Should doctors be more blunt with patients?

In My Humble Opinion
41

And it would also be average survival time assuming every effort was made. My mom’s body had cancer throughout and they told her six months. But her lungs filled back up after surgery for her comfort and she didn’t want anything extraordinary so six months became a few days.

She was pretty lucky with doctors being upfront and straightforward with her. She had a tumor growing for years and didn’t get it examined or treated at all, but she verbally told them what she had at the physical she had to go to annually for insurance. They would outline how they would typically treat such a thing but they completely respected her choices.

42

There’s a reason I’m an OR nurse now, and not a clinic nurse. And that reason is that I spent two years in a clinic patiently, tactfully, and professionally attempting to educate people that the reason your back and your knees hurt and that you have high blood pressure and type two diabetes is that your “BMI is higher than we’d like it to be. Here’s a referral to a totally free wellness center that has totally free nutrition counselors and exercise physiologists who will give you all the help you need with a personalized diet and exercise plan.” (I was in the AF, and the wellness center on base saw dependents and retirees). And no matter how tactfully and kindly I put it, I would still catch attitude for daring to mention that they could possibly be overweight.

Finally, when I realized that it was only a matter of time before I was going to tell someone QUIT STUFFING THE HO HOS DOWN THE PIE HOLE AND TAKE A FUCKING WALK!!, I was mercifully given the chance to train for the OR. It’s nice in the OR. Patients don’t talk to you, and if they try, anesthesia makes them stop. I love anesthesia.

43

For what it is worth (not sure if this would matter in your mom’s case),iIt is possible to do a stress test on people who can’t walk on a treadmill. If you are still at the point where your mom would want to pursue surgery, it might be worth asking if a “chemical” stress test (injecting medication to stress the heart as if you were walking) would provide enough information.

As for the general issue you mention, I am not surprised the communication problem happened with a surgeon. Surgeons are not known in the medical world for having the best bedside manner or communication. A lot of surgeons are attracted to surgery because it is such a black and white specialty without a lot of interpersonal/social work type of stuff in it. There is something very appealing about being able to fix the acute problem then move on without a lot of chit chat or handholding for some surgeons.

It sounds like your mother has some cognitive problems - whether those cognitive problems are from dementia, mental illness, effects of her physical illness (like uremia if her kidneys are failing) and/or just a lifetime of low IQ.
I definitely think that it is true that there are some patients who are offended by overly blunt and direct language, especially about life threatening matters. However, I agree that with someone who is not functioning well cognitively that doctors should try to be careful to make things easy to understand. It might help if in the future anyone who goes to doctor appointments with your mother tries to discreetly let the doctor/office staff know that mom has trouble with comprehension. I think it might help if the doctor knows going into the situation that it is best to be very simple and direct with her.
It might also help you to not be as frustrated with her if you try to remember that it really isn’t her choice to be like this. If her brain isn’t functioning the way it should (regardless of whether it is because of mental illness, low IQ, or physical illness) then she really can’t help that she is having a hard time understanding and behaving appropriately.

44

I don’t get this idea that bluntness and lots of information are the same thing. If anything, bluntness is more often terse and uninformative. Having to think about how you are going to say something also leads to having to think about not only being nice but also making sure you are understood.

The thing that is correlated with bluntness is rudeness. And, no, I don’t think doctors need to start being more rude, that’s for sure. But not being rude doesn’t mean lying, which is honestly even more rude.

If you’re going to need to say something you consider “blunt,” say it nicesly, and most people won’t even consider it all that blunt. Think about it. When someone says “To be blunt…,” isn’t what usually follows is some amount of rudeness? Take that part away, and it comes off less blunt and more acceptable.

I don’t think people reject bluntness as much as they reject even the slightest rudeness. For quite a lot of people, bluntness and rudeness are inextricably connected.

45

Even worse is when they offer it when it isn’t relevant to the issue at hand. That’s what happened with the doctor I (and others she did it to) got fired from my current doctor’s practice.

That’s what I mean with my previous post. People associate doctors like her with “bluntness.”

46

As said multiple times, many people just don’t understand, or don’t want to understand what the doctor is telling them because they don’t want to make the changes.

Anecdote time. My FIL is ‘pre-diabetic’. He will manage his diet until he gets a week to a month of good, normal readings on a daily basis. Once he has a streak of good readings, he thinks he can justifiably start eating like he used to and drinking rum/beer. He’ll do that for a while until he gets a streak of high numbers, and will decide to go back on his ‘diet’. He has been doing this for a few years now. He does not tell his doctor that he does this, and no matter how much the rest of us tell him that this is BAD for him, he won’t listen.

