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What if the biggest driver of unnecessary ER visits, malpractice claims, and patient anxiety isn’t a missed diagnosis but a missed sentence? Alan P. Feren, a retired surgeon, independent physician, health care consultant, and patient advocate, returns to the show to break down why clinical reasoning that stays inside a doctor’s head fails everyone involved. Based on his KevinMD article, “Clinical communication skills: the power of structured language,” this conversation introduces his five disciplines of language, a practical framework that helps physicians translate their thinking into words patients can actually use. You’ll learn why vague instructions like “return if symptoms worsen” leave patients guessing, how 30 to 40 percent of malpractice suits trace back to communication failures, and why naming what has been ruled out can matter just as much as naming the diagnosis. Feren also addresses treatment burden, the overlooked question of whether a patient can realistically follow the plan you just prescribed. None of this requires extra time or systemic overhaul, just a shift in how you structure what you already say. If you want one framework that improves patient satisfaction, reduces downstream costs, and restores meaning to the clinical encounter, press play.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Alan Feren, otolaryngologist and patient advocate. Today’s KevinMD article is “Clinical Communication Skills: The Power of Structured Language.” Alan, welcome back to the show.
Alan P. Feren: Thanks, Kevin. Glad to be back.
Kevin Pho: All right, tell us what your latest article’s about.
Alan P. Feren: The article really is focusing on clinical reasoning and how it’s translated for patients. Basically clinical reasoning unfolds internally. It’s in our mind. And the language in medicine is typically treated as tone rather than meaning. By that, I mean, people talk about empathy and they talk about bedside manner. But it’s language that really makes clinical reasoning visible. So that’s really what the crux of the article is about.
If translation of your clinical reasoning doesn’t occur, patients leave with fragments rather than a roadmap, and as a result of that, they seek ways, usually the internet, AI now, to interpret what your reasoning left out that they did not understand. We as clinicians think in probabilities, patients experience symptoms. The translation, the sentence, is really the bridge to all that. So that structured language really has the power to alter the trajectory of your care.
Kevin Pho: And I think there are multiple studies that patients only retain a small percentage of the information that is given to them in the exam room. And they often come back with questions that the physicians think were presented very clearly.
Alan P. Feren: Absolutely. And I think the other, the flip side of the coin, and I don’t like to always move into the malpractice sphere, but studies show that 30 to 40 percent of malpractice suits have their root cause in communication. And so it’s very, very important for us to be able to make that bridge, that translation of what we’re thinking of internally.
One of the things that I came up with in this article is the concept of the five disciplines of language. And so when you are interacting with patients, it’s very important for you to have, sometime during this encounter, during that 15 minutes, name what’s most likely. What’s been reasonably excluded? Name what still remains out there, what else is possible? That’s the uncertainty and the unfinishedness that I had spoken about previously with you, Kevin.
Then define what would change this treatment plan that you’ve prescribed for me. It’s important to know what are the metrics that you’re going to be using and to help understand what does worse mean? Is it more severe? Is it more often? Is it something related to duration? Is it shift in the character of the symptoms?
And then clarify the follow-up pathway. And this is the who, what, where, and why. In other words, who do you follow up with? We’ve got a fragmented system currently, and patients don’t know who to call, when to call them. Some people are confused and may often, unfortunately, use the portal, and it’s clearly stated on most portals, particularly on the EMRs that I use, that that’s a three-day gap to expect a response. So don’t use the portal, and can you call the PA, can you call my NP? What is this pathway?
Kevin Pho: So it sounds like this is a systematic method for physicians to be a little bit more precise in their language. Like you said, it’s a more concrete way of asking those questions, the who, what, where, why, and asking physicians to be systematically more precise.
Alan P. Feren: Absolutely. But the interesting thing about the five disciplines is there’s a flip side, and the flip side is for the patients. And so the patients need to be able to ask and understand what’s been ruled out, what’s still under consideration, what specific changes would prompt me to contact you sooner than what you’ve indicated, and what’s the follow-up plan? So the five disciplines work both on the physician side and on the patient side. And these are the orientation statements that I commonly refer to.
Patients don’t expect certainty. They are willing to accept uncertainty as long as it’s spelled out and as long as they’re oriented as to what you think is reasonably going on and what’s still under consideration. The elephant in the room is typically the uncertainty. When people walk out of a physician’s office, a clinician’s office, they want to believe that what they heard is what the physician is thinking. And if they don’t have that firmly in their mind, they’re going to look elsewhere to try to reconstruct the clinician reasoning that wasn’t explained to them in a way that they could understand it. And nothing about this requires extra time. It just requires discipline, translation of the clinical reasoning into language that patients can understand.
Kevin Pho: One example that you gave was giving ambiguous follow-up instructions, like “return if your symptoms worsen,” without adding that specificity.
