 |
|
Charting the
doctor-patient relationship |
|
--Barbara Seaman |
|
 “You are feeling better today,” announced the gastroenterologist as he sat down by my hospital bed. I was genuinely surprised. “Really? What’s better?” “Well,” he sputtered, his face flushing, “in my professional opinion, you are better!” I sighed, searching for more conciliatory words. “Look, it’s just that it helps me to hear specifics.” “Your lymphocytes are better and you look better,” he said after a pause. I smiled, privately wondering how I could look better when my hair was one day dirtier, but I knew I couldn’t afford to challenge him again. I needed his help. Can you hear the tension in this encounter? Why are doctors and patients so often at odds? Why are both expressing more frustration and less satisfaction? To answer these questions, more and more researchers are putting the doctor-patient relationship under the microscope. What they are finding is fascinating Tug of War If you’re wondering why so many office visits turn into a tug of war, it’s partly because doctors and patients are on different ends of the rope.  To the doctor, illness is a disease process that can be measured and understood through laboratory tests and clinical observations. To the patient, illness is a disrupted life.
(1)(2)
The doctor’s focus is more on keeping up with the rapid advances in medical science than on trying to understand the patient’s feelings and concerns.
(3) Yet patient satisfaction comes primarily from a sense of being heard and understood.
(4)
Many doctors do not see the role of physician as listener, but
instead view their function more as a human car mechanic: Find it and fix it.
(5) Yet patients often feel devalued when their illness is reduced to mechanical process.
Doctors feel frustrated, even betrayed, when patients withhold
pertinent information. Yet patients who use alternative medicine, for example, may not tell their doctors for fear of ridicule or being
labeled as flaky or gullible. (6)(7)Keep the change Changes in our culture and in the practice of medicine have also added tension to the doctor-patient relationship. In some ways we have become more doctor dependent because we see doctors sooner than people did 50 years ago, says Barbara Korsch, M.D., co-author of The Intelligent Patient’s Guide to the Doctor-patient Relationship (Oxford University Press, 1997). (8) Yet we are less dependent on the doctor for information and decision making. (9) In addition, the managed care upheaval with its cost-cutting strategies has shortened office visits and threatened to reduce the traditional doctor-patient covenant to a business contract. (10) Fault Line All these changes are unsettling for both doctors and patients. Then there’s the blame factor. Doctors often blame patients when communication breaks down. (11) But researchers have found that many doctors have shaky interviewing skills. For example:
Doctors do more talking than listening. (12) A new study published this year in Journal of the American Medical Association (JAMA) found that 72% of the doctors interrupted the patient’s opening statement after an average of 23 seconds. Patients who were
allowed to state their concerns without interruption used only an average of 6 more seconds.
(13)
Doctors often ignore the patient’s emotional health. A study of 21 doctors at an urban, university-based clinic found that when
patients dropped emotional clues or talked openly about emotions, the doctor seldom acknowledged their feelings. Instead the
conversation was directed back to technical talk.
(14)
Doctors underestimate the amount of information patients want and overestimate how much they actually give. In one study of 20-minute office visits, doctors spent about 1 minute per visit informing patients but believed they were spending 9 minutes per visit doing so.
(15)
Doctors who can’t communicate are more likely to end up in court. An analysis of 45 malpractice cases found that many of the doctors being sued delivered information poorly and devalued the patient’s views.
(16)Pain in the neck patients Patients aren’t perfect either. In one survey doctors rated 15% of their patients as “difficult.“ (17) Disagreements involve everything from expecting an instant cure to demanding prescriptions. While one doctor’s difficult patient may be another doctor’s favorite, researchers have identified common characteristics of patients that everyone agrees are hard to manage. Patients described as “frustrating” by doctors
do not trust or agree with the doctor.
present too many problems for one visit.
do not follow instructions.
are demanding or controlling. (18)Patients labeled as “difficult”--sometimes known among doctors as “crocks” or “turkeys”--are more likely to be single and often have a history of unexplained physical symptoms, depression, panic states, obsessive-compulsive disorders, or physical abuse, according to a study of rheumatology patients at the University of Washington Medical Center. (19) Patients who present themselves as overly helpless may risk turning the doctor off, Dr. Korsch notes. (20) She also believes that the more melodramatic the patient’s description of pain, the more likely the doctor will discount it. (21) Patients who use the doctor as a scapegoat for their anger at the illness are less likely to get good care. “Doctors are profoundly influenced by the demeanor, comments, and attitudes of their patients,” write Debra Rotter and Judith Hall in Doctors Talking with Patients/Patients Talking with Doctors (Auburn House, 1992). “A patient who is consistently rude and irritable will almost certainly not receive the same medical care as a patient who conveys more positive attitudes.” (22) Pulling in the same direction In spite of all these problems, there is reason for hope. Yes, doctors and patients will always be on opposite ends of the healthcare system, but that doesn’t mean they can’t pull in the same direction. What can doctors do?
Cultivate a patient-centered partnership.
(23) “The patient desires to be known as a human being, not merely to be recognized as the outer wrappings for a disease,” says Bernard Lown, M.D., emeritus professor at Harvard School of Public Health and author of
The Lost Art of Healing (Houghton Mifflin, 1996). (24) Research supports his views. In a video-taped study of 171 office visits, doctors who encouraged patients to talk about psychosocial issues such as family and job had more satisfied patients and the visits were only an average of two minutes longer.
(25) Incidentally, doctors also benefit from the patient-centered approach, researchers note, because they feel more job satisfaction and are less likely to burn out.
(26)
Check posture and body language. A fascinating study of time perception found that when doctors sat down during an office visit, the patients always thought the visit was longer than when the doctors remained standing, even though the length of both visits was exactly the same.
(27) Other simple gestures, such as leaning forward, have been found to help the patients relax, as well as improve satisfaction and recall.
(28)
Solicit the patient’s concerns and opinions through open-ended questions, such as “What’s been going on since you were here last?” In the
JAMA study, last minute questions--a pet peeve for many doctors--occurred less frequently when the patient was invited to talk.
(29)
To improve patient compliance, work on mutual trust. Research confirms that the health of the doctor-patient relationship is the best predictor of whether the patient will follow the doctor’s instructions and advice.
(30)
Develop a system to communicate test results to patients. No news is good news, patients often assume, but according to a survey published in
Archives of Internal Medicine, one in three doctors do not always inform patients of abnormal test results, especially if the results are mildly abnormal. About half the doctors surveyed thought it was important to inform patients of normal results, but only 28% always did so.
(31)
Respect patients as experts in the experience of illness. Traditionally, doctors have been taught to view the patient as “an unreliable narrator” and to chart patient observations in subjective language that implies a certain skepticism, such as “the patient believes” or “the patient denies.”
(32) However, Rotter and Hall argue for a patient-centered relationship that accepts the patient’s unique knowledge as just as important to outcome as the doctor’s scientific knowledge. They conclude, “The medical visit is truly a meeting between experts.”
(33)What can patients do?
Know how to tell your illness
story. Many patients tend to start with interpretation, “I think I have bronchitis” rather than plain facts, “I’ve been coughing for two weeks.” Brief, focused facts will usually get the doctor on the right track, Dr. Lown believes. He also recommends developing a clear description of the symptoms before the visit, not during.
(34)
Use concrete examples to explain how illness affects your daily life. For example, “I’m getting worse” is less helpful than “We’ve buying milk in quarts because I can’t lift gallons anymore.” Everyday details also help the doctor understand how the medical data translates into real life.
Study your doctor’s individual style. What are his/her likes and dislikes, strengths and weaknesses? Optimistic or pessimistic? Intense or mellow? Organized or absent-minded? Cautious or a risk-taker? The more you understand how your doctor thinks, the more likely you’ll know which approaches will work and which won’t.
Learn about your illness so you can ask the right questions and help make decisions. Patients who take an active role in their care do better and earn more respect from the doctor.
(35) “An informed patient is always the best,” says Donald A.B. Lindberg, M.D., Director, National Library of Medicine, “even though that puts more pressure on us to keep up to date.”
(36)
Be willing to demonstrate the attitudes that you want from your doctor. For example, if you would like more give and take in the relationship, demonstrate your own flexibility by offering to negotiate and make concessions. “Patients can be a powerful agent for change of a physician’s behavior,” says William Godolphin, M.D., professor at the University of British Columbia and director of a physician-patient education program.
(37)
Accept realistic treatment goals. Many chronic diseases can be managed, but not cured. “In this age of hype, patients have come to expect the impossible,” says Lown.
(38) “Doctors frequently grope in the dark, not because they are delinquent in learning, but because the science is not there.”
(39)But even when a cure is impossible, healing may be possible, Lown points out. “While medical science has limits, hope does not. If a patient is ready to be helped, even a little, and grateful for the marginal, it enhances the doctor’s commitment to fostering a relationship between equals. Only such a relationship, bonded by understanding and respect, can deepen into a true healing partnership.” (40) (41) |
 |
|
|||
| Related
links: A doctor discovers how to talk to a doctor  Zeev Neuwirth M.D. describes his terror when he unexpectedly finds himself in the role of patient. Intel
looks at the human side of medicine Hippocrates
was right: Treat people, not their disease Making
the most of physician-patient email Get
better care by being a little pushy with your doctor |
|
|
|
|
|||
| References: 1. Toombs, Kay, Ph.D., The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient, (Kluwer Academic Publishers, 1992) pg. 12, 19-20, 25, 26 2. Korsch, Barbara M. &, Harding, C. The Intelligent Patients Guide To the Doctor-Patient Relationship (Oxford University Press, 1998) pg. 15 3. Rotter DL & Hall JA Doctors Talking with Patients / Patients Talking with Doctors (Auburn House, 1992), pg. 9 4. Ibid., pg. 72 5. Ibid., pg. 17,20 6. Crock RD, et al., Confronting the communication gap between conventional and alternative medicine: a survey of physicians’ attitudes Altern Ther Health Med 1999 March;5(2):61-6 7. LaPuma, John, M.D. Trust Should Be Thrust of Managed Care System, pg. 4 http://www.managedcaremag.com/archiveMC/9903/9903.ethics.shtml 8. Korsch, Barbara M. & Harding, C. The Intelligent Patients Guide To the Doctor-Patient Relationship (Oxford University Press, 1998) pg. 90 9. LaPuma, John, M.D. Accountability in Managed Care: What Should We Expect from Patients?, pg. 2 http://www.managedcaremag.com/archiveMC/9603/MC9603.ethics.shtml 10. Thomasama, DC Edmund D. Pellegrino on the Future of Bioethics Cambridge Quarterly of Healthcare Ethics 1997; 6(4):373-5 11. Levinson W et al. Physician frustration in communicating with patients Med Care 1993 Apr;31(4):285-95 12. Korsch, Barbara M. & Harding, C. The Intelligent Patients Guide To the Doctor-Patient Relationship (Oxford University Press, 1998) pg. 20 13. Marvel KM et al. Soliciting the patient’s agenda: Have we improved? JAMA 1999;281:283-287 14. Suchman AL et al. A model of empathic communication in the medical interview JAMA 1997;277:678-682 15. Waitzkin H Doctor-Patient Communication JAMA 1984;252:2441-2446 16. Beckman HB et al. The doctor-patient relationship and malpractice: Lessons from plaintiff depositions. Arch Intern Med 1994 Jun 27;154(12):1365-70 17. Hahn SR et al. The difficult patient: prevalence, psychopathology, and functional impairment J Gen Intern Med 1996 Jan;11(1):1-8 18. Levinson W et al. Physician frustration in communicating with patients Med Care 1993 Apr;31(4):285-95 19. Walker EA et al. Predictors of physician frustration in the care of patients with rheumatological complaints Gen Hosp Psychiatry 1997 Sep;19(5):315-23 20. Korsch, Barbara M. & Harding, C. The Intelligent Patients Guide To the Doctor-Patient Relationship (Oxford University Press, 1998) pg. 38 21. Ibid. pg. 133 22. Rotter DL & Hall JA Doctors Talking with Patients / Patients Talking with Doctors (Auburn House, 1992), pg. 16 23. Meland Eivind Patient centered method and self directed behaviour change http:www.uib.no/isf/people/patient.htm 24. Lown, Bernard, M.D. The Lost Art of Healing (Houghton Mifflin Company, 1996), pg. 313 25. Marvel MK et al. Levels of physician involvement with psychosocial concerns of individual patients: a developmental model Fam Med 1993 May;25(5):337-42 26. Appleby C Getting doctors to listen to patients, pg. 3, Managed Care Magazine 27. Toombs, Kay, Ph.D. The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient, (Kluwer Academic Publishers, 1992) pg. 66 28. Amack LO Enhancing Physician-Patient Rapport, http://lawinfo.com/forum/physician-patient.html 29. Marvel KM et al. Soliciting the patient’s agenda: Have we improved? JAMA 1999;281:283-287 30. Korsch, Barbara, M. & Harding, C. The Intelligent Patients Guide To the Doctor-Patient Relationship (Oxford University Press, 1998) pg. 72 31. Boohaker EA et al. Patient notification and follow-up of abnormal test results: A physician survey Arch Intern Med 1996 Feb;156(3):327-31 32.Toombs, Kay, Ph.D., The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient, (Kluwer Academic Publishers, 1992) pg. 26 33. Rotter DL & Hall JA Doctors Talking with Patients / Patients Talking with Doctors (Auburn House, 1992), pg. 12 34. Lown, Bernard, M.D. The Lost Art of Healing (Houghton Mifflin Company, 1996), pg. 324 35. Daltroy LH Doctor-patient communication in rheumatological disorders Baillieres Clin Rheumatol 1993 Jun;7(2):221-39 36. infomedicine.com/comments.htm 37. Media Release from the University of British Columbia Public Affairs: Closing the doctor-patient communication gap, Nov 21, 1996 publicaffairs.ubc.ca/mr/mr96/mr-96.html 38. Lown, Bernard, M.D. The Lost Art of Healing (Houghton Mifflin Company, 1996), pg. 314 39. Ibid. pg. 315 40. Ibid. pg. 319 41. Ibid. pg. 320 |
|||
Although
in the past decade many medical schools have worked diligently
to teach doctors-in-training the importance of listening to
patients, it is nonetheless important for patients to acquire
their own, more assertive "bedside manner" to
equalize the power imbalance inherent in the doctor-patient
relationship. 
