I very recently started work at a new hospital as part of a yearly rotation while in training.
This hospital has a fire board with the names of staff, followed by two circles containing the words IN and OUT, and a tiny black magnet that closely resembles a knight from a portable chessboard.
The board is situated in the office space where staff return when they are not attending to clinical duties on the wards, and indicates whether each person is currently in or out of the office.
Two days into my new job, a junior colleague and I were heading to the wards to review a patient when he stopped at the board and moved the magnet beside his name from the IN circle to the OUT circle.
To my eyes, this now indicated that he was in, though we were in reality headed out.
I pointed this out to him while moving my own little magnetic black knight in the opposite direction. With a self-deprecating smile, my colleague said that he had got the concept wrong, copied what I had done, and we carried on with our duties.
I thought little more of it. A few days later, however, we had a fire tour as part of the induction programme for newcomers and, unsurprisingly, the tour culminated in front of the fire board.
A foundation year doctor, only days into her life as a practising doctor, raised a very pertinent question that none of the other doctors in the group had thought to ask.
How exactly was the position of the magnet supposed to be interpreted? The member of staff giving us the tour laughed.
We would not believe, she told us, the amount of debate that this very question had generated among the healthcare professionals working in the building.
Eventually, a consensus had been reached. “What you see is your current status,” she explained.
I understood this to mean that if the little black magnet was sitting over OUT, obscuring the word, then IN remained visible. The person was therefore in the office and would need to be accounted for in the event of a fire drill or an actual emergency.
That seemed clear enough. Except the doctor who had asked the question and another colleague promptly moved their magnets from OUT to IN.
They were standing inside the office while the board was now effectively declaring that they were out.
They had heard exactly the same explanation I had. They had simply understood something different.
My colleague from a few days earlier was standing beside me. Watching what had just happened, he muttered, almost rhetorically:
“Why would they design something that is so confusing?”
The member of staff looked at the board for a moment, her eyebrows drawn together, perhaps slightly perplexed by what had just happened. Then, with a smile, she explained it again.
The magnets needed to sit over OUT, so that IN remained visible. The doctors moved their magnets back.
The misunderstanding had lasted perhaps a minute. But I found myself thinking about it long after we had walked away.
The member of staff had not given us an especially complicated instruction. We were all speaking the same language. Nobody appeared distracted. The instruction itself contained no unfamiliar terminology.
And yet the meaning received was not the same as the meaning intended. It made me wonder how often the same thing happens in considerably more important conversations.
As doctors, we spend an enormous proportion of our working lives communicating.
We explain diagnoses. We discuss medications. We talk about benefits and side effects. We explain why we think an investigation is necessary, what its results might mean, what happens next and when somebody should seek help again.
And sometimes, after explaining all of this, we ask:
“Does that make sense?” The patient nods.
“Yes, doctor.” And we move on.
But I wonder sometimes whether we mistake having explained something for having communicated it. The distinction matters.
A patient may hear that a tablet should be taken twice daily and interpret that differently from what we intended. Someone may leave an appointment having misunderstood which medication has been stopped and which should continue.
We may explain a risk using language that seems perfectly ordinary to us, but carries very little meaning for someone who does not spend their working life immersed in medicine.
Even apparently simple instructions can become less simple when the person receiving them is frightened, unwell, in pain, or overwhelmed by information.
Add differences in language, culture, health literacy, cognition, or previous experience, and the distance between what we say and what another person understands can become wider still.
There is also a particularly human temptation to ask, “Do you understand?” It is an easy question to answer with a yes.
Sometimes people genuinely believe they have understood. Sometimes they may feel embarrassed admitting otherwise.
Sometimes they simply want to leave the consultation. And sometimes we ourselves may be relieved to hear the answer because there is another patient waiting outside.
One useful alternative is the teach-back method: rather than simply asking whether someone understands, we ask them to explain the plan back to us in their own words.
Not as a test of the patient, but as a test of our communication.
In a strange way, that was exactly what happened in front of the fire board.
The member of staff explained the system. The two doctors then demonstrated what they had understood by moving their magnets.
Their actions immediately revealed that the message they had received was not the message she had intended to convey.
So she explained it differently. Nobody was blamed. Nobody was embarrassed. The misunderstanding was simply discovered and corrected.
Perhaps there is something worth carrying from that little fire board into our clinical encounters.
Communication is not simply the transmission of words from one person to another. The same sentence can enter two minds and emerge with two different meanings.
As doctors, we may therefore need to become a little less confident in the phrase, “I explained it to them.”
Perhaps the more important question is: What did they understand from what I explained?
I will probably never look at that fire board in quite the same way again.
Every morning, I will move my little black knight to obscure OUT, leaving IN visible. And every evening, I will do the reverse. It is a tiny ritual that takes only a second.
But perhaps it will also serve as a small reminder that being clear in our own minds does not necessarily mean we have been clear in somebody else’s.
Sometimes, the only way to know is to ask them to show or tell us what they understood.
The author is a psychiatrist.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
