your life? What are the challenges? How does diabetes fit into your life? What do you find so hard?" It's amazing how asking a couple of those types of questions can open the door to learning so much about a patient.
I have a good friend who is a young endocrinologist. She recently shared that sometimes a good visit doesn't mean going over every medical detail. She found that some of her best, most informative visits with her patients are just about getting to know them. Isn't it wonderful to develop that bond? Most people want to talk about themselves at some point in time. Wouldn't it be great if your provider just really knew you?
Thank you Dr. Siminerio for sharing your insights on improving the patient experience through provider communication.
Tell us a time when diabetes care got lost in translation.