Medicine is unique among the sciences as we are forced to be versatile in our communication skills. As medical scientists we’re tasked with communicating in medical terminology with our peers but then must translate that information into simpler terms and constructs for the benefit of our patients. Granted, there are some scientists who have made it their job to communicate complex cosmology principles to the general public, but for the most part, physicists talk the language of physics with each other, while chemists talk the language of chemistry with other chemists. Doctors talk medicine to other doctors but also have to be able to translate that information to physicists, chemists, mothers, bank tellers, and everyone else in society. In addition, we are charged with having to communicate with the same specificity to both our colleagues and our patients. It’s a delicate balance and we often fail to communicate our full understanding.
But it’s not for lack of trying or training. In medical school we’re taught how to understand and work through a case, then present that information on rounds in a concise, understandable manner. We feel comfortable because this communication happens within a medical frame of reference. People can generally agree on what happened in medicine. In dealing with patients, their communication is sometimes clear. I have chest pain. I broke my arm. I have a tick stuck to my leg. The why and how in medicine is harder to parse and harder to explain.
Consider a mailbox. Imagine that you had no previous connection to the mail, or any cultural context about mail delivery. Would you be able to understand that this thing on a pole is where you get letters and bills? Is that a door that opens? What is that red flag for? The information that you need to work a mailbox and the thousands of other objects you interact with every day is not written down anywhere. Generally, there’s not an instruction manual for these things. You know how and why to use them because it’s part of the unwritten framework of the world.
The modern design guru Don Norman talks about this concept in terms of what he calls “mental models” in his book “The Design of Everyday Things.” Norman denotes the framework for how we interact with objects in the world using this concept. You can’t understand a mailbox, or a doorknob, or a blood pressure cuff without cultural context and without a mental framework for interacting with the object or idea.
If we apply Norman’s concept to medicine, we find the intersection of communication, illness, and perspective. The difficulty in communication doesn’t arise because patients are not intelligent or lack knowledge. They lack a mental framework that allows for the synthesis of new information into the preexisting idea about how the body works. If your only understanding of “pressure” comes from pipes in your basement that sometimes leak or burst, you probably assume that blood pressure works the same way, and that if blood pressure goes up to high, you might pop!
Imagine trying to explain hypertension to someone without the mental model of what “high blood pressure” means. Doctors attempt to do this every day, but they often fail precisely because they don’t consider a patient’s underlying mental model of what blood pressure. Now extend this to thousands of other medical concepts. Communication is most effective when language and concepts are shared, and communication is more than words. In order to process new information, context matters, and you must lay the groundwork for that. We’re all taught to adapt our language from colleague to patient, trying to avoid medical jargon, but this isn’t enough. As physicians, we must realize that nothing will truly be understood without a mental model for how it is to be understood. We need to properly prepare a cubby hole in the cerebral cortex of each patient for them to digest and then file the information we are trying to convey. Changing the terminology alone is insufficient, we must prepare the patients internal framework to understand and accept the information as well. They must understand the concept to understand the significance of the information.
One of the true joys of Emergency Medicine is that we can keep that patient in that room (or hallway) for as long as we need them to stay there. In an office practice, you need to clear the room in 10 minutes for the next group of three siblings with cold symptoms. You might not have the time to assess what your patient knows about why they’re taking their medication and may only have time to default to “We’re adjusting your medicine because your blood pressure is still too high.” In the ED, If time allows and we are conscientious enough, there are often opportunities to delve deeper into the patient's understanding of his or her disorder.
It is important to remember that communication is a means to an end. Understanding is not a static goal, but rather a constantly evolving process. Our world is made up of things we have taken the time to understand, within our current framework of how things “work.” When that framework changes, our understanding of the world changes as well. Medicine is a system of knowledge, but also a physical experience of what it’s like living inside a human body. The interpretation of symptoms and feelings that happen inside you is different from those that happen inside others because we have different knowledge and ideas about what could be causing those symptoms and feelings in addition to how we convey that knowledge to a doctor. We should be cognizant that how we understand and utilize our own mailboxes might be different from how our patients understand and utilize their own.
Going forward, this column will explore this relationship between what patients hear and understand, and what we actually say to them. We’ll talk about diverse topics like vertigo, local dialects, and copper pipes. In exploring the mental framework of our patients, we can better understand how to build a better bridge to true communication.
Ryan Richman is an Emergency Physician in Cooperstown, New York. Parts of this article originally appeared in an Doximity op-ed in October 2024.
