Communication failure

George Bernard Shaw said: “The single biggest problem in communication is the illusion that it has taken place.”  

She was 68, generally healthy, and there for her annual health maintenance visit. A retired executive assistant for a local attorney, she was well educated, well read, well travelled, and articulate. The only problem with her visits was that they tended to run long because it was hard not to spend time with her. We discussed her health status, reviewed her stable (mild) diabetes and osteoarthritis, and decided that the singles vaccine would be worth doing. Then I asked, “Is there anything else you are concerned about or would like to address?”

There was. She was worried that she might have a brain tumor. 

She had seen her audiologist because her hearing aids were not working properly. The audiologist had found  and repaired the problem with the hearing aids (corroded contact) but had told her that she had ‘failed two of her screening tests’ so she was referred to the otolaryngologist in the building. 

My patient said he told her she had developed asymmetric hearing loss, which was a ‘red flag for a tumor of the hearing nerve or the part of the brain that manages hearing’ but that the hearing loss was mild so she might not have a tumor. In order to be sure, he would have to do an MRI, but he didn’t think ‘it was worth it, because at her age they wouldn’t operate, anyway.’  In response to my question, she said there was no follow-up visit planned.

She said she did not have any ringing in her ears (tinnitus) and was not having any difficulty with headaches or balance and felt otherwise fine - other than she had found herself anxious and tearful for no reason several times a week in the four months since that visit.

I told her I would get a copy of the office visit note and talk to the doctor and then get back to her. The note was complete and well organized, described a small degree of new asymmetry in her hearing loss, probably insignificant, with a remote possibility of anacoustic neuroma (unlikely given the minimal findings and absence of other findings) and that he would reassess her in 6 months at which time, if her asymmetry had worsened, would consider an MRI ‘though at her age, it might not make sense to operate on a small and slow growing neuroma.’

I called him to make sure I was not missing anything. He was blown away. He was certain he had been clear - that this was almost definitely a benign and stable finding, but that it was worth a follow-up, both to make sure nothing more serious was missed and for the reassurance to both patient and clinician. He had, indeed, mentioned the possibility of tumor, but in the context of it being quite unlikely and that there was no risk in managing this with observation for now because at her age, it would usually be managed without surgery because they are usually very slow growing (decades) and the surgery has significant risks. He said she was on his recall list to contact for follow-up, as they had not been able to schedule a follow-up appointment at her visit because of uncertainties in his schedule.

I called her back, went over the findings, the low risk for serious disease, and the plan for follow-up.

I know the otolaryngologist. He is new to the community and recently trained, but his reputation is excellent. He has sent me detailed letters when I refer patients, and patients reliably say he listens well and answers their questions. He is convinced that he carefully explained the likely innocent nature of the finding and the reasonable plan of follow-up to be sure they weren’t missing anything. The patient is equally convinced that this conversation did not happen. 

I will never understand why communication can misfire so badly. I am always surprised when something like this happens,  concerned that it likely happens more often that I know, puzzled by the fact that it seems so random, and particularly upset when I am the person whose communication fails so spectacularly. 


Links to more on this topic::