Reflections

There is a quiet gap in medicine that rarely appears on a laboratory report. It exists between the moment a diagnosis is made and the moment a patient accepts that the diagnosis belongs to them. We often assume that once we have explained an illness, the patient understands it. We assume that once the words have been spoken, they have been heard. But hearing is not always understanding, and understanding is not always acceptance.

Consider the numbers. A 2024 health-literacy fact sheet from the Center for Health Care Strategies reports that only about one in ten English-speaking adults in the United States has proficient health-literacy skills. The remaining majority are described as having intermediate, basic, or below-basic skills. This does not mean that nine out of ten people cannot read. It means that health information can be difficult to find, interpret, and use—especially when it is filled with unfamiliar words, percentages, risks, and instructions. [1]

Now consider the time available to make that information meaningful. In one observational study of hospital medicine teams, physicians spent a mean of about 5.3 minutes per patient per day speaking directly with patients. The time varied considerably, and this figure is not a universal measure of every hospital or every physician. It is, however, a sobering reminder of how little uninterrupted time may be available for a conversation that could shape the rest of someone’s life. [2]

Five minutes. Sometimes that is enough to explain a test result. Sometimes it is enough to outline a treatment plan. But is it enough to help someone confront a diagnosis they have spent months—or years—trying not to acknowledge?

There is another layer to this problem, one that statistics alone cannot fully capture: denial. A patient may hear the word diabetes and think, “Not me.” They may see a blood pressure reading and decide it was a stressful day. They may be told that their kidneys are showing signs of damage, yet leave the clinic believing that they feel perfectly fine. The absence of pain can become mistaken for the absence of disease.

Denial is not always stubbornness. It can be fear, shame, uncertainty, financial strain, cultural beliefs, a previous bad experience with health care, or simply the mind’s attempt to make an overwhelming reality feel manageable. Some people do not understand the diagnosis. Others understand it but cannot yet accept what it might mean for their future. And sometimes, as clinicians, we mistake a patient’s silence or polite nod for comprehension.

But chronic diseases do not pause while we negotiate with the truth. Diabetes can quietly injure blood vessels and nerves. High blood glucose over time increases the risk of kidney disease, vision loss, cardiovascular disease, and problems with the feet. Neuropathy may dull the warning signal of pain. A small blister can become an ulcer; an ulcer can become infected; an infection can progress to tissue death. What began as a diagnosis on a laboratory report can eventually become a hospital admission, an operation, or an amputation.

Imagine a patient who came to the hospital with a gangrenous diabetic foot. The sight difficult to ignore. The tissue no longer healthy; the problem had moved far beyond a routine clinic conversation. Approximately four years earlier had had an HbA1c of 15%. That number was not a subtle warning. An HbA1c of 15% reflects profoundly elevated average blood glucose over the preceding months—roughly corresponding to an estimated average blood glucose of 384 mg/dL, which is high all the time.

Yet, when the diagnosis was discussed, patient insisted that no one had ever mentioned diabetes.

I found myself caught between two realities. There was the laboratory record, carrying the weight of a result that should have prompted urgent attention. And a patient facing the unfortunate clinical diagnosis. Somewhere between those two realities, communication had failed—or the message had not become something she could accept, remember, or act upon. We could not know from that conversation alone exactly what had happened four years earlier.

Perhaps the diagnosis had been explained in language that did not connect. Perhaps she had been overwhelmed. Perhaps she had heard the words but pushed them away because diabetes felt like a life sentence. Perhaps there had been barriers to follow-up, medication, food, transportation, or trust. Or perhaps the explanation had never been as clear as the medical record suggested. The chart could tell us what the number was. It could not tell us what she understood when she heard it.

That distinction matters. It is tempting to look at such a story and conclude that the patient simply refused to listen. But medicine is not only the transfer of information from one person to another. It is the difficult work of making information understandable, relevant, and actionable. A diagnosis documented is not necessarily a diagnosis understood. A prescription written is not necessarily a treatment begun. A warning delivered is not necessarily a warning accepted.

And yet, we must also acknowledge the limits of the encounter. Clinicians work within crowded schedules, competing demands, and systems that often reward completed tasks more visibly than meaningful conversations. A few minutes may be all that is available to explain a lifelong condition, its complications, and the changes required to manage it. We cannot solve every barrier in one visit. But we can ask one more question: “Can you tell me, in your own words, what you understand about this diagnosis?”

That question may reveal more than another paragraph in the medical record. It gives the patient room to say what they heard, what they fear, and what they do not understand. It allows us to replace medical jargon with plain language, use an interpreter when needed, involve family with permission, and agree on one realistic next step. It also reminds us to confirm that follow-up is possible—not merely recommended.

For patients, the lesson is equally important: feeling well does not always mean being well. Some of the most damaging illnesses are quiet in their early stages. A diagnosis is not a judgment on your character, and accepting it is not surrender. It is the beginning of having a say in what happens next. Ask questions. Ask again if the explanation is unclear. Bring someone you trust. Find out what the numbers mean and what you can do today.

When that woman arrived with a gangrenous foot, the conversation was no longer simply about an elevated HbA1c. It was about years that could not be recovered, choices that may have been made without full understanding, and consequences that were now painfully visible. The tragedy was not just that diabetes had gone untreated. It was that the opportunity to act may have existed long before the complication announced itself.

Perhaps this is the part of medicine we need to remember: our responsibility does not end when we name the disease, and the patient’s responsibility does not begin and end with receiving the news. Between diagnosis and action lies a human conversation—sometimes brief, sometimes difficult, always worth making clearer.

Because the most dangerous complication may not be the one we discover on the examination table. It may be the truth that was never fully understood, never fully accepted, and never given the chance to change the course of a life.

Sources
[1] Center for Health Care Strategies. What is Health Literacy? (2024). Read the fact sheet.
[2] The Relationship Between Time Spent Communicating and Communication Outcomes on a Hospital Medicine Service. Read the study.

Note: The clinical vignette is presented as an illustrative account. This piece is for reflection and education and does not replace individualized medical advice.