BRITISH MEDICAL JOURNAL VOLUME 282 7 MARCH 1981

Dealing zvith the Disadavantaged

Communicating with patients with speech problems

JANET THRUSH

Explaining a problem to the doctor
depends entirely on the ability to com-

4 J r |\municate. The person with a speech
/ 19 t P 8;1 \ difficulty is at an obvious disadvantage

at a consultation and anything the
doctor can do to help will not only

Iernational YarOf save him time in tortuous question-
Disabled lPeo ing, but will also save the patient

great embarrassment. Speech prob-
lems may be divided into those

affecting only expressive speech or talking and those involving
language in all its forms. Talking may be impaired due to loss of
voice, as in laryngectomy; defective articulation, as in Parkin-
son's disease; or lack of fluency, as in stammering. These
patients have no difficulty in understanding and, unless there is
an additional handicap, they can always communicate in
writing. When language ability is impaired, however, both
expression and comprehension of speech are affected, and
writing and mime, being dependent on internal language, are
unable to provide alternative means of communication. The
following suggestions will help the doctor to get the best possible
communication with patients with a speech problem and in a
further article I will suggest ways to help those who have a
language difficulty.

General points
(1) People with all types of speech problem speak better when

they are relaxed. Concealing the pressures on your time and
spending a few moments making the patient feel at ease save
time later when the patient has to talk.

(2) Do not treat speech-handicapped people as if they were
mentally deficient; they are not.

(3) People with defective speech are sometimes thought to be
drunk or just fooling about, particularly on the telephone. If the
receptionist is aware of this, she is less likely to be dismissive on
the wrong occasion. If it is very difficult to understand what the
patient is saying, it is best to say so tactfully and extract the
necessary information by questions which can be answered with
"Yes" or "No"-for example, it is no good asking "Can you
come on Tuesday or Wednesday ?" Each part of a question must
be taken separately.

(4) Keep out extraneous noise by shutting doors and windows.
Talking is very tiring for speech-handicapped people even
without the need to compete with passing cars, and having to
repeat usually launches the stammerer into a stammer.

Stammering

It is easy for the fluent speaker to underestimate the amount
of courage it takes a severe stammerer to enter any situation

Newton Ferrers, Devon
JANET THRUSH, LCST, speech therapist

where he is totally dependent on his speech. The doctor can
help him by remembering the following suggestions.

(1) Maintain personal contact with the speaker even when he
is blocking completely. There is no need for this to develop into
a staring match, but refrain from shuffling papers, sorting out
drawers, and generally making it clear that your attention is
elsewhere.

(2) Do not finish sentences for the patient unless he is totally
stuck and you are pretty sure you will get it right.

(3) Advice such as "Take a deep breath before you start,"
"Talk more slowly," is rarely helpful and often irritating.

(4) Some people find it so difficult to confess to having a
stammer that they reappear in the surgery on several occasions,
making up reasons for their attendance, before they can screw
up courage to ask for help. It is difficult to deal with this, but if
the doctor is aware that it occurs, the patient is less likely to
leave the surgery with yet another bottle of cough medicine,
when he really wanted a referral for speech therapy.

(5) Children passing through the normal non-fluency stage at
the age of 3 or 4 are sometimes mislabelled stammerers and then
live up to the label. Early referral to the speech therapist could
avoid this by providing support and reassurance for the parents.

Dysarthria

Dysarthria is a difficulty in articulating or enunciating words.
Comprehension is intact.

(1) Resist the temptation to pretend that you have understood
when you have not; it rarely saves time in the long run and may
be frustrating for the patient.

(2) Do not shout. (Just as people tend to raise their voices
when talking to foreigners, they do so with the speech-im-
paired.)

(3) A reminder to slow down may help. (People with Parkin-
son's disease find this particularly difficult to remember.)

(4) Do not "talk down"; just because someone cannot speak
properly does not mean that he cannot understand. Nursing and
remedial staff sometimes need reminding of the irritation caused
by the "how are we today ?" approach.

(5) Pay attention when the patient is speaking; do not sort
through notes etc.

(6) The effort of talking is very tiring. If possible, divide up
the consultation by doing the physical examination in the
middle.

(7) Ask the patient to write down salient points before a
return visit if communication is very difficult; writing may be
very time-consuming.

Voice disorders, including laryngectomy

(1) Anticipate when the patient needs to interrupt you and
give him chance to do so. Dysphonic patients and those who
have undergone laryngectomy often have difficulty in initiating
speech, so it is difficult for them to butt in when someone else is
talking.

802

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BRITISH MEDICAL JOURNAL VOLUME 282 7 MARCH 1981 803

(2) Use lip-reading; watching a patient's lips may give
sufficient additional clues to enable you to understand.

