Patient-Centered Communications

“Hey, Curmudge, everybody’s writing about the future of health care. Why don’t you take a daring leap and describe all-electronic diagnosis and plan of care? The technician will stick electrodes on the patient, push his arm through the bp cuff, and press a button. Then she will check the boxes on the diagnosis algorithm, send the data to a diagnosis reminder system like an advanced version of Isabel (1), and a Pyxis-like machine will eject the prepackaged meds needed to cure the patient. Amazing!”

“Please return to Planet Earth, Jaded Julie. Your plan totally excluded physicians. That’s not going to happen in my lifetime and probably won’t in yours. Let’s continue our discussion of the humanistic side of patient care. We’ve already talked about how nurses can make a difference and how patients can help themselves. Now let’s bring doctors into the discussion and focus on physician-patient communications.”

“Curmudge, we’ve both read Dr. Groopman’s book, How Doctors Think (2), so I presume it will be our principal resource. We don’t want our readers to think that our statements are the original thoughts of a fictional nurse and a semi-useless old man.”

“Thanks for the left-handed compliment, cher collègue; but if I must be semi-anything, I would prefer semi-useful. Anyway, unless otherwise indicated, quoted material will be from Groopman. To begin with, good communication with patients is not equally important for all physicians. It is vitally important for those in primary care, emergency medicine, pediatrics, internal medicine, and several other areas; but ‘the higher we go on the scale of specialist training, the less complex the medical problem becomes.’ So we’ll focus on communications by the docs who really need it—those involved in the initial encounter with the patient and who must make the initial diagnosis.”

“I’m disturbed, Curmudge, by the observation that, ‘on average, physicians interrupt patients within eighteen seconds of when they begin telling their story.’ These data contradict the advice that if you listen to the patient long enough, in most cases he will tell you the diagnosis.”

“It’s more than just listening, Julie. The physician needs to ask leading questions and respond to the patient’s emotions so that the patient feels free to participate in a dialogue. The questions and the way they are asked will ‘shape the patient’s answers and guide your thinking.’ ‘Once you remove yourself from the patient’s story, you are no longer truly a doctor.’ A physician gains these communication skills from years of experience and from remembering his/her misguided decisions.”

“Cultural differences must make communication even more difficult (3, 4). Imagine the gulf between a young, white, female doctor and an elderly man of color. Or consider reversing race, role, and gender. It’s even worse when the doctor and the patient don’t speak the same language and have to converse through an interpreter. Bridging these gaps will take conscious effort; ignoring them could lead to serious misunderstanding.”

“Regrettably, Julie, not all verbal communications are helpful. Some patients may be disingenuous when describing their symptoms in an attempt at obtaining drugs. In a physician’s encounter with an intoxicated or drug-influenced patient, he must discern whether it is the patient or the substance talking. On the other hand, the physician must be careful not to overlook a valid medical problem in an impaired patient.”

“Disin…what? Well I suppose that if a druggie needs a fix bad enough, he might be untruthful. So Curmudge, what’s the bottom line?”

“We’re not there yet; we’ll talk more about this next week. But here is our lesson for today: ‘You need information to get at the diagnosis, and the best way to get that information is by establishing rapport with the patient.’”

Affinity’s Kaizen Curmudgeon

(1) http://us.isabelhealthcare.com/info/components_and_emr.jsp
http://hollandhart.typepad.com/healthcare/2006/12/medical_clinica.html
(2) Groopman, Jerome. How Doctors Think. (Mariner, 2008)
(3) Lasser, K. E., et al. Discussions about preventive services: A qualitative study. http://www.medscape.com/viewarticle/586215_print_print
(4)Kane, L. R. Patient communications: Solving today’s hurdles. http://www.medscape.com/viewarticle/587906_print