Patient-doctor communications

The relationship between patient and doctor lies at the heart of the healthcare system. Understanding its dynamics requires looking closely at how the two parties communicate, what their assumptions are, and what they want. If the style, manner, or content of the conversation changes, the relationship itself will change. Assumptions about the proper role of the patient or of the doctor, about what is wholly appropriate, what lies on the edge, and what lies outside the relationship change over time.

It may even be that the term “patient” isn’t the right one to use here. A patient, the dictionary informs us, is a person who is under medical care or treatment. If a doctor diagnoses a person and then treats their condition, say, by prescribing medicine, monitoring their progress and making appropriate changes along the way, most everyone would agree that the person treated is a patient. But what if someone goes to the doctor for just a physical exam and then, without the doctor’s input, decides what steps they’ll take in light of the results? What if they treat their doctor as an authority for diagnosing problems, but as no more than an advisor for the treatment itself? What if they go to the doctor’s office just to pick up some educational materials about healthier eating or exercise? In these cases, the “patient” may be better described as a consumer, since they’re researching their options, weighing the results, and making their decisions without really being in the care of a physician.

These examples suggest that there is often a big gap between what consumers want and expect from healthcare and what physicians want from it. For example, suppose a consumer/patient hears or reads that she should receive better healthcare communication from her physician. What does she understand that to mean? And if her physician gets the same message – that patients should receive better communication from their physician –what does the physician understand that to mean?

These two ways of understanding could be so different, in fact, that they may seem to be looking at fundamentally different things. For example, the patient might expect that improved quality of communication would mean that their physician will:

• be more sensitive and empathetic to the patient’s needs and concerns
• provide just the right amount of patient-oriented informational or educational material at the time of the visit (with the “right amount” depending on the particular patient)
• enter the world of late twentieth-century communications by accommodating e-mail or the Internet as a means of communicating with the doctor’s office
• take steps to avoid making the patient feel rushed during an examination or appointment
• carry the conversation beyond statistics, probability, and clinical studies when the patient asks, “Why did this happen to me? Why did this happen now? How do I live with this?”

What all these expectations have in common is a concern for the manner or medium of communication, and not just the content itself. Of course, the content is important, but the way it is conveyed is often key to its successful reception. This can refer to tone of voice, timeliness of communication, appropriateness of the physical form of communication (brochure, internet site, article, book), body language, a willingness to speak person-to-person, or to impart wisdom rather than just information.

Meanwhile, the physician may think about better communication and come to the conclusion that better content lies at the heart of the matter. The patient must want more content, and especially content that is more reliable and authoritative. Therefore, a bibliography of the leading research in the field, or of medical books and literature, will satisfy the patient’s need for more information, and for more authoritative information.

The issue here seems almost like a problem of a relationship in which the two parties have drifted apart and aren’t really able to understand the other – like an old couple who have been married too long to get a divorce, but who have dealt with the other one too long to be able to hear anything new or noteworthy in what the other is saying.

There is an anthropologist-turned-marketing-expert, Clotaire Rapaille, who has written a number of things on culture and commerce, especially The Culture Code (Subtitle: An ingenious way to understand why people around the world live and buy as they do). He manages to combine anthropology and marketing as a way of understanding how the internal culture of a company or even an entire country can shape how they relate to the world. Rapaille takes pains to describes them in terms of a “Code” that seems to govern how they think about the world. He does this sort of analysis for organizations as well as for entire countries. For instance, he identifies the Code for health and wellness in America as Movement. By that he means that Americans see being on the move, being active, going to the gym, doing yoga, or even starting a book club, as things that are active, and are associated with being healthy precisely for that reason. For Americans, being active makes them feel they are alive and healthy.

In light of Rapaille’s work, it wouldn’t be out of line to see the Code for the doctor-patient relationship as “dysfunctional marriage.” After all, the relationship probably started off with fairly high expectations and the tacit acknowledgement that they would remain together in sickness and in health. Over time, however, it bogged down and lost the momentum and good intentions it started off with. In fact, what’s wrong with American healthcare, at least seen through the lens of the doctor-patient relationship, is precisely that it doesn’t seem particularly healthy because it’s fallen into a kind of stalemate, and that’s not an active thing.

Consider the following dialogue between a female character called “Patient” and a male character called “Doctor” in a kind of allegory of the doctor-patient relationship in the US (male and female for convenience only; it could just as easily be the other way around):

Patient: I ask for better communication and what do you do?

Doc: I gave you just what you asked for better communication. More articles, web sites, a bibliography, principles and guidelines for determining the value of what you find, whether on line, in the library, or anywhere else. Brochures with tips on healthy eating and suggestions for exercise. Is there something else that you wanted?

Patient: That’s not really what I wanted in the first place.

Doc: You don’t want better information?

Patient: That’s not what I said. Look, if it’s a question of whether I want better information or worse information, of course I want better information. Who wouldn’t? But that’s not what I asked for.

Doc: You wanted better communication. I gave you more information. I showed you the latest research. What did I miss?

Patient: That’s not what I wanted.

Doc: Ok, then, why don’t you say what you want?

Patient: You should know what I want.

