The Hidden Communication Gap in Modern Healthcare

Why Leaders And Clinicians Talk Past Each Other

The Affordable Care Act, followed by the pandemic, sped up a long-term trend in American healthcare. Hospitals and clinics are increasingly part of large systems.

A 2024 report says that over 75% of all doctors are now employed. Healthcare is run more like a business. One resulting problem often gets overlooked or misunderstood: doctors and executives do not always understand each other’s perspective.

The issue is not about what words they use. It’s about how they put their words together.  Doctors and leaders follow different rules when they explain problems or make decisions.

How Doctors Are Taught to Talk

Doctors (and other clinicians) are trained to build a case step by step. We start with the chief complaint (“I have chest pain”). Then we write the history of present illness, the past history, and so on. Only at the end do we give the assessment (our opinion) and the plan (what we recommend).

This approach makes sense in medicine. It tells the whole story and shows how we reached our decision. However, it also takes time and reveals the most relevant point — what must be done — only in the end.

Every good detective show begins with a problem —  a crime that no one knows how it was committed. Every good detective show ends with the solution — the explanation of how it was done. Every day in medicine is like a detective show.

Dr. Smith’s Different Way

During my residency, I worked with an endocrinologist I’ll call Dr. Smith. He wanted us to write notes in the opposite order:

1. Recommendations
2. Assessment
3. Chief complaint and history

Why? Why do the reveal before telling the whole story?

Dr. Smith would say, “The person consulting you? Their time is valuable. They want to know your recommendation. They may not care how you got there.”

At the time, this felt unusual. No other attending physician I knew told us to document this way. But it made sense when you thought about the reader as not wanting the whole story, but a shortcut to the expert’s recommendations.

What I Learned in Business School

Years later, I heard the same idea again—this time in my Executive MBA program. I learned about Barbara Minto, the first woman MBA hired at McKinsey & Company. She noticed that executives were often buried in details. So she developed what became known as The Pyramid Principle.

The principle is simple:

1. Start with the answer.
2. Show the key reasons.
3. Give background only if needed.

It was the same thing Dr. Smith had taught us years before. All MBA programs teach this.

Two Styles, Two Mindsets

Doctors are detectives. They gather clues and build a case. That is why medical notes tell the whole story before giving the plan.

Executives, on the other hand, need to make fast decisions. They want the bottom line first, then reasons, then details.

Both methods are useful. Both are logical. But when doctors and leaders talk to each other, the clash in style can cause problems.

Doctors may feel ignored.

Leaders may feel overwhelmed.

Everyone walks away frustrated.

Why This Matters

If you are a leader in healthcare, you sit at this crossroads. You must be able to hear and respect the doctors’ careful process. And you must also know how to deliver a clear, short answer when executives need it.

Leadership is not only about making the right decision. It is about ensuring your message resonates with your audience.

What’s Next

In my next post, I’ll share an example. You’ll see two versions of the same psychiatry consult note—one written in the classic style, one written “backwards.” And we’ll look at how knowing your audience can make all the difference.