(3) Encourage the use of the laryngeal vibrator if the patient
has one; patients are sometimes self-conscious about using
vibrators in unfamiliar surroundings.

Children

If the child is old enough to be attending the surgery alone
then the preceding points will apply, and if he is accompanied

by an adult the problem of communication will be circumvented,
but a few points are worth making.

(1) Talk to the child wherever possible; because he does not
speak clearly does not mean that he does not understand.

(2) The presence of a few toys and a relaxed approach will,
with the speech-handicapped as with the normal child, prevent
an examination turning into a tussle and future visits to the
doctor becoming a cause of nightmares.

(3) Do not feel that a child should not be referred for speech
therapy because he is too young or he has no speech at all.

Letter from . . . Chicago

Reading aloud

GEORGE DUNEA

At the beginning of a new presidency we may well reflect on
Plato's view that the human race will enjoy no respite from evil
until its leaders "become genuine and adequate philosophers,
and political power and philosophy are brought together." Yet
we may at least enjoy the comforting thought that most of the
effective leaders of the past, many of whom have conferred great
benefits on humanity, were far from being intellectuals. Few of
these successful men of action would have understood the
raptures of the literary critic who, in a recent review on Jane
Austen, extolled the pleasures of reading aloud as a peaceful
enriching way of establishing an atmosphere of intimacy between
the author and his readers, with frequent pauses for discussion-
"especially on the many nights when there is nothing on TV."
And I was vicariously reminded of the rather unkind and
undoubtedly apochryphal anecdote about a head of state who
after his heart attack was confined to complete bed rest, as was
the fashion of the times, while the doctors hovered anxiously
over his ailing myocardium, periodically tranquilising the
populace with reassuring press releases. After a few days, the
time of maximal danger having passed, the patient asked to see
the newspapers. The doctors, however, denied his request,
fearing he might become too tired from moving his lips.

Achiever facilitator

For those who find the written word less of a challenge,
however, Jane Austen remains an ever-present source of delight.
Not that the liberated twentieth-century woman would readily
agree with the observation that, "a woman, especially if she have
the misfortune of knowing anything, should conceal it as well as
she can." For, unlike the earlier Hanoverian and Regency ladies,
the modern executive woman is so busy pursuing her career that
she would be well served by having a "wife" in the home.
Unfortunately, as Maryanne Vandervelde points out, only 200°4,
of husbands are of the "non-achiever facilitator" kind, who
would do the housework, take care of the children, plan their
lives around their successful wives, and readily move if their
successful better half had an opportunity of promotion in another

Cook County Hospital, Chicago, Illinois
GEORGE DUNEA, FRCP, FRCPED, attending physician

city. Leaving out the "non-achiever obstructionists," who
amount to less than 5% of husbands, we find that most men,
over half, conform to the traditional "achiever obstructionist"
pattern; and that less than one-quarter belong to that ideal type,
the "achiever facilitator," who helps and encourages his wife,
shares the household responsibilities, and is not threatened by
her success. Some ambitious women, of course, retain the
option of never marrying, getting divorced, or having no
children.
But returning to the achiever facilitator who reads aloud with

his wife, we find that this blissful couple devoured all of Trollope
during one summer and all of Miss Austen during the next. A
reference to Sanditon, the fragment finished by Another Lady,
from Australia, reminded me of the formidable Lady Denham,
who at the age of 70 was still opposed to taking physic and had
never consulted a doctor. She was determined that no member
of that particular tribe should ever set foot in her beloved
seaside resort, for, "it would only be encouraging our servants
and the poor to fancy themselves ill"; and even her dear Sir
Harry might have stayed alive had he not put himself in the
hands of a doctor: "Ten fees, one after another, did the man
take who sent him out of this world. I beseech you ... no
doctors here."

Crisis of excess

Echoing Lady Denham's view, some 200 years later, are
those alarmed by the predicted surplus of doctors in the US,
especially as each new doctor generated an additional $300 000
in expenses to an already overinflated annual medical bill of
$256 billion. Yet what in the 'sixties was deemed to be a crisis of
access is rapidly becoming a crisis of excess; so that an estimated
deficit of 50 000 doctors in the late 'sixties could turn into a
projected surplus of as many as 130 000 by the year 2000, with
one doctor for 200 people. Already the number of doctors has
grown from 320 000 in 1970 to 440 000 last year, with a pre-
dicted "inexorable" increment to almost 600 000 by the end of
this decade. And, while some shortages may persist in unpopular
areas, the overall projection is one of too many doctors engaging
in cut-throat competition for patients, with an increased focus
on the financial aspects of medicine, practising perhaps at a
higher cost per patient visit, with more laboratory tests, more

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