When Your Client Nods and Smiles

but has no clue what you just said

I recently saw a patient for the first time who was referred to me for evaluation and treatment of chronic hepatitis C. In my urban clinic, this is something that happens quite frequently, at least a few times a week. In general I prefer that the referring physician do only the hepatitis C antibody test and a viral load (level of virus in the blood) to confirm that the patient has gone on to develop chronic infection. In a small percentage, 10-15% of the time, patients will spontaneously clear the infection without treatment, so they will have positive antibody but the virus will not be detected in their blood.

Copyright nito500/123RF Stock Photo

Copyright nito500/123RF Stock Photo

In an attempt to be helpful, the referring physician in this case had done a more extensive work up, and the patient was surprised and a bit dismayed to find out she needed more testing. I carefully explained the additional tests that I needed and the ones that would need to be repeated. I needed to make sure the results were recent enough for her insurance to approve the expensive but effective new treatments for hepatitis C. After my explanation, she agreed to do the lab work and the ultrasound of her liver. We scheduled a three-week follow up to review the results.

Three weeks later, I searched for the results before I went into the room to talk to her, but I couldn’t find them. I went in to ask where she’d had them done.

Oh, I don’t need to have any labs. I just had a whole bunch done by my primary care doctor.

–If you remember, there was some additional information I needed before I could decide if you should be treated now or just monitor for a while. Do you still have the lab slips I gave you?

Oh, yes, I still have them.

–Can you go downstairs right now and have them drawn, and I’ll see you back in two weeks?


A few minutes later, the nurse came out of the room and said, “The patient doesn’t understand why she needs to come back in two weeks, and she needs to have her lab and ultrasound slips printed out again.”

Now, I don’t see myself as being imposing or overbearing. I don’t wear a white coat, mostly for my own comfort, but also to alleviate “white coat syndrome” in my patients, because I know anxiety can be a barrier to effective communication. Yet apparently, for some patients, my role alone is enough to make them uncomfortable to ask questions when they don’t understand or to ask to have complicated information repeated.

Don’t get me wrong. Most of my patients have no problem asking me all kinds of questions. Some come in with a list already written out so they don’t forget anything. But some are like this patient, or some have more of a language barrier than they are willing to admit. They make it through the nurse intake, but look at me blankly when I ask my first question. The extra few seconds that it takes to set up the language line are well worth it to get an accurate picture of symptoms or response to treatment.

This episode is humbling, just in case I was patting myself on the back for being a great communicator. This story makes me grateful that I have tools like language line, and that I work in a team. Thank goodness my patients can be open and honest with my nurses and my front desk staff and my counselors and case managers, and thank goodness we all talk to each other. Our patients’ health depends on it.

Click here for a one-page summary on teach-back, which could have prevented this situation.

When was the last time you thought you had communicated well, but it turned out that you hadn’t? It happens in all human situations, not only in the work place. Share a story in the comments below.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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2 thoughts on “When Your Client Nods and Smiles

  1. Debby you ARE a role model for ideal doctor-patient skills!
    “Teach back,” where I ask the patient to tell me what they understand that I said, and what they will do, is something that seems too rudimentary and yet it does sometimes catch the non-understanding, mis-understanding, or patient’s intent NOT to do what is asked! I don’t use that technique nearly enough-I think sometimes I’m afraid it will seem too simplistic and demeaning to a patient.

    • Yes, the few seconds that it takes to check a patient’s understanding, though, can save a lot of inefficiency. Thanks for the reminder of this great tool.