Same guy is in the process of getting ready for back surgery. First, both knees had to be replaced. In preparation for the first replacement, he had to lose 30 lbs. and strengthen up his core and legs. Well, he lost about 15 lbs. through diet, but his ‘strengthening’ was 15 minutes of core workouts on a bosu ball once a week. He REALLY regretted that after his first knee was done. He struggled. What’d he say about it? “They never told me it would be this hard on me.” Yes, yes they did, and they tried to make it easier on you by prescribing weight loss and strengthening. His second knee replacement went much better.

(But now he’s addicted to percocet. He’s a mess, honestly.)

47

I agree, I don’t think they’re synonymous, but I think they’re related. And I was trying to work off what became apparent in subsequent posts by the OP: he and his sister don’t think the doctor gave her enough straightforward information in a way that was easy to understand.

Another anecdote / thought experiment. You’ve got an 86 year old woman who has chronic cardiac conditions. She often has weakness and dizziness and has fallen several times recently. Suddenly (as in, last week it was fine and this week it isn’t) her heart starts beating in an irregular pattern, and her dizziness and weakness gets worse. Her doctor recommends elective cardioversion.

What do you tell her? Now, the books say that it’s the doctor’s job to explain the cardioversion procedure, the risks, the benefits and answer any questions the patient has. And maybe he did. All you know is that the day after she saw the doctor and the day before the procedure is scheduled to be done, she has no idea what is planned for her. And now she’s asking you for help understanding what’s going to happen to her. What do you say?

“Sorry, you’ll have to talk to your doctor about that.” That’s very unsatisfying, no matter who you are, and really erodes the trust between you and the patient.

“They’re going to stop your heart and then start it again, and hopefully it will start back in its normal rhythm and you won’t be so dizzy and weak.” Blunt. Accurate, but blunt. And also terrifying. They’re going to WHAT to my WHAT?! is a common response. Once you’ve told someone you’re going to stop their motherfucking heart, they tend not to be able to hear anything else after that.

“Your heart is beating out of a normal rhythm, and it’s making it hard for your blood to get around your body as it normally does, so you’re dizzy and weak from poor circulation. This procedure is designed to make your heart beat normally again, with the goal of making you feel better when it’s done.” Fairly blunt. Accurate, but incomplete. This is the answer many people want, though. They want to know why they’re feeling like they’re feeling, and that the doctor’s plan may fix it. But they don’t actually want to know the nitty-gritty scary bits like stopping their heart.

But then again, you get people like me (and maybe the OP) who do want the nitty-gritty, and are very upset later to find out that they stopped your heart without making it clear that was the plan.

You also get people who you did tell they were going to stop the heart who didn’t register that information because it was too scary to process, and get angry later when they found out you stopped their heart “without telling them.”

There’s no one size fits all answer. There’s a skill to learning how to read a person and assess their responses to your information to make sure they’re getting exactly as much information as they can process without unduly stressing them and compromising their outcome. I personally tend to err on the side of too much information in too blunt a fashion, and I’m working on it. Other more experienced nurses and doctors often err in the other direction, in my humble opinion. Somewhere in the middle are the very best doctors and nurses, those who have an excellent bedside manner and educated, empowered patients. I hope I become one of those nurses someday.

48

Doctors ideally should give accurate information in a manner that patients can understand and that helps them make the best possible decisions and that motivate the needed behaviors.

That requires some appreciation of where the individual patient (and patient family) is at and adjusting the approach to meet the patient there, which is a skill that … bluntly … most docs do not have. It requires fostering communication back from the patient about what their understanding is. And many docs, even those who are good at step one, don’t take that step.

Being a clear communicator is not bluntness or rudeness. It does require us doing some things that we have not been as well trained for as we have at other things and we often avoid doing things that make us feel less than competent.

The doc who merely says “you need to eat less” and leaves the room AND the doctor who does sugar coats a prognosis or avoids discussing it or just dances around it never stating it clearly are both doing versions the same thing: avoiding the actual required task while fooling themselves that they have done their job.

And I do not give myself a pass here. I sometimes skip the feedback part myself and probably sometimes I have given more information than a particular family wants or needs. I had a senoir partner who was amazing at adjusting his level to the room; I wish I was as good at it as he was.

On review - yes what WhyNot is saying!

49

Here’s my anecdote. When my father had his stroke, my two sisters and I sat down with the doctor to figure out what was next.

The doctor explained in detail that the CAT scan had shown half his brain was “dead.” As in, there was no activity, no responses, nothing.

One sister and I knew exactly what he was saying. My other sister kept asking how long it would take for brain activity to return, when the doctor would schedule the next CAT scan, ettc.

The doctor had to explain that there was no point in doing another CAT scan, because half the brain was “dead,” and there was nothing to scan for. And explain it again, before my sister finally figured out what he meant by “dead.”