Doc: How do I do that without asking you?

Patient: Do I always have to spell everything out for you? You’ve known me how long and you still don’t know what I want?

Doc: I know you want to be healthy. I know you want to stay in good shape. I know you want to eat right, get exercise. . .

Patient: Oh, for crying out loud. I’m talking about what I want from you, not from healthcare.

Doc. What’s the difference?

Patient: You’re a person, healthcare’s a thing. I need you to treat me like a person, not just a set of symptoms.

And so on …

We can see where this is going. The doctor is acting as if what the patient wants is more and better information, so that’s what he provides. (Actually, the doctor is trying to give the patient what he thinks she needs, but that’s another matter.) The patient doesn’t want that though, or doesn’t think she wants it. Instead, she says that the doctor isn’t listening to her, but she doesn’t say exactly what she wants. She may be discontented, yet not able to articulate her frustration. The doctor, for his part, may content himself that it’s not really a problem until it’s articulated – after all, how can he solve something he doesn’t know about and can’t identify?

One person who has a lot to say about communications in healthcare is Jerome Groopman, who has written such books as How doctors think; The measure of our days: a spiritual exploration of illness; and The anatomy of hope: how people prevail in the face of illness. Even Groopman, himself a doctor, admits that doctors can be very bad at answering such questions about meaning in a way that resonates with patients. Groopman notes in How doctors think that patients describing symptoms are interrupted by their doctors within 18 seconds, on average. Why is this? Maybe it’s because doctors are impatient and are trying to move the patient along. Or maybe it’s because they’re trying to think with the patient, trying to engage with the patient to show that they’re working together. Or maybe the doctors are trying to help their patients articulate something that’s difficult to put into words.

Whatever the case, one clear problem is precisely that there are unarticulated problems. Or rather, the problem is that it is difficult for the patient to articulate something and until this particular issue can be formulated and addressed, additional problems will follow. What are those problems? It depends on the particulars of the case, but there could any or all of the following: problems of non-compliance with the doctor’s program; loss of trust or faith in the physician by the patient; blind or uninformed attempts at addressing the problem by the physician; attempts to address the issue through complementary medicine by the patient (without telling the physician); and so on.

In part, this may be happening because the patient isn’t exactly sure what she wants, but she does knows she’s not getting something she feels she should be getting. She may be afraid to say what she wants, since it isn’t really information she’s seeking but rather a feeling – of assurance, of connection, of respect, of safety. What may be happening is that she doesn’t come out and say what she wants because she’s afraid – afraid that once she unburdens herself she will feel more unsettled, less connected, more disrespected, or less safe than before, and this inhibits her from voicing what she wants.

But perhaps in even larger part, the patient fears that what she wants she knows the physician can’t give. She wants answers to existential questions, like what did I do to deserve this? Or, I didn’t deserve this, why me? Or how do I (mentally) deal with this? Or, what does this mean?

As Jerome Groopman notes, when responding to the kind of “existential” question that patients want answered, “doctors usually frame their answers to such questions in language that forgoes any meaning for the individual. Whether cancer will return is a matter of statistical likelihoods derived from the study of large groups of patients – or, in lay terms, “bad luck.” There is no meaning in randomness, and for the patient no sense of control.”

The difference between how doctors and patients think about what’s going on has to do with the typical way they tell stories. Both doctors and patients tell stories about disease and illness. Their stories all have settings, heroes and villains, progress, setbacks, development, crisis, dénouement. The difference lies in who the heroes and the villains are, and whose story it is. For a lot of doctors, the main character is an antihero – the disease itself. The setting is the patient’s body. And the hero? Well… that could be the doctor, or it could be Medicine, or it could be the Team.

Patients often see things differently. First, they don’t see themselves primarily as a setting, a scene where the forces of illness and recovery do battle. They are living an actual life, their own story, and the illness needs to be incorporated into their own personal story. They want and in fact need to make sense of what’s happening to their life. They can’t view themselves as a bystander in their own story – they need to make sense of their own story so they can then influence it.

This is probably why a lot of people turn to complementary medicine – because for many people, complementary medicine provides meaning that they can’t get or can’t find by contemplating medical statistics. Perhaps it’s because they find meaning in energy flows that have been interrupted or blocked, or in a chronic misalignment of certain bones which if properly aligned can relieve pain and allow activity, or in a diet that contains too much red meat, fluorine, salt, or artificial compounds, and so on. Whatever the case, these are all causes that patients can easily make sense of and incorporate into their own story because they are causes that can be addressed and potentially overcome.

Doctors may see it very differently. For them, the important story may be that studies have shown that 0.17% of the population comes down with this condition and that, with a certain kind of medication, 64% of that population will be symptom-free after two years. These findings may be important for the patient to know, but they do not form a framework for meaning that patients can use to build their own stories. The 0.17% rate fits easily into the doctor’s story, but it needs to be interpreted to fit into the patient’s.

No individual sees himself as part of a percentage… he’s just himself. Physicians, on the other hand, live in a world of data and statistics. The challenge for the future of healthcare communications is this: how do we merge the patient need for “me-centered” care with the medical professional’s focus on probability and statistics?