“Just checking if you advised the last patient to take six tablets once or twice daily?,” a nurse asks.
“Definitely the first,” I gasp. The correct dose is six tablets daily.
Patients can get confused, especially when printed instructions don’t match their recall. It turns out that the patient was too preoccupied by her dread to absorb all the things I said and the near-miss incident leaves me sobered.
Evidence shows that very little of what is said in a consultation stays with the patient. Typically, patients forget up to 80% of medical information (the more given, the less recalled). Alarmingly, a significant proportion of recalled information is erroneous.
Lack of understanding is related to patient dissatisfaction, poor adherence, and reduced capacity for shared decision-making. Poor directions, long waits, malfunctioning hearing aids, a lack of interpreters, and relatives running late are seemingly fixed attributes of a clinic, but by far the greatest obstacle is anxiety, particularly pronounced in oncology, where every gesture and every word is heavy with meaning.
The fog of treatment, coupled with all the elements of a life-threatening diagnosis, makes every consultation a challenge to be heard and understood. Patients don’t always ask the questions they need to; doctors don’t always answer the questions they ought. And then there is the consultation that has gone extremely well in the doctor’s estimation, only to turn out to be the opposite. Nothing is more sobering than the revelation, typically from a concerned nurse, that the obliging patient barely remembered what I said.
With all this in mind, when the next patient’s daughter asks, “Doctor, do you mind if I record this conversation?”, my answer is yes but I immediately feel on edge. Normally I’d welcome a crowd into my room and now, in the time of telehealth, barely shrug at a gallery of relatives on my screen, but somehow the notion of that same conversation being recorded feels uncomfortable, even intrusive.
I wonder if the phone sliding across my desk will alter what I say and how I say it.
This patient has a poor prognosis from metastatic cancer. She is frail, elderly and unfit for chemotherapy, which has a high chance of harm. I strive for honesty but the recording will capture only the statistics, not the sensitivity of the moment without which the consultation would lose its meaning.
One relative has been causing tension in the family by demanding a second opinion. What if my attempt to dissuade is perceived as suboptimal care? Then there is the matter of prognosis. I have previously suggested that the patient has a few months to live and advocated palliative care. But if my opinion is recorded, might I dress my instinct in so many layers of data that it ends up being nonsensical? And in the extreme event that this consultation attracts a malpractice claim, will my words haunt me? I shudder at the thought of these sacrosanct minutes being scrutinised in a court.
But when I turn my focus on the patient, I immediately see a family that is anxious and reeling from the shock of a cancer diagnosis. Several people don’t speak English; the daughter who does will be the valiant go-between at home. It is likely that, in their efforts to be grateful and compliant, they will neither question my judgement nor assert what matters to them. The ability to listen back to a recorded conversation at their own pace and to return with important questions might be just the bridge they need.
In an ageing population, carers and loved ones often have pertinent questions about the direction of care and are indeed charged with dispensing that care. But unless they are present and assertive, their concerns aren’t always met, and information later relayed by unwell patients can be compromised by misunderstanding, miscommunication or plain forgetfulness. As medicine gathers pace and patients are expected to navigate increasingly complicated conversations, finding out from a relative what the doctor said becomes an inquisition – and this is why recorded consultations could one day become a standard feature of clinical medicine, provided they meet rigorous standards.
Nearly 10% of adverse events occur in an outpatient setting, with a quarter causing permanent disability or death.
If a medical error has occurred, the highest priority ought to be transparency and remedy. To ensure common understanding, many paediatricians send the same correspondence to the parent and the GP. For others, recording a consultation may provide an additional impetus to improve communication; one US hospital offers discounts on medical indemnity to doctors who agree to recording.
Australian cancer researchers are testing a mobile app called Second Ears to record a consultation, with hopeful results in a pilot. Unsurprisingly, most patients could download an app and hit record. Somewhat unexpectedly, most doctors didn’t object to being recorded, realising that if this encouraged a more transparent and thorough discussion about consent or treatment options, this was time well spent.
Knowing that recordings don’t increase litigation, and that a saved copy in the hospital records might actually protect doctors from conflict and litigation, was helpful. There is growing recognition that the way to avoid covert and awkward recordings is to have a proper policy, and the rapid transition to telehealth during the pandemic has resulted in an increased willingness to consider technology as a partner in healthcare.
Translating a commendable pilot from an academic centre into widespread use will require (achievable) investments on several fronts: reassurance that the primary reason for recording a consultation is not to trip up the doctor but help the patient; clear communication about any medico-legal implications; agreement about appropriate use and storage; additional safeguards for professionals and patients dealing with issues of mental health, sexuality, abuse and violence. And a robust emphasis on education so that no patient is discouraged from recording a consultation because the doctor is not confident with communication.
No single improvement will transform healthcare but, with due attention and oversight, recorded consultations may turn out to be a useful, cost-effective and inclusive path to patient-centred care.
• This article was amended on 19 November 2020 to more accurately reflect the writer’s account of the conversation with the nurse in relation to the correct dose of chemotherapy tablets.