What You Say Isn't Always What Patients Hear

A few years ago, my aunt Edna (name changed for the purpose of this story) suffered a stroke. After a short hospital stay, she was transferred to a nursing home for rehabilitation. When she arrived at the nursing home, Edna requested a private room. The administrator of the home explained that Medicare does not cover private rooms and that she would be placed in a semiprivate room. This upset Edna. She promptly took her frustration out on the administrator (as though he could change Medicare regulations right then and there).

To ease the situation, the administrator told Edna an empty, semiprivate room was available and that he could place her there by herself until the other bed was needed. Edna immediately said she wanted the room, but with the stipulation that no one else would be placed in the room. The administrator repeated his explanation of Medicare regulations and told her he could not promise she would not be given a roommate.

Edna persisted and told him he should put any new patients in other rooms with available beds. The administrator maintained his stance, but finished by saying, "We won't place another patient in your room unless we absolutely have to."

As the nurse began to wheel Edna down the hall to her room, the administrator looked pleased with himself. I could tell he was thinking, I won. I was thinking, You just shot your staff in the head. You just don't know it yet.

When he told Edna, "We won't place another patient in your room unless we absolutely have to," Edna stopped listening halfway through the sentence. She only heard him say, "We won't place another patient in your room." The "unless we absolutely have to" part did not register. To make it worse, he referred to the room as "your room," essentially (in her mind) making it her "private" room.

After lunch on the third day of Edna's stay, a nurse's aide came in and placed a name tag on the bed next to Edna's. Edna was getting a roommate. That was when the fight started. Edna had a fit. She loudly told everyone in the facility, "This is my room and he promised he would not put anyone else in here!"

The fit would turn out to be one of several during the stay that ended with Edna checking herself out of the home early, against the doctor's orders.

One of the truly unfortunate results of Edna's privacy issues was the nursing staff taking the brunt of Edna's fit. The administrator had minimal contact with Edna. I am sure he was completely unaware of how his last statement to Edna would be interpreted and he had no intention of creating problems for his nursing staff.

The Problem: Giving Responses the Patient Can Misinterpret

This is a perfect example of a patient hearing what they want to hear, a situation that unfortunately occurs in all areas of health care. For example, the doctor may be dealing with a patient who is insisting his next appointment be immediate or at a specific time. The doctor may say to the patient, "We'll get you in as soon as possible" or "We'll get you in. Just tell them up front."

The first available appointment might be in a week or the specific time requested might not be available. But the patient's interpretation of the doctor's response is, "You'll get in first" or "You can come when you want." And that is what the patient will tell the front-desk staff.

The odds are high that in most offices, the doctor either does not have more than that day's schedule at hand or if the schedule is available, he has no intention of being the one to schedule the next appointment. That job has been assigned to someone else. Once assigned, the doctor should not interfere in scheduling unless there is a good reason to intervene.

The next step is for the doctor to avoid giving vague responses to patient questions and demands about appointment times – responses that can be unconsciously or consciously misinterpreted by the patient.

The Solution: Change Your Vocab

When I encountered these problems in my practice (actually, I should say when I created these problems in my practice), I had to change my vocabulary. Instead of saying, "We'll get you in as soon as possible," I began saying:

"I realize you want in quickly, but you're giving me credit for being smarter than I am. I cannot memorize the appointment schedule. Carol has the schedule up front and she will give you the next available appointment. If that is a little further out than you want, we will put you on the list to call if there is a cancellation. But remember, there are other people on the cancellation list ahead of you."

I currently work in an interventional pain and spine practice where invasive procedures are performed on an outpatient basis. During the first visit, all patients are screened for illegal and prescription drugs, and no prescriptions are written that day. If the screening comes back positive for illegal drugs or prescription drugs that have not been prescribed (taking someone else's medications), the patient is dismissed.

After screening, if the patient requires a procedure, the procedure must be scheduled and the preauthorization process initiated. If the patient stresses his desire to have the procedure immediately, instead of informing the patient of the next steps and the timeline, the doctor will often say, "We'll get you in as soon as possible." Again, to the patient this means immediately and when the patient wants.

The problem here is the schedule is booked at least two weeks out, even for routine follow-up visits; and the precertification process can take days to weeks.

Medicare does not require preauthorization of most invasive pain procedures. Other carriers do and depending upon the carrier and the procedure, the authorization may be given immediately over the phone, require 10-30 days and/or involve the submission of records for review. Obviously, "We'll get you in as soon as possible" is overpromising.

The staff is left to deal with the patient's displeasure in having to wait for the appointment and preauthorization. The doctor has essentially "thrown the staff under the bus." He should have briefly discussed his awareness of the schedule and the need for preauthorization. A better response to a patient's insistence on being treated immediately would be: "You will be scheduled based on the time required for your insurance company to preauthorize the procedure."

Preauthorization is not a frequent requirement in chiropractic practice; however, it is becoming more frequent for ordering an MRI and other diagnostic procedures. Preauthorization could take days and the patient's next chiropractic appointment will depend upon the time required for preauthorization, scanner availability after preauthorization and the time required to obtain results. Saying, "We'll get you in as soon as possible," without clarification of the statement by the doctor, can cause problems, especially for staff members.

Master the Art of Speaking to Your Patients

I can't stress enough the importance of details when doctors are speaking to patients. It's absolutely critical in order to avoid patient misunderstandings that ultimately must be dealt with by staff members. Doctors must describe the true circumstances for follow-up visits and procedures, and how staff members operate under those circumstances. Otherwise, the staff will become the focus of the patient's dissatisfaction.

It is always the doctor's prerogative to override the schedule. However, he should make the staff aware of the situation prior to informing the patient. The staff should not hear of a change in normal scheduling procedures from the patient, especially since patients often hear what they want to hear or completely misinterpret what the doctor said.

All too often, doctors make promises staff members cannot keep, even if not the doctor's intent. Doctors, ask your staff if you are placing them in these positions. If you survive the beating, ask how they think the situations can be avoided.