Table.

Physician-Patient Communication: Helping the Patient to Hear What You Mean

While Doing a Mole Check, the Physician Says:	Patient Perception	Rephrasing Example	Why Rephrasing Is Beneficial
“Don’t worry about that mole, it’s OK.”	“The doctor dismissed me. I feel stupid for asking. No need to think about it anymore. No need to do skin self-examination.”	“This mole is not skin cancer. It is actually called a benign nevus, which is not harmful. Benign nevi do not turn into skin cancer. Even benign nevi can have a bit of an irregular border. Since this is the only unusual feature of the mole, you can be confident that it is benign.”	Inform patient it is not melanoma or NMSC. Identify the characteristics of the mole that make it benign. Inform patient what potential changes (if any) would be concerning. The patient will most likely feel relieved he or she does not have cancer and it is a helpful SSE teaching opportunity.
“I think it’s OK. If the mole starts to change, we can do a biopsy then.”	“What can be done to be sure?  How will I know it changed?  Who is watching it?  What are we watching?  I want to do the biopsy now to be sure it is not bad.”	“This mole is most likely not melanoma, but I can’t be sure. I would like to monitor it for change during the next 3–4 months. Come back to let me check it in 3 months. If it changes (gets larger, more shades of color, or seems to “grow legs” from the edges), I recommend doing a biopsy. A reason not to do a biopsy now is the possibility that the biopsy will create an unsightly or uncomfortable scar. In the meantime, examine and measure it each month and call us if it gets larger, etc.”	Involve patient in monitoring plan and explain the course of action. Try to be specific when describing “changes to look for.” Give the patient a rationale for decisions (eg, reasons to wait to do a biopsy). Patients who can participate in their care (ie, SSE) and understand the course of action are likely to feel more empowered rather than helpless.
“Let me do the worrying for both of us.”	“I do not have to take responsibility for my health.”	“You seem very worried. Feeling concerned is natural, but as we continue to monitor the mole (receive information about the biopsy results) we will develop a plan based on the information we have instead of worrying about the unknowns.”	Trying to protect the patient isn’t helpful to him or her. Patients need to be informed of their risks so they can make informed decisions about their health. In addition, patients can become an active participant in their own care if given the opportunity. Acknowledging patients’ concerns and involving them in the care plan, whether it is SSE for monitoring the mole, waiting for biopsy results, or discussing treatment options for melanoma may provide them with a sense of control.
“The chance of the mole ever turning bad is very small.”	“What does the doctor mean by “bad”? What is very small?”	“The chance of the mole turning into melanoma is about 5%. While it is not likely, it is still a good idea to look for changes during your regular skin exams. If you notice changes during SSEs, call our office.”	Words and phrases like “bad” and “very small” may lead to confusion and anxiety, in patients. For example, “very small” may be a 5% chance to a physician, but the patient may interpret it as a 25% chance. Communication between you and the patient can be improved if less ambiguous words are used.
“You want me to give you the chances of you surviving this melanoma. I do not like to put numbers onto things. The numbers give estimates for lots of people, but there is only 1 of you. Either it will be OK or it won’t. There is no need to live your life by some number.”	“Give me a range. Is it 2%, 20%, or 80%? If I am not going to make it, I need to be able to make plans for my family.”	“It seems like it would be helpful for you to make sense of everything if there were percentages to go along with your diagnosis. Your melanoma is classified as a stage IIA and has not spread to your lymph nodes. The average 5-year survival rate for a similar diagnosis is 70% to 80%. It is important to understand that this is an average number and individuals vary on preexisting health conditions and other factors that may impact those rates.”	Some patients may want percentages, while others find them overwhelming. Framing the message in terms of survival is generally preferable. While it can be hard to deliver less than optimal results about patients’ health, patients need to know the information in order to plan and choose from treatment options. Providing patients with accurate information in a way they can process it best and learn from it can be helpful. If you are not sure, ask patients what they prefer.

Abbreviations: NMSC, nonmelanoma skin cancer; SSE, skin self-examination.