Three people, same information, same presentation, simultaneous. Two of us got it, one didn’t. I don’t think my sister couldn’t understand the word “dead.” I think she wasn’t prepared to accept the diagnosis. It didn’t matter what the doctor said or how he said it.

50

Anecdote time:

My mom’s doctor has expressed concern about the amount she’s been drinking all my life. It took my mom a trip to the ER after she’d been vomiting blood for hours (she actually googled it before she went to the ER) and four blood transfusions to get her to admit that she had a problem. Even then, when she was told she needed a liver transplant, after her first trip to the AA (a requirement), she said she didn’t want to be around those people. Finally her doctor told her point blank that she was one of those people and she could die at any minute with that attitude. She cleaned up her act and is on the transplant list after a year’s worth of sobering up.

I love my mom, but no amount of family interventions or even gentle, “Have you thought of counseling?” made her stop drinking. She had to come to that conclusion herself - in one of the most drastic ways possible. Yes, her doctor had to remind her, but there’s no way in hell she would’ve stopped drinking unless something horrible happened. She knew damn well it was wrong to start the day at 8 a.m. with a glass of gin, but she depended upon it too much. Sometimes you just can’t tell someone - they have to experience consequences first hand, especially if they’re scared or doing something could mean changing a behavior that self-soothes.

51

I can’t find the study right now but I recently read something that illustrates (if I am recalling accurately) how difficult dealing with alcoholism is - alcoholics use drinking to cope with anxiety; information that informs them that they are alcoholics and at serious risk of serious consequences produces anxiety; as a result many alcoholics exposed to such information may drink more.

Some behavior changes are tough sells.

52

Something both my cousins who are doctors complain about is that they can tell a patient to eat less fat and sugar and more fiber, get more exercise, even if it’s just talking a walk every day, watch their weight, and reduce stress, and offer specific advice, or referrals to anyone the patient wants who can help toward those ends, and the patient gets all huffy that the elitist doctor in the ivory tower is trying to control them and judge them, and this happens no matter how delicately and kindly they say it. But when people go to acupuncturists, chiropractors, naturopaths, and homeopaths, in the middle of all the gobbledy-gook, they tell people to eat less fat and sugar and more fiber, get more exercise, even if it’s just talking a walk every day, watch their weight, and reduce stress, people do it. Then they feel better, and go tell everyone how the homeopathic acupuncturist saved their life.

I don’t know why this is. Maybe people expect doctors to use sophisticated science, and don’t understand that “Eat more fiber and take a walk every day” is science, in the sense that there is research behind it, and it has the desired effect of lowing all the bad numbers and raising the good ones without side effects, other than it doesn’t taste good and it’s boring.

53

Part of it, I think, is that homeopaths (ick) and naturopaths and acupuncturists give advice, it’s more likely to look like:

“Processed foods are evil and they’re made by Monsanto and full of GMO’s that will kill you. Eat real food, eat plants. Here, have a recipe for chia seed pudding, you should be eating that every morning. Alkalizing foods are good for you. Your pH is all messed up because you eat too many acidic foods like sugar and meat. You need to eat more alkalizing foods, like vegetables and organic grains. Here, I have a list for you: Alkaline Food Chart. And to help your body detoxify from all the toxins in your environment, you need to do deep breathing and yoga and start taking a walk every day.”

In other words, there’s some good, concrete, specific advice buried in a pile of bovine excrement. And the mindset isn’t that *your *behavior (eating the food) is the problem, the mindset is that you’re a VICTIM of the big bad Agricultural Industry, which is always easier to hear. Secondly, it feels like it was diet advice tailored to them and their specific needs and that the provider was actually listening to them and considering them as an individual (nevermind that every single person who visits the office gets told they’re too acidic and full of toxins.) And it ultimately empowers them to hear that they can be doing things differently. If you do this and this and that and follow this list, you’ll be all better. It just so happens that the list includes a lot of fiber and daily exercise. :wink:

There are *some *things that doctors can learn from quacks. Every so often, Medscape has an interesting article on Alternative Medicine and what we can learn from it - not necessarily the remedies, but the patient interaction. Providing concrete examples (believe it or not, many people don’t know what “fiber” is or what foods it’s in) and compassion is definitely on that list. Devolving into pseudoscience is not on that list.

54

I do think that doctors, in general, should be more blunt with their patients. I also think they should try more than one explanation for why they want their patient to eat better or exercise more or take their medicine regularly. The problem can be that everyone “hears” things differently and may not be hearing it the way the doctor is explaining. Of course, that all takes time, which many doctors just don’t seem to have.

On the other hand, with some patients, bluntness does absolutely no good. When my ex-husband was having trouble with IBS, he went to see a new-to-him doctor. When he told the doctor that he smoked a pack-and-a-half of cigarettes every day, the doctor said, “You need to quit. A lot of your health problems will go away.” Ex-husband said he’d never quit. The doctor replied:

“Smoking is causing most of your health problems. I’m sorry, but I have too many other patients who are willing to do something to help themselves to better health, to waste my limited time with you.”

