How to Avoid a Monologue and Move Toward a Dialogue: Closing the Encounter Strong
Working with patients and families during a busy day can be routine for most of us, but there is always a little bit of stress and anxiety that can set in when you start you day and see just how many patients are on your list. Whether it is more or less than average, sometimes it feels like all work can expand to fit all time. This is why effective communication tactics to ensure our patients and families truly understand what we are telling them are so important.
When closing an encounter with a family, we often have multiple things to achieve: explaining our diagnosis and why we think it is what it is, prescribing a treatment plan, establishing when to follow up or escalate if things aren’t progressing as expected and then of course, answering questions about all of that! Being that it is the end of the encounter, it is also the one that can feel the most rushed. However, this is where lots of miscommunication and confusion can take place for a patient or family. That’s why it behooves us to take special care in how we deliver our information to ensure that the message is truly received and truly understood by the patients and families we serve.
In traditional medicine, this portion of the visit is usually where most of us will do the common “data dump”. For example, a routine visit with a new (but easily treatable problem) like say cellulitis might go something like this:
“I think your child has a cellulitis of their right arm. Cellulitis is a small infection of the skin and soft tissues that can cause the symptoms he is experiencing. We can treat cellulitis pretty easily so I am going to prescribe you some Keflex and he should take it three times a day for the next week. If it doesn’t get better then I want to see him again. Remember to make sure he takes the medicine for the full course otherwise the infection could get worse and he may need to get hospitalized and I wouldn’t want that to happen to him if we can avoid it. Any questions?”
This type of conversation is really a monologue. Moreover, this is where we can be particularly guilty of using medical jargon which further can confuse patients and families. But when we think of relationship-centered care we want to shift this more towards a dialogue where both people are having a conversation. I don’t know about you, but in settings where I am not as educated as the person talking to me, remembering everything they said (say car mechanic listing off all the things they just did on my car and when I need to come back and what to pay attention to for example) can be particularly difficult. Studies have shown that in the typical example given above, patients often don’t retain much of what we tell them (40-80%). In fact, some of the information that is retained is often incorrect.1,2
So, how can we ameliorate this? How do we turn the monologue into a dialogue? One trick is to employ the use of Ask-Respond-Tell or ART loops.3 This framework and tool helps change our usual data dump into more of a conversation. So for the example above, using ART Loops it could go something more like this:
Provider: “So we’re at the end of our time together, thank you for bringing in your son to get checked out. After talking with you and examining him, I think he has a case of what we call cellulitis (pause then…)ASK#1: Have you ever heard of the term cellulitis before?
Patient: “No I don’t think so?”
RESPOND: “No worries! Not many people would know unless they’ve experienced it so I wouldn’t expect you to know! TELL: I can explain. Cellulitis simply means a mild infection of the skin and some of the tissue below the skin. It’s easily treatable with antibiotics so I am going to write you a prescription for a medication called Keflex today.
Patient: “Ok”
ASK#2: Has your son ever had to take antibiotics before?
Patient: “Not for something like this but for an ear infection once”
RESPOND: “Ah ok got it, yes that is pretty common”. TELL: This antibiotic will need to be taken three times a day for 7 days. ASK #3: Do you foresee any trouble getting him the medication three times a day for the next week?” (and so on and so forth)
With the reframing into ART loops, we’ve now changed the monologue into a dialogue and we are simply having a conversation with our patient about the care plan. Studies have shown that doing this style of communication can improve retention of the information we are providing. Moreover, this style of conversation may uncover impediments to our treatment or follow up plans that we have not have uncovered until later leading to delays in care or unnecessary inbasket messages, patient phone calls, or repeat visits to clinic.
While it may feel like it takes more time to do this, I encourage you try on this style on for size at the end your visits with patients. As a hospitalist, I have shifted to doing this more and I have found that patients and parents have responded well with increased understanding of the plans each day and seem to be more engaged. And this also has led to less pages to return to clarify something simple that was misunderstood if I had employed the usual monologue/download. I would be interested to hear your experiences and thoughts or other tips and tricks for effective communication skills. Please feel free to email me at amit.singh@cookchildrens.org.
Amit Singh, M.D.
On behalf of the Cook Children’s Experience Team
References
- Kessels RP. Patients' memory for medical information. J R Soc Med. 2003 May;96(5):219-22. doi: 10.1177/014107680309600504. PMID: 12724430; PMCID: PMC539473.
- Ley, P. (1989). Improving patients’ understanding, recall, satisfaction and compliance. In: Broome, A.K. (eds) Health Psychology. Springer, Boston, MA. https://doi.org/10.1007/978-1-4899-3228-0_5
Chou, C. M. (2017). Skill set three: Delivering diagnoses and treatment plans. In C. M. Chou & L. Cooley (Eds.), Communication Rx: Transforming healthcare through relationship-centered communication (pp. 50–52). McGraw-Hill Education.