Hear my voice

Asking patients if they have any questions isn't the best way to be sure they understand.


I received a message yesterday from a former student in my very first small group, who reached out to share a pivotal moment he'd had in patient care. Jim is now a second-year ENT resident.

Courtesy of Kimberly Manning
Courtesy of Kimberly Manning.

Jim was taking care of an elder with some cognitive issues and very limited literacy. The man had not even a full elementary education and the kind of difficulty understanding things that was even harder back in the day because there weren't any names for such things or early interventions.

This elder unfortunately had a recurrent throat cancer. Laryngeal cancer, to be exact. And Jim, being the head and neck surgeon, was charged with coming in there to see this man and talk to him all about this procedure he was going to have. A procedure that would take away his ability to speak. For good.

Jim spent a lot of time talking to this gentleman and did so with care. No, I wasn't there, but I was there from the first day Jim started medical school. I listened to him and talked to him over the years so I know that it was important to him that this man understand what his surgery would entail. No matter how long it took, without question, I can say that Jim wanted to do all he could to give this patient the chance to make the most informed decision possible.

And so. He talked. He explained. Carefully. And fully caring, too.

The gentleman had a tracheostomy tube in his throat at the time that limited his ability to speak during that conversation. So after this young doctor spent all of that time speaking to the patient, Jim bit the bullet and did the thing that we are all taught to do but often come up with excuses to avoid. He asked the patient to tell back—or teach back—exactly what the gist of the plan was based upon the patient's understanding.

This can be loaded. Mostly because if the person gets it all wrong, you're back at square one. Which, in my opinion, is always where you are when the patient doesn't understand, whether you take the time to confirm it or not.

A lot of times we feel the pressure of a ticking clock looming over us. The cop-out question gets asked: “Any questions?” Which, most of the time, is often met with a “not right now.” That response gives the doctor the wrap-up he or she was looking for. Especially if the questions are generic enough to convince us that we've explained things well.

But Jim did something even more extraordinary. He asked this question—”What is your understanding of this surgery that I just talked to you about?”—to a patient with a less-than-sixth-grade education and some learning disabilities who also could not respond verbally. Having him write would be very tedious and time-consuming, but there wasn't another option.

Jim respected that man enough to ask. Even more, he respected him enough to talk to him with the dignity he deserved and then positioned himself to have to wipe down the chalkboard and start explaining all over again.

And so. As his doctor patiently waited, the patient took a piece of paper and scrawled these words in response to that question:

Courtesy of Anthony Chin-Quee
Courtesy of Anthony Chin-Quee.

And I will tell you exactly what Jim said to me about this:

“Not sure exactly why yet, but I know this is one of the most important images that I'll see during my training.”

I think he's right.