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Clinical Take-Aways

  • The remarkable thing about clinician-patient communication is not how often it fails but how often it succeeds.

  • Creating shared understanding is often complicated by differences in clinicians’ and patients’ life experiences and perspectives on health.

  • Three types of communication failures are not understanding (the result of making unfounded assumptions), misunderstanding (saying it or hearing it wrong), and disagreeing (having different opinions).

  • Clinicians should:

    • Cultivate curiosity, asking “what might it be like to be this patient?”

    • Cultivate humility, recognizing that it is easy to miscommunicate one’s intentions or misunderstand patients’ concerns.

    • Be alert to verbal, paraverbal, and nonverbal clues that the patient is confused about or skeptical of an explanation or suggestion.

    • Be aware of the potential for implicit bias related to race, ethnicity, gender, age, sexual orientation, and other nonclinical patient characteristics.


George Bernard Shaw famously observed, “The single biggest problem in communication is the illusion that it has taken place.” While this may be true in nearly all literature and in much of life, the stakes in health care are such that illusory communication hardly suffices. We need the real thing. Miscommunication in health care has consequences—for medical decision-making, for patient satisfaction and morale, for professional self-regard and burnout. And not incidentally, for the clinical negotiation.

In her book Of Two Minds, which describes the way American psychiatrists are trained, anthropologist Tanya Luhrmann notes that “When young psychiatrists learn to diagnose and prescribe, they learn that a patient can hurt a doctor.”1 Later, “When young psychiatrists learn to do psychotherapy…they learn…that doctors can hurt patients.” Luhrmann was talking about the power of words, and not just as wielded by psychiatrists. Doctors’ words can soothe, comfort, and empower—or frighten, disrupt, and undermine. Furthermore, words are the raw material of negotiation, clinical or otherwise. In the struggle to find common ground with patients, clinicians must start with the right words. As even the most skilled clinical communicator will tell you, this is sometimes easy and sometimes exquisitely difficult. All of us can recall situations where communication simply went off the rails.

In this chapter our purpose is to promote a communication skillset that will facilitate the clinical negotiation. But to do so we work backwards. By looking at how communication fails, we see how it can succeed. By unpacking how things go wrong, we can see more clearly how to set them right.

Consider these patients.

Mr. Strahern, a 45-year-old man with alcohol-related liver disease, signs out of the hospital against medical advice when his medical team refuses his request for more opioid pain medication.

Mrs. Ungerleider, an 86-year-old European immigrant who lives alone, calls the office repeatedly with minor concerns. She recently filed a complaint with the Patient Relations Department alleging that “Dr. Brown never calls me back.”


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