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The Question Every Patient Conversation Should Include

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"Do you know what I found that contains a lot of sodium?" Mrs. Smith asked me in a low, conspiratorial tone.

“What?” I asked.

"Salt, there's a lot of sodium in salt,” she said.

I worked with Mrs. Smith as a resident on the transplant service. She was a mother of three in her late 50s who did not have much money but did her best to appear as well-composed as her resources allowed. Her medical team tried to move her directly from chronic renal failure to transplant without putting her on dialysis in between. As part of that plan, the nephrologist wanted her on a salt-restricted diet. As the resident on the team, it had fallen to me to do the educating.

I explained to Mrs. Smith why she needed to restrict her sodium intake. I went over handouts with her on which foods she could eat and which foods to avoid. We discussed how to read nutrition labels to identify the right foods to buy at the store, and which to leave on the shelf. She was motivated to avoid dialysis, and I felt she got the idea at the end of our discussion.

Then, at her follow-up visit, she dropped the "there's a lot of sodium in salt" bomb on me. It was a classic case of assuming the patient knew something because I knew it. Of course, salt contains sodium; salt is synonymous with sodium. And of course I knew that, but I never thought to explain something I considered fundamental to the patient. I just assumed everyone knew what I knew — and I was wrong.

After a moment, I responded, "You’re right, salt is mostly sodium. You will need to avoid salt in the future."

Mrs. Smith’s eyes narrowed, and her mouth turned down at the edges. As a longtime smoker, she had overcome cigarette-induced loss of taste with the liberal application of table salt. I had now identified this as a problem, but only by a backdoor method. If she had not looked at the label on her table salt, she would have continued to salt her food, nullifying all the good my attempt to educate her could have done. I realized that if I wanted to empower patients about their health, I needed to find out what they did and did not know first.

Now, I like to use a train analogy. Imagine that I wanted to take Mrs. Smith by train to San Francisco. The first thing I would need to do is escort Mrs. Smith onto the correct train, but I can't do that if Mrs. Smith is starting in New York and I am in Chicago. The train will pass us both as we wait in two different places for the other person to arrive.

As educated professionals, it is our job to meet patients where they are. Mrs. Smith can't come forward to join me, but I can go back to meet her. Instead, what I had done was the equivalent of sitting in Chicago and expecting Mrs. Smith to meet me there. But she couldn’t do that. She couldn’t jump ahead in her understanding. She needed me to go back and meet her in New York. By failing to do that, I had missed an opportunity to get her on the low sodium train two weeks earlier. 

Mrs. Smith reminded me how important it is to resist the impulse to approach our patients where we think they are, or where we want them to be. We must meet them at their level of comprehension if we're going to bring them to our level of understanding. In short, we must meet the patient where the patient is.

Of course, this is easier said than done. In order to find out which station the patient is starting from, we need to talk less and listen more. We need to ask questions to assess what the patient does and does not know. Once we do that, we can identify the appropriate starting point from which to shepherd the patient to where they need to be. If they are in New York and we are assuming they’re starting in Buffalo, Chicago, or Denver, we will miss the opportunity to connect with them.

Based on my experience with Mrs. Smith, I try to ask more questions now before launching into an explanation. Questions like: “What do you know about X?” “What have others told you?” “Do you know anyone in a similar situation?” “Have you thought about what you would like to do?” “What do you hope will happen?” “What would be an acceptable outcome in your mind?”

And, of course, the 600-pound gorilla in the room: “What are you afraid of?”

Finding the answers to these questions allows me to identify where the patient is so I can meet them there. The questioning might seem time-consuming, but I have found that by getting their answers out in the open, I can have more effective conversations and arrive at the final destination sooner. 

I think the final question is especially critical. It is imperative to find out what the patient (and their family) fears. Often those fears are based on misunderstanding or bad information. If so, irrational fears can be dispelled once they are brought out into the open. Other times, their fears are accurate, based on realistic concerns, and acknowledging that can build a bridge of trust between clinician and patient — but it can't happen if we don't know what those concerns are, and we can't find that out unless we ask.

Today, rather than lecture Mrs. Smith on a low sodium diet to show off how much I know, I would instead start by asking questions to assess how much she understands or thinks she understands.

“Tell me, Mrs. Smith, what do you know about sodium?”

That one question would have told me that she had no idea what sodium was. She certainly had no idea that it was synonymous with salt. We could have started from there. Rather than lecture her on reading labels, I could have done much more good by encouraging her to put the salt shaker away.

It is our job to be knowledgeable, but it's also our job to impart that knowledge to others in a way that they can understand. We can only do that by taking the time to ask questions, listen, and assess. The best advice in the world is useless if the listener does not understand it or know how to use it. Find out which station your patient is waiting in, and then go meet them there.

How have you traversed gaps in understanding with your patients? Share your strategies in the comments!

Charles Black is a general surgeon, father, landscape photographer, writer, outdoorsman, and fireside philosopher. Catch up with him at where he writes about life, the universe and everything. You can also view his photos on Dr. Black was a 2019-2020 Doximity Op-Med Fellow, a 2020–2021 Doximity Op-Med Fellow, and is currently a 2021–2022 Doximity Op-Med Fellow.

All names and identifying information have been modified to protect patient privacy.

Illustration Collage by Jennifer Bogartz / TeraVector / Guz Anna / Shutterstock

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