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to flood. How they lacked the resources to evacuate ahead of the storm. How an already inadequate safety net health care system was devastated by the hurricane. We are less likely to remember Hurricane Ike, which struck Galveston in 2008 with much the same effect on a smaller scale. Nor would we know that the hurricane essentially coincided with the withdrawal of the university hospital from providing most uncompensated care. Pearson volunteers at a student-run free clinic at St. Vincent's House, where the students and volunteer doctors find themselves increasingly trying to plug the holes in a deteriorating health care system. St. Vincent's, a clinic equipped for primary care, scrambles to find treatment for advanced cancer patients abandoned by the larger health care system. Her medical education comes to include not only the skills of medical care, but the importance of simply being present with someone dying for lack of care. She also confronts the humbling reality of her own fai- lures and mistakes. Pearson tells the story of the darker side of American health care in the most personal way possible. She tells us the story, not in the big picture of statistics and numbers, but in the very intimate details of patients dying for lack of care and a few doctors trying to practice decent humanistic medicine in a system not designed for that. It's a story that needs to be told and one that deserves to be heard. It's a story I thought I already knew, but learned it here in a new and dif- ferent way. —David Welch, RN What Patients Say, What Doctors Hear By Danielle Ofri, MD; Beacon Press ignore and forgive the title that refers to doctors only. Dr. Danielle Ofri has written a wonderful, thought-pro- voking book for all medical providers. The book rightly examines commu- nication between providers and patients as the most important tool in medicine. As Ofri explains, despite the vast array of lab tests and medical technology we now have for probing the problems of the human body, the story the patient tells the provider and the resulting conversation "should be viewed as the single most important tool of medical care. It should be given the deference and attention that we lavish upon the swankiest of medical technologies…the simple conversation is, in fact, a highly sophisticated technology. It's far more intricate, powerful, and flexible than most of our other medical technologies, which generally do only one thing in only one way." In each chapter of her book, Ofri tackles a different aspect of communication. She explains what her reporting and the research literature tell us about how communication happens, what works (or doesn't work) between patients and providers, its measurable health and industry impacts, the importance of what is left unsaid (as in cases of domestic violence or addiction), and why the value of communication, as well as skills and tactics, is not taught in school. Throughout the book, she weaves through the stories of a few pro- vider-patient relationships, which offer real-world case studies and examples of her findings. Up until the 1970s, researchers had no way to really quantify and qualify communication. Enter Debra Roter, who created the Roter Interaction Analysis System (RIAS), a scientific way of measuring both the factual content and emotional components of conversa- tions between doctors and patients and what has become the "standard yardstick" in communication studies. Every utterance by a patient or doctor could be categorized and coded to offer insight into the communication. Roter's creation of RIAS would be a launching off point for more research in this field. Not surprisingly, research shows that communication is not simply one-way speech. In fact, the act of listening by the audience shapes the telling by the speaker. An attentive, affirming, and non- interrupting listener usually encourages the speaker to tell the ful- lest story. You can imagine how well (or poorly) this plays out during a typical medical visit or assessment, when doctors and registered nurses pressed for time are constantly multitasking: looking up lab results, charting on the computer, and managing alarms all while trying to talk to the patient. Nurses will not be surprised to learn from Ofri that communica- tion with patients provides healing and real, measurable medical results. In her book, she covers research studies that show patients who received a simple 20-minute informational talk about post-op pain actually experienced less pain, how talking during placebo physical therapy sessions was actually more effective in pain reduc- tion than the therapy itself, and that setting expectations for a medi- cation through communication can be as important as taking the actual drug. Though these studies show that good communication has the potential to improve medical care and save money at the same time (for example, by not needing to provide as much pain relief medication), we all know that insurance companies do not reim- burse for listening and, as a result, hospitals and other care setting do not value listening because they can't bill for listening. Ofri reports that this is changing in the Netherlands, though: Appar- ently the Dutch government has now approved an insurance code for listening to patients' end-of-life concerns. Listening in this case actually does carry direct monetary value. It's a tiny fraction of all the listening and communication that happens, but is a small start nonetheless. And yes, good communication skills can be taught. In one study where oncologists received a three-day training, "compared with doctors who did not undergo the training, these participants dem- onstrated significantly more effective communication skills. Their questions to patients were less leading and more open-ended. They refrained from interrupting and were better at summarizing infor- mation for the patients. They were more astute at following the patients' leads in conversations." Sadly, because it is labor intensive, expensive, and perhaps because the medical community devalues skills and knowledge that it believes are outside the purview of "medical education" or can be attained by anyone, communication training still gets short shrift. Ofri acknowledges that nurses get it, though. Nurses spend the most time with patients and learn that chatting is part of assessing them clinically. Nurses also present themselves as people to be talked to, rather than doctors who do all the talking. Overall, What Patients Say is a well-written, thought-provoking book that not only furthers what we know about the importance of communication in medicine, but can offer nurse readers ideas for ways to improve their own practice. —Lucia Hwang J U LY | A U G U S T | S E P T E M B E R 2 0 1 8 W W W . N A T I O N A L N U R S E S U N I T E D . O R G N A T I O N A L N U R S E 19