Write It Down!

It does not follow that if you know the letters of the alphabet, you can spell; if you know words, you can write; nor does knowing how to do something qualify you to instruct others how to do it.

Whatever is written down possesses the quality of permanency. The spoken word does not. A great many of our patients, as well as certain members of our staff, have a somewhat limited attention span. It therefore behooves us to write things down that will require referencing. While this procedure is common knowledge in the workplace, it is frequently superseded by the remark, "Don't worry, I'll remember."

The strict policy of writing things down that you want your patients to remember is essential to successful patient management. This is especially true when your patient is being exposed to unfamiliar nomenclature. Whenever possible, use simple language. If the use of technical language is unavoidable, make sure the patient understands what you mean. Do this by tactfully asking for verbal feedback. Be advised, however, that even if a patient appears to comprehend your oral communication, use the written word for further reassurance.

When patients are told something orally, there is a tendency for them to filter your remarks through their own experiences and unique prejudices. Surely you have had patients confidently report that your advice worked beautifully. Then, after some casual interrogation, discover that they did just the opposite. It is not unlike laughing at a joke for the wrong reason.

Another justification for writing things down is retrievability. Keeping written records should be the backbone of every practice. Countless articles in our literature stress the importance of writing things down. A written message is readily accessible, and it can be reread several times if the meaning is unclear.

Contrary to the oral message, which is generally spontaneous, written messages can be thought out beforehand. Those DCs writing instructions for patients should be able to answer three questions:

1. Who is going to read these instructions?
2. What is the reader supposed to do?
3. What must I do to be understood?

Number one is important. A distinction should be made between a patient who is 18 years old and one who is 68 years old. Their ability to comprehend might not be the same. Number two is equally important because unless a patient follows your orders as you intended, their value is negated. Number three is the most important consideration, are you being understood? A popular communication myth suggests that if you write things down clearly, and use the proper words, you will be understood. Wrong! Permit me to give you an example: A professor of education at a West Coast university struck a blow for the kind of tax reform tax payers would like to see the most, CLARITY! Using excerpts taken from a 1973 Form 1040, he asked 35 graduate students to apply the principles it advanced to 12 sample situations. The average student got less than six of the examples right. To illustrate my point, here are the instructions given to the students:

"It may pay you to use the 'averaging method' if after subtracting 3,000 dollars from your 1973 taxable income [line 48], the balance is over 30% of the total of your taxable income for the last four years (1969 through 1972)."

If there are any tax-wise readers of this column, I sure would like to know if the IRS has improved their communicative writing skills in the past 25 years. My guess is that they have not. My reasoning goes as follows: During the past 25 years, the number of immigrants in this country has sustained a staggering increase. Many are non-English speaking who are obliged to pay taxes. If the aforementioned graduate students had difficulty understanding the IRS instructions, imagine how the immigrants would fare.

Let us look at written instructions from another perspective. You are going on vacation and another doctor is covering your office. How will that doctor know what treatment should be given to each of your patients? In your patient file or folder there should be a clearly stated diagnosis and a chronological description of the treatment that has been rendered. Merely saying, "cervical and lumbar adjustments" is not enough. You must be more explicit. What type of cervical and lumbar adjustments? How much force should be employed? Note anything relevant to the patient's reaction to the adjustment. The same admonition goes for any adjunctive treatment. Be explicit. It would also be helpful to the covering doctor if you identified in writing any patients who required special attention.

In writing instructions for either members of your staff or your patients, certain grammatical pitfalls should be avoided, or kept to a minimum: (a) incomplete sentences; (b) run-on sentences; (c) the excessive use of colons, semi-colons, dashes, parentheses, commas; and (d) beginning sentences with conjunctions such as "and" or "but."

Perhaps the most glaring mistake doctors make when giving their patients (or staff) written instructions is to use words or phrases that can be interpreted in more than one way. Here are some of the more common offenders [see the capitalized letters]:

1. WAIT A LITTLE WHILE ... after eating before you take your vitamins. 2. Eat SLOWLY. 3. Do your exercise very CAREFULLY. 4. Now, try and be COMPLETELY RELAXED. 5. Remain very CALM.

From a semantic viewpoint, the words (or phrases), "wait a little while," "slowly," "carefully," "completely relaxed," and "calm," are all open to interpretation. Patients could easily react to these directives differently. Add to these ambiguities the difficulty foreigners might have when they are translated into their native tongue. For instance, how long is "a little while" in Peru, Barcelona, or Kenya?

A final word about writing things down concerns legibility. While medical doctors have the reputation of having terrible handwriting, members of the chiropractic profession may well be guilty of a similar charge. In any case, it would behoove every chiropractic physician whose handwriting is in serious need of repair to print any handwritten instructions or orders. For those doctors in denial, i.e., "My handwriting is not that bad," I strongly suggest that they get the opinion of a competent and literate nurse or receptionist. The doctor's ego should be put aside to give way to a clearer form of written communication. Adherence to the axiom, "Write it down," falls short of its goal or purpose when it cannot be understood by the individual for whom it is intended. Reread and, if necessary, re-write your patient notes. It will be time well spent.

Abne Eisenberg, DC, PhD
Croton-on-Hudson, New York

Editor's note: As a professor of communication, Dr. Eisenberg is frequently asked to speak at meetings and conventions. You may write to him at 2 Wells Avenue, Croton-on-Hudson, NY 10520, or call (914) 271-4441.