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I am sometimes unpleasantly surprised by the recalcitrance of some of my patients to accept and follow the advice I give them. We’ll sit down and have a discussion about the best treatment for their particular problem. I’ll lay out the details, they’ll nod, and then blithely ignore the counseling. It’s understandable. Many patients come to the doctor with certain expectations, and when those expectations are not fulfilled, may block out or ignore otherwise good advice.
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As difficult as it may be for us caregivers to realize, our patients will make their own decisions. They are adults, and our contemporary society is much less authoritarian and patriarchal than it was in the past. As a result, the patient is now part of the healthcare team, and it is our job as healthcare providers to be as effective as possible when giving our professional advice.
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Here are my suggestions to give the most effective advice to patients:
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Be eye to eye - This might sound remedial, but caregivers should always sit at eye level with their patients and look them directly in the eye when speaking. Standing while talking gives the impression of being in a hurry, and standing over a patient creates an authoritarian atmosphere. Sitting below eye level creates a less authoritative impression. Communicate at the middle ground and sit down at eye level while giving the patient the respect of looking them in the eye when speaking. Do NOT focus on your computer when speaking with patients.
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Establish a relationship whenever possible - It’s much more likely that a caregiver will provide successful advice when they know their patient and when the patient knows and trusts them. For new patients, unless it’s an emergency, it is often best to hold detailed, complex, or potentially invasive advice for a subsequent appointment. Advice is more likely to be followed once you have established a mutually respectful relationship based on trust and knowledge.
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Be gentle but firm - Kindness and clear displays of caring are mandatory. Remember that you are giving potentially upsetting advice to a patient, and they may need time to process that advice. Similarly, being excessively blunt may alienate patients. Telling someone with plantar fasciitis to “lose weight; you’re too fat” is obviously coarse and insulting and will be ineffective advice.
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Take time - Referred and second opinion patients consistently complain to me that their prior doctor did not take the time to listen to their stories and their needs. Allowing the patient time to relate their concerns establishes that all-important rapport while providing the caregiver further information about their patient.
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Make your advice as simple and straightforward as possible - Don’t be overly complicated or give too many options. It’s well known that people have a harder time making decisions when given too many choices. Don’t use medical jargon. Patients are not stupid, but they’re also not physicians and definitely aren’t experts in the foot and ankle. Keep any statistics you might use very basic and very germane to the particular situation. Your job is not to show how smart you are but to help your patient heal.
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Don’t take it personally when they disagree or ignore your advice - Don’t appear judgmental. Remember, that you are giving your professional advice, but it is the patient’s medical problem. They will have to live with the result of their decision. Approaching the process from this somewhat more detached direction will also allow you to make better decisions.
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Chart your advice in detail - Recalling that a physician’s documentation is medicolegal protection, be sure to document the details of the discussion, including your advice, the patient’s stated response (agrees to the plan, disagrees and will do something else, etc), and their later outcomes as they relate to your advice.
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Recently I had a patient who presented with a large plantar great toe ulcer with exposed flexor tendon, palpable periosteum, and clear radiographic evidence of a bone infection. To make matters more complicated they had moderate to severe peripheral arterial disease. They had already seen one physician who recommended a toe amputation. While discussing treatment options I made a mistake by presenting two options as if they were equivalent: (1) amputation or (2) bone debridement and reconstruction (I did not feel this patient would respond to parenteral antibiotics). Without giving too many details here, although the reconstructive version was possible, it would require a somewhat heroic effort with more than one operative intervention in the face of a patient with poor arterial supply. What the patient heard was, “Dr Shapiro will save my toe.” I’ve never been one to overpromise, and this was clearly not my intention. I started the patient on oral antibiotics to suppress the spread of the infection as much as possible and consulted a vascular specialist.
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At the next appointment, I sat down with the patient again and spent more time discussing the benefits and downfalls of each of the options. We discussed the high risk of failure with the reconstructive option due to their peripheral arterial disease and significant amount of tissue destruction leading to potential devascularization of their toe after a surgery. Of course, they were not happy with this information, but was more accepting of the amputation. They thanked me for my honesty and, although worried about their situation (rightfully so), they were much more open to considering their options.
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Perhaps the best piece of advice anyone could give on giving advice would be to follow the golden rule and treat your patients like you would want to be treated. Kindness, respect, and patience always wins the day.
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