Everyday phrases physicians use can backfire with patients, new book argues

Wendy S. Harpham, M.D., FACP, was a medical resident sent to get informed consent from a patient. When she finished going over the form, she asked, “Any questions? Do you understand?”

The man stood up, pointed at the door and told her to get out. As she walked away with the unsigned form, he added, “Don’t ever come back!”

Harpham, a retired Dallas internist, opens the introduction to her new book, “Clinical Communication: Finding the Best Words to Inform, Comfort, and Motivate Patients,” with that encounter.

She writes that she suspected, without facts to confirm it, that the question left him feeling infantilized. “Just like a medicine, clinicians’ words can help or harm,” she wrote.

The book is from CRC Press, an imprint of Taylor & Francis Group, and was announced Sept. 21. Many of its vignettes first appeared in her Oncology Times column, “View from the Other Side of the Stethoscope.” The essays pair patient stories with suggested wording and close with takeaways for clinicians.

From solo practice to patient

Harpham opened a solo internal medicine practice in Dallas in 1983. Seven years later, weeks after her 36th birthday and with three young children at home, she was diagnosed with non-Hodgkin lymphoma. Months after she returned to work, a biopsy confirmed a recurrence.

Over the next 15 years she received eight courses of therapy, including investigational treatments in early-phase clinical trials. She has been in complete remission since 2007.

Ongoing illness forced her to retire from clinical medicine in 1993. In 2022 she was diagnosed with aplastic anemia, a rare blood disorder.

“Then cancer yanked me to the other side of the stethoscope,” she wrote in the book’s preface. A refrain started playing in her head: “I didn’t have a clue.”

She has since written nine books. She received the American College of Physicians’ 2018 Nicholas E. Davies Memorial Scholar Award for work in the humanities and history of medicine.

Why can ‘How are you?’ leave a patient tongue-tied?

At one appointment, a nurse greeted Harpham with “How are you?” According to the publisher’s announcement, she didn’t know which answer to give. She could report her exhaustion with any exertion. She could mention the anxiety and sadness she had been dealing with. Or she could project confidence so she would be taken seriously.

“I stammered, frozen with uncertainty,” she said in the release. “Different sides of me competed to answer, leaving me tongue-tied.”

She suggests that clinicians ask something specific instead, such as “How have you been feeling since we last spoke?” or “What brings you in today?” Her reminder to patients is that “doctor visits are not social visits.”

Ronald M. Epstein, M.D., FAAHPM, is a professor of family medicine and palliative care at the University of Rochester, where Harpham earned her medical degree in 1980. He was on the receiving end of a version of the question during an emergency department visit for abdominal pain.

The physicians ran the right tests and gave him correct information, he told Melissa Lucarelli, M.D., FAAFP, a family physician and Medical Economics editorial advisor, on an episode of “Off the Chart: A Business of Medicine Podcast” earlier this year. The moment he remembers came from the transport worker taking him to the CT scanner.

“He stopped at one point during this long trajectory down the labyrinth and just looked me in the eye and said, ‘How are you doing?’ And that suddenly I felt myself relax,” Epstein said.

Epstein is the author of “Attending: Medicine, Mindfulness, and Humanity.” “When you ask patients what they really want in a visit with a doctor, uniformly, the thing that rises to the top is to feel understood and to understand, and then secondarily, to get a treatment that will help them with their condition,” he said.

What should physicians say before delivering bad news?

When she was the one getting bad news, Harpham valued physicians who warned her first with lines like “I wish I had better news for you today.” Another was “This is going to be difficult for me to say and, I expect, difficult for you to hear.” In the release, she says a warning delivered calmly communicates both sorrow and competence.

She also asks patients and physicians to stop hoping for good news while waiting on test results. She argues that “good news” sets up a binary of good or bad, while accurate news gives patients what they need to make decisions. That includes results such as partial responses and stable disease.

“More than I hope for good news, I hope for accurate news — however long I have to wait,” she said.

For patients who put off coming in because they were afraid, she suggests: “Coming in is difficult. I understand trying to give it time to go away. I’m glad you are here today. Now let’s see what we can do.” For false alarms, she suggests: “You did the right thing. Better a false alarm than a missed opportunity.”

Anthony Orsini, D.O., a neonatologist at Jupiter Medical Center, founder of The Orsini Way communication training program and a member of the Medical Economics Editorial Advisory Board, trains physicians to disclose medical errors and deliver tragic news. On a recent “Off the Chart” episode, he told Todd Shryock, Medical Economics managing editor, that clinicians retreat to technical language under stress.

“It’s natural for us when we’re in an uncomfortable situation to go to where we are most comfortable, and where physicians and nurses are most comfortable are back to medical school or when they’re doing rounds, and so it’s natural for us to just start speaking in medical jargon and to not explain things,” Orsini said.

Screens, shorter visits and artificial intelligence

“Computer screens and smart phones pulling clinicians’ gaze away from patients symbolize the problem,” Harpham wrote in the introduction. “Simply put, you have more to do and less time in which to do it.”

She also names a newer pressure. “Generative artificial intelligence adds another voice, offering patients diagnoses and treatment recommendations that often complicate discussions,” she wrote.

A patient Epstein had cared for more than 10 years told him during a visit that “ever since you got this new computer system, I just kind of feel like you haven’t been listening in the same way.”

His fix, he said, was to tell himself, “I’m going to try this little experiment for the first minute or minute and a half of every visit. I’m not going to turn on the computer. I’m not going to do anything but look this person in the eye and just listen to what they have to say.”

“One is that I actually remembered what patients said better. The second is that the visits were no longer, and the third was I felt a lot better at the end of the day,” Epstein said.

Amber Maraccini, Ph.D., leads the health care and life sciences practice at Medallia. In an interview with Medical Economics earlier this year, she said patient comments about artificial intelligence (AI) tools can reveal gaps in the relationship with a physician.

“A red flag is when the patient [is] saying it’s easier to ask AI than my doctor. It’s easier to interact with AI than my doctor, or AI is more empathetic than my doctor,” Maraccini said. “To me, that’s more of a red flag on the relationship and the communication skills with the provider.”

Does better communication lower malpractice risk?

Epstein said the risk management department at his institution gives clinicians who complete one of his mindful practice workshops of three hours or more “a 15% discount on their medical malpractice.”

“The argument is, is that if physicians are more present, if they communicate better, even if errors do occur, they’re less likely to get sued and they’re less likely to get sued for as much,” he said. He cited a colleague’s review of malpractice claims and said “embedded in almost all of the complaints is a failure of communication.”

Harpham writes that her insights and tips “are not intended to be dogmatic or prescriptive.” She says the essays address everyday dilemmas in patient care “for which you’ll find little data, if any.”

For patients who hesitate to report symptoms, she suggests: “Reporting symptoms is not complaining but, rather, providing information that helps your care.” Another suggestion prepares patients for the toll of following treatment instructions: “All these tests and treatments demand a lot of your time and effort. When you keep us informed of any difficulties following through, we may be able to make changes without compromising your chance of the best outcome.”

“To be clear, I hate being a patient,” Harpham wrote in the preface. “That said, I treasure all I’ve learned.”