Tapper

Like many internal medicine doctors, I often see eighty-something-year-old men and women coming to hospital with a diagnosis of frailty. The word frailty is more or less the same as fragile. Being fragile, a senior gets easily bulged with ailments, and then bursts.

As one of my fragile patients went downhill, one family member after another asked for escalation of treatment to save his life, understandably so. That patient had weak muscles, scanty comprehensible words and quite some bruises (after doctors' attempts at taking blood), and was making each breath with difficulty. That's why he had a tube inserted into his chest (which appeared to have burst), and ended up breathing (through a tight mask) from a pressure machine. And yet, as we read the advance care plan that accompanied the elderly man, we recognized the clearly written statements not to carry out cardiopulmonary resuscitation, not to have ventilator support, not to give artificial nutrition. At the end of that statement, his daughter dated and signed it. It isn't right to be aggressive in terms of treatment, I thought. I thought the family should have thought so.

But, no. The daughter knew she'd signed a document. "It's about my dad's ill health and a fast channel to get him into hospital without having to go thru the emergency room." She knew next to nothing about palliative care of his dad, leaving me awestruck by her convoluted concept. The patient further deteriorated two days ago, when I happened to be on call at night. He was dying. And that's what I told my intern and the patient's family. Easier to understand than the word frailty.

After a hectic night, I taught a large group of medical students. It's about communication. Not communication to sign a advance care plan. Still, the theme is similar. Doctors who want effective communication with patient or family, in a nutshell, have to "unknow" what we know and get the listeners' perspective. Medical students, like doctors, know so much about a topic, and it's rather difficult for them to imagine a listener who can't understand their knowledge and language. Elizabeth Newton, a Stanford University graduate student in psychology, explained this concept nicely in 1990 by performing a now-famous experiment of tappers and listeners. That experiment simply divided a group of people into "tappers" and listeners." For those who are assigned tappers, they picked from a list of well-known songs such as "Happy Birthday to You" and tapped the rhythm of the song on a table. For the listeners, the job was to guess the song.

Easy job? If you answered "yes" to this question then you - like the tappers in the experiment - may be suffering from the curse of knowledge. The tappers predicted that listeners would get the correct answer 50 percent of the time. In reality, the listeners correctly identified 2.5 percent of the songs. Why? The tappers heard the song in their heads at the same time of tapping. While the tappers had the knowledge, the listeners were simply perceiving a bunch of disconnected taps, like a kind of bizarre Morse code.

And so, I told the students, when we give a lecture on a medical condition like atrial fibrillation, the listeners are more often not following what we say. We are giving them a bunch of Morse code.