Say What?

Many years ago, I worked with a man of few words who had even fewer problems communicating with people. I first met Avi Avedesian when he was the program director at a YMCA sailing camp in Rhode Island. A large and powerful man who was covered from head to toe with dark body hair, Avi was a high school physical education teacher who also coached football and swimming teams. He had the kind of animal magnetism and natural charisma that made everyone adore him. He often used a unique language which kids and athletes had no problem understanding. His gestures and peculiar forms of physical punctuation evolved into a style of communicative shorthand that combined grunts, whistles, flicks of his cigar, and spitting sounds with a variety of hand movements to remarkable effect. No one ever questioned what Avi meant – it was obvious to anyone in his presence. Even on his deathbed, when it was too painful for him to talk, he was able to communicate with his family just by using his eyes and fingers.

Several weeks ago I was seated across from two teenagers while riding a streetcar. One was Hispanic, the other Filipino. One boasted a sizable inventory of “bling bling.” His friend was appropriately “thugged out” in the latest adolescent fashions. Because these two boys weren’t very vocal, I kept wondering how clearly they were communicating with each other. Although they punctuated their thoughts with the kinds of gestures made popular by rap musicians, I couldn’t help but wonder if they simply didn’t have much to say.

Of course, one of the benefits of living across the street from a high school is being able to listen to teenagers without having to live with them. Since Mission High has a racially diverse population, one hears all kinds of loud and trendy new epithets as its students taunt each other on the sidewalk, at the bus stop, and anywhere else they choose to interact. The strange thing about medical transcriptionists is that, as a rule, we tend to listen to language. And because we listen very carefully to whatever we hear, we often end up worrying about the future of our society.

Even though I consider myself to have a fairly well trained set of ears, audibility proved to be a distinct challenge while watching a documentary filmed at Oakland’s “Peace Out: The Second Annual World Homo Hip-Hop Festival.” Aimed at capturing the excitement of “free-stylin’ hip hop” among competing rappers such as Juba Kalamka, Jen-Ro and Deep Dickollective, the film was alive with creative energy. There was just one problem. The performance styles of many of the artists in the film made it impossible to understand what they were saying. Having spent many years as an arts critic, I wondered if I had overreacted to technical considerations (like an artist holding the microphone too close to his mouth). But when a friend stopped me in the lobby of the theater and asked “Could you understand those kids?” I had to admit total failure.

As we compared notes on the film, we both mourned the loss of diction among today’s performers. When push comes to shove, very few people spit out their consonants with the clarity of Robert Preston, Julie Andrews, or Angela Lansbury. The saddest irony in watching a documentary about young rappers was that here was a wealth of young talent -- street poets of their generation -- who were consistently failing to communicate because their physical movements, the way they used the microphone, and their inability to enunciate the words they had written created so much sound distortion that their speech was horribly muffled. Their thoughts were lost in the accompanying din before the audience could even understand what the performers were trying to say.

How sad, I thought, to have so much hope and exuberance riding on those words– only to have their poetry evaporate into a sound system. How tragic to use your natural talent to create a rap with something to say –only to watch it become something unable to be heard. And then I thought about the doctors I listen to on a daily basis– many of whom are equally incapable of communicating information which carries greater weight than what came out of the mouths of these teen rappers.

I remembered a doctor who, after proudly demonstrating his dictation technique to me, was shocked when I told him that he would need to slow down and speak with more clarity if he ever expected to become one of our clients. “You’re the first person who’s ever said that to me! I wonder why no one else has?” he asked.

How do we make dictating doctors understand that their failure to communicate can lead to critical risks for their patients. And that transcriptionists are not listening to their dictation for its sheer entertainment value? Should we force doctors to perform tongue twisters – or Gilbert & Sullivan’s famous patter songs -- in order to make them understand the mess they make when they fail to speak clearly? Or should we show them a clip of Martin Short (as Comedy Central’s mock TV talk show host, Jiminy Glick) turning to his audience and gushing: “Sometimes I think God put words in the English language just to mess with my mind!”

What is the critical difference – the element of necessity – that makes it so important for doctors to dictate coherently? It’s the fact that they are creating a legal document which must accurately describe a patient’s physical condition and medical treatment. Thankfully, there is some good news to report. The State of Massachusetts is considering a plan that would require doctors to prove their patient communication skills before they can earn a license to practice medicine. According to media reports, in the course of a day-long exam student doctors would have to examine ten mock patients who would then evaluate how well the student doctors were able to communicate, get the information they needed to make a diagnosis, and document the treatment.

It sounds like a grand idea to me. But, at present, state and national doctors' groups oppose the plan (partly because it costs $1,000 for each student doctor). However, not only is the National Board of Medical Examiners encouraging the plan, Nancy Achen Audesse (Executive Director of the State of Massachusetts’ Board of Registration in Medicine) claims that communication problems are behind one-third to one-half of doctors who are disciplined.

How I wish medical transcriptionists could have a say in this matter! I’m sure they could explain how a physician’s inability to draft a coherent sentence might compromise the quality of patient care. I’m sure they could draw a parallel between the doctors who can’t think on their feet and the doctors who suffer from problems with procrastination and lack of organization. Hell’s bells. We can already identify some of the losers who are currently dictating medical reports. What the State of Massachusetts is asking is whether, perhaps, we should start thinning out the herd before medical students even become licensed to practice medicine. That couldn’t happen soon enough for me!