Blunt? You bet! I loved it. My ex was furious, of course, since he felt that smoking was a God-given right. He was still smoking up a storm when I left him three years ago.

55

Do you think your husband might have been persuaded by more information on WHY smoking has anything at all to do with IBS? That’s exactly when I find more information tends to help with “patient compliance”. When you just say, “stop smoking”, they clench up, because jesusfrickingchrist everyone ALWAYS says stop smoking and I’m not here for lung cancer, doc, I’m here for IBS!

“See, your intestine is lined with receptors for nicotine. When you smoke, the nicotine fits into those receptors and makes your intestine squeeze. That’s why those post meal smokes are so awesome; they get things moving so you don’t feel so stuffed! But bad when you have IBS; smoking really makes all the bad parts of IBS much worse. I can develop a plan to care for your IBS, but it really won’t work until you quit smoking. When you’ve set a quit date, then we can talk about the rest of the plan.”

It doesn’t work for everyone (the theme of the thread) but it helps for some.

56

The acupuncturist generally tends to be better at appearing empathetic. My SiL is wobbly enough on the actual hard science bits (see: giving homeopathic medications to her children; believing for many years that “the average” equals “the only possible value”) but patients love her and she’s got better responses than many of her colleagues because she can listen. She’s a GP.

Doctors will often say “you need to eat more fiber and exercise more”. The woo salesmen will put it in terms of “you should favor wholegrains over white bread, white bread is very bad for health; do you like going for walks?.. Oh, good! Go for walks more often, the open air will do you good!” The message is the same, but it’s sold better and, as WhyNot said, it seems more specific even when it’s not. My mother didn’t learn about “soft fiber vs hard fiber” from her doctors, but from her masseuse - she confirmed the information with the doc and told him “so why the hell did I need to learn this from my masseuse? YOU should have told me!”

57

Exactly. And also the hugglebunny communication style works extremely well with some people.

What doesn’t help is that some physicians don’t have [or take (depending) ] the time to review the patient’s entire chart. While I’m not a hugglebunny, I do expect my doctor to notice that I’ve lost thirty pounds before lecturing me on weight loss. True story, that.

58

duplicate post. stoopid me.

59

Doctors should be as blunt with patients as the patients are capable of tolerating, and should be psychologically savvy enough to have a handle on that.

Luckily, my doctors know me, they know what I will do and what I won’t do according to doctor’s orders, they know where I draw the line between stoicism and hypochondria, and they have a handle on the amount of medical knowledge I already possess and how much more I can understand.

It is not a lot to ask, of a doctor to recognize those kinds of characteristics in his patients, and note it in their files, which they presumably brief themselves on before an appointment.

60

You’re probably right, but FWIW, both my cousins are pretty soft-spoken and gentle. One is a woman, and I think she’d be a lot more successful at passing on lifestyle advice, but she’s an orthopod, and she’s dealing with people who are already hurt when they get to her, I think, and they feel like they deserve a little indulgence. I don’t think she actually gives lifestyle advice as often as the cousin who is a GP, but I’ve listened to them commiserating before.

Cripes, that makes sense! I have IBS, and sometimes when I get stuck in a smokey room (which fortunately happens rarely now) I feel nauseated, the way I do before a bad case of the runs (I get nausea predictably about 4-6 hrs before an especially bad case of the trots). I know to take medication, so I can head off the attack sometimes, but I still have the nausea. People told me it was psychosomatic, because I was anticipating the allergic reaction where I get itchy, and burning skin, runny eyes and nose, and general unpleasantness.

In regard to why people take the exact same advice from quacks that they won’t take from real doctors, I guess there’s a lot of truth in what people say regarding the fact that even though the homeopath/acupuncturist/aromatherapist is telling everyone the same thing, patients don’t know that. This reminds me of a friend I had (he’s passed away) who was a pet therapist. He did therapy with pets, where he took animals to nursing homes and such, but he was also an actual therapist for pets, which meant if you thought your pet had an emotional problem, you called him. It sounded like the most bogus thing in the world to me, until I saw him in action. You toy poodle widdles on the carpet every day while you are at work? He doesn’t berate you for expecting a 8 lb. dog to hold its bladder for 10 hours, idiot. He tells you you have a special pet who needs special care, and aren’t you a wonderful person for being willing to take on the responsibility of this special pet; you must be very compassionate and have a big heart. You will have to come home in the middle of the day, put in a dog door, or hire someone to come over an let the dog out during the day, and bless you for doing it. The world would be a better place if there were more people like you. And then he’d refer you to people he knew who installed dog doors, or came over and walked pets during the day. :rolleyes: