Better communication leads to better care
■ What can physicians and patients do to improve the medical encounter?
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted Jan. 31, 2011.
An online group of patients and doctors decided that the most important resolutions doctors and patients can make is to communicate more openly.
Reply: New Year's resolution of a doctor: I resolve to feel less rushed and less know-it-all and really listen to the concerns of my patients.
New Year's resolution of a patient: Though I look to the doctor for help, I resolve not to be an inert object of the doctor's attention but to have self-confidence and speak firmly about my needs, desires and requests.
This time of year, we all come face to face with how difficult it can be to follow New Year's resolutions. This article examines how physicians and patients can resolve to communicate better -- a resolution they can work to achieve.
There is certainly room for a host of possible resolutions on the part of patient and doctor, all with the aim of improving the relationship to make it a therapeutic and healing one -- what medical care is all about. We learned from feedback to our separate Internet blogs on bioethics and patient privacy that one major deficiency in many physician-patient relationships is communication. That is why the example resolution of the doctor is to take time and listen.
If the patient is afraid to speak, however, the physician's resolution would be incomplete. That's why it is important that the patient make a complementary resolution "not to be an inert object of the doctor's attention but to have self-confidence and speak firmly about my needs, desires and requests."
The fictional dialogue is between a doctor and a patient of either gender in the doctor's office, across the desk before an examination and starts with the assumption that each knows the other's resolution. The bracketed expressions in italics represent the individual's unvoiced thoughts.
Doctor: Why don't you, as a patient, have any self-confidence?
Patient: Because this is your office, and it's an alien environment to me. I don't know what to expect, and you know exactly what's going to happen next. [I'd feel a lot more comfortable if this were a house call. You would be the visitor, and I would feel more in charge.]
Doctor: Why do you consider yourself an "inert object" in my eyes?
Patient: Because you appear more interested in me as a collection of symptomatic body parts than as a whole person with symptoms and feelings. [Can't you see me as a person rather than simply as an object?]
Doctor: [Come on, You know why you are here. Oops, sorry. I should follow up on my resolution.] Say more about that. Why do you think that I can't see you as a "whole person with feelings"?
Patient: I don't think it's a matter of "can't." I am sure you can. You just seem in a rush to get the job done. Maybe that's why you interrupt when I'm trying to tell you my many concerns.
Doctor: [It appears to you that I am in a rush?] Well, yes, I am in sort of a rush. You know there is a whole list of patients sitting out there waiting for me to finish so I can attend to them. What else would you have me do?
Patient: Encourage me to talk, ask questions, look me in the eye. [Sometimes it seems as though you are somewhere else entirely.]
Doctor: [I was looking in the patient's eyes, wasn't I? Or was I looking down at my notes?] So talk. I will listen.
Patient: At times I feel exposed and vulnerable, embarrassed even, particularly when examined -- it's called modesty. I know that you have to examine me, but that's how I feel. Don't you feel that way sometimes when you go to be examined by a doctor? Do you think I'm stupid to feel like that?
Doctor: [I suppose there are times when I get slightly uncomfortable, too, when I am a patient in a colleague's office.] No, not stupid. But why should you feel vulnerable here? We all behave professionally.
Patient: I don't know. [It's not about how you behave, it's about how I feel. I'm not saying my feelings make sense, but now I'm determined to state them.]
Doctor: [I never before had patients actually tell me that they are vulnerable and embarrassed. What's going on here? I'd better listen. This patient is probably not the only one who feels this way.] Tell me more. Most patients never tell me this.
Patient: Everybody knows that when you go to the doctor you have to take your clothes off. That doesn't make it any easier. I lose my self-confidence when my whole body is exposed, particularly when I think it's unnecessary or if an assistant joins or someone peeks into the room. I feel powerless to protect myself.
Doctor: [If I hadn't resolved to listen to this patient, I would never have been aware of how disturbed a patient could be about the physical exam. I do a dozen a day and never think twice about it.] How can I make you feel more comfortable?
Patient: [Lucky I made this resolution to speak up. The doctor appears to be really listening to me now.] It's OK with just you in the room. But make sure no one else comes in and the door remains closed. And I prefer to keep a sheet on me until you need to remove it.
Doctor: Well, it's time now for the exam. I can understand your concerns about being exposed during the exam. I will see to it that you have privacy in the exam room and remain covered until I am ready to examine you.
Patient: OK, let's get on with it.
Despite the fading of paternalism and the awakening of patient autonomy, there is a power imbalance between physicians and patients, with patients sensing their own weakness. This imbalance often leads to the patient's being afraid to speak up about important concerns that should be brought out and discussed. Thus, interpersonal communication is the key area in which doctors and patients should resolve to improve this year.
When they do speak up, patients often want to discuss a hidden concern that is either unthought-of or given minor importance by physicians as they proceed with their professional duties. That hidden concern, and the second one selected for this colloquy, is patient modesty, a matter we have learned much about from visitors to our Internet blogs.
To varying degrees (from minor annoyance to rejection of essential medical attention), modesty concerns virtually all patients who enter the medical care system. For the doctor to understand the degree of the patient's discomfort and its impact on what he or she considers to be appropriate medical care, there must be communication, conversation and understanding by both parties. That means that they must be willing to talk and also listen to each other, despite the doctor's limited time schedule or the patient's reticence about bringing up sensitive matters. And that's where the New Year's resolutions come in.
Some of the many components of patients' modesty can be mitigated easily; others cannot be changed in the short term. But whatever means we find to resolve these concerns, it is critical that medical professionals learn to encourage those patients who are willing to speak up and listen to those who do.
Furthermore, doctors ought to understand that the concerns of these patients require professional attention individually and through changes to the health care system. With regard to following up on those "resolutions," don't you think that simply speaking up and listening are challenges that most doctors and most patients can meet?
Maurice Bernstein, MD, associate clinical professor of medicine, Keck School of Medicine, University of Southern California; moderator, Bioethics Discussion Blog (link)
Doug Capra, co-moderator of a blog on patient modesty and privacy concerns (link)
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.