Alan P. Feren: Correct. And trying to interpret what worsening means, it means different things to different patients. If someone is in a pain situation, they’re going to want, is persistence worsening? Or is it the duration of the pain, as I mentioned earlier? So all these dimensions are very, very important. So explaining to someone, to clarify better what worsening means, you can just spell out in less than 30 seconds what worse means for that particular sign or symptom.
Kevin Pho: And just to emphasize your point, going through a more systematic approach and being more precise with the questions and the information as transmitted doesn’t necessarily take more time in the exam room, because that is going to be a common pushback from physicians who try to adopt this approach, correct?
Alan P. Feren: Absolutely. And I think that’s one of the key things that I hear from colleagues saying, “Gee, Alan, if you want me to do all this, I only have 15 minutes, how am I going to get it in?” And the truth is that it doesn’t take more time to speak in a way that patients can understand, invite questions, and there’s a downstream effect here as well, because if you’re unclear, what happens in a case where symptoms are worsening? Patients don’t know what to do. Their first recourse is urgent care or the emergency room. So this is driving up unnecessary visits and potentially unnecessary testing. So being very clear and making sure your patients understand what your clinical reasoning and thinking is and what else might be under consideration can be very helpful.
Kevin Pho: Now, what kind of training or discipline should a physician have to effectively utilize and adopt this approach consistently?
Alan P. Feren: I think that this is not something that needs specific training. I think it’s just being mindful of the five disciplines as and to ensure that before a patient exits the exam room that you have gone through the five disciplines with patients. And you can actually encourage a question in terms of, is this clear? Is there anything else?
One other point that I would make is that one of the things that’s typically left out of most encounters, and I write about this as well, which is the feasibility and treatment burden. We give treatment plans to patients and we expect them to follow them, but we don’t understand what the burden of that treatment is and what its feasibility is. By that I mean, you can have patients who are also caregivers and they don’t have time for the PT that you’ve prescribed, or there are people who are uncomfortable and are forgetful and unable to take medications twice a day or three times a day or take it at a certain time during the day. And so being mindful of, are there any obstacles that would prevent you from doing what I’ve recommended, is an important question to ask. And this often may require a referral to some other service to help the patient overcome a particular obstacle.
Kevin Pho: And just to recap the five disciplines, I’m just going to read it from the linked article that you wrote. Number one, name what is most likely. Number two, name what has been reasonably excluded. Number three, name what remains possible. Four, define what would change the treatment plan. And finally, clarify the follow-up pathway. So I think within that framework, a lot of physicians can just up the level of their effectiveness when they communicate with patients.
Alan P. Feren: I agree.
Kevin Pho: So if busy physicians are listening to you now and just implementing the entire framework sounds a little bit overwhelming, it changes so much of their workflow in the exam room. What’s the first thing that they could do? Just the number one thing that they could do just to take the first steps to adopt this.
Alan P. Feren: Well, I think you can begin adding the five disciplines into your practice and maybe not all five. I think the first three are extremely orienting for patients, naming what you think is most likely and what’s been excluded. People want to know that something that is a serious or potentially life-threatening condition is no longer in the differential diagnosis. And then you can begin to add, OK, so what else might be possible?
I think establishing that relationship with patients is the foundation for the partnership that I also am a strong proponent of. That partnership means that patients are working together with you, understanding what you are saying, what you are recommending. The partnership really is going to result in the best clinical outcome. And we as physicians, and I firmly believe this, are trying to do what’s best for our patients in all instances under a constrained and compressed system.
And so making these simple changes in language and at the encounter level are things that don’t require massive system change and reorganization. I’m a big proponent of incremental change rather than revolutionary change. And I think the encounter is really the source from where all care starts and theoretically ends. So by really focusing on what your patient is saying to you, listening carefully for that first minute to let them get through their story, and then making sure that they’re oriented before they leave the office is going to have a very good impact on your relationship with them and higher satisfaction scores, and will restore the meaning that many of us are losing because of the system that we’re working under and the strain that we are currently experiencing.
Kevin Pho: We are talking to Alan Feren, otolaryngologist and patient advocate. Today’s KevinMD article is “Clinical Communication Skills: The Power of Structured Language.” Alan, as always, we’ll end with take-home messages they want to leave with the KevinMD audience.
Alan P. Feren: I think the biggest take-home message is explore and try to implement the five disciplines. If you’re a clinician, on the patient side, make sure you understand thoroughly what your physician has recommended. Identify any concerns that still remain. Make sure that your clinician is informed of any potential barriers or obstacles to the treatment plan that they have prescribed for you. Do not leave that office with questions, if you can do so.
Kevin Pho: Alan, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.
Alan P. Feren: Great, Kevin. It’s good to be back.
