Doctor-Patient Communication: Intimate Conversation Among Strangers
In polite society, where a certain level of reserve is expected among strangers, plain talk in a doctor’s office is scarce. Patients don’t know how to talk to doctors, and doctors don’t know how to make patients feel comfortable.
After all, the doctor-patient relationship is essentially intimate talk about a person’s body … among strangers. So it should come as no surprise that this whole thing is often awkward from the start.
In spite of decades of research and published papers on communication in the medical field, things haven’t improved much. A quick Google search reveals a litany of examples.
One patient posted an online review suggesting her doctor should be doing autopsies since he was unfit to communicate with the living. The physician, she said, comes in and fails to greet her or say hello. “He just points at you,” she wrote. “And then tells the staff what to do and leaves.”
But there are two sides to every relationship. And these doctors don’t get to make a public review of their patients.
What’s Causing the Tension?
While doctors may be accused of speaking in too much medical jargon, or as not being empathetic enough, or not listening, they also deal with a lengthy list of their own frustrations about how patients communicate.
These are four key contributing factors to blame for this complicated communication barrier. And the first step to resolution is acceptance. So, let’s accept these four truths:
- A patient’s fear.
Most of the time, when a patient comes across as obtuse, really, they are just scared, intimidated, or uncomfortable. A patient’s ability to communicate and fully understand and buy into a diagnosis is often compromised by anxiety, pain, and fear.
While the doctor is offering up tedious instructions on how to adjust or correct a health issue, a vulnerable person is sitting in front of them, panicked. This panic becomes confusion, and suddenly, they aren’t hearing a word the doctor is saying. The communication break-down happens here.
Focus groups set up by Palo Alto Medical Foundation’s Research Institute studied doctor-patient communication and determined that even well-educated patients feel intimidated in a physician’s office.
“In the context of a medical consultation, people feel uniquely vulnerable,” Dominick Frosch, PhD, says. Frosch is an associate investigator at the research institute. “Asserting their views might require disagreeing. Patients fear that will lead to negative consequences that might impact their care in the future.”
So what happens? Patients hold back. They already feel vulnerable and stupid. And, while it’s important for a physician to acknowledge and accept a patient’s anxiety, it’s equally as important to avoid type-casting a patient as an anxious person.
Australian oncologist and Fulbright scholar Ranjana Srivastava cites a common refrain she hears from patients: “I guess I’m just anxious.” It’s an apology that dismisses their own concerns. And when it happens, Srivastava uses it. She asks her patients to name what’s making them anxious.
“They will often venture a thoughtful explanation, which will give us something to work with,” she says.
2. Time is a paradox for the physician.
Relationships take time, and the medical community doesn’t allow for time. Overbooked schedules and waiting rooms that don’t empty easily undermine most communication tactics a physician might otherwise employ. Not to mention, billings.
“Doctors have one eye on the patient, and one eye on the clock,” David Rothman said in an interview with USA Today. Rothman studies the history of medicine at Columbia University’s College of Physicians and Surgeons.
Time is literally money and physicians, especially primary care physicians, feel pressure to keep the lights on. Even those who are naturally curious about their patients' lives and well being and find themselves easily engaged in conversation, inwardly flog themselves for taking too much time with each patient, falling behind schedule and gradually increasing wait times as the day goes on.
“Doctors are thinking, ‘I have to meet my bottom line, pay my overhead, pay my staff and keep my doors open. So it’s a hamster wheel, and they’re seeing more and more patients. And what ends up happening is the 15-minute visit,” said Dr. Reid Blackwelder, former president of the American Academy of Family Physicians. His medical practice is in Kingsport, Tennessee.
A University of South Carolina study found that resident primary care physicians and patients spoke, on average, 12 seconds before an interruption.
Common interruptions were a knock on the door, beeps and computer use. The time with patients averaged 11 minutes, with the patient speaking for about 4 minutes.
Even worse is the cause-and-effect these truncated doctor’s visits have on a physician’s degree of engagement. A medical paper published by Cancer Research UK Psychological Medicine Group cites the unwillingness among physicians to engage patients on an emotional level. And a lot of that unwillingness can be traced back to time constraints.
“(Doctors avoided) discussion of the emotional and social impact of patients’ problems because it distressed them when they could not handle these issues or they did not have the time to do so adequately. As a result, these avoidances often increased patient distress and resulted in an unwillingness by the patient to disclose problems, which adversely impacts recovery.”
3. Time is a paradox for the patient.
Once face-to-face with a physician, the patient has time. In some cases, plenty of time. But in the waiting room, the same patient is short on time and impatient. The longer the wait, the more entitlement a patient feels to get the most out of what took forever to gain access to.
My own grandmother used to walk into the doctor’s office with a list. She’d schedule the appointment for a straight-forward issue — like maybe a sinus infection — but she’d have a single, yellow sheet torn from a junior legal pad folded and tucked into her billfold ready to deploy. On the sheet, there were items totally unrelated to sinuses like, for example, the lack of effective treatment she was receiving for her arthritis. But remember, the appointment was for a sinus infection…
4. Communication impacts recovery.
Here’s the thing: Relationship and communication matter, even if no one has time for “feelings.” Not only does good communication between doctor and patient help regulate a patient’s emotions and aid in the comprehension of medical information, it also affects how a patient responds to treatment.
Those in the medical community may recognize this action-reaction as the “biology of self-confidence,” which is described by Dr. David Sobel in the medical paper, “Rethinking Medicine: Improving Health Outcomes with Cost-Effective Psychosocial Interventions.”
“Even in those patients with organic medical disorders, functional health status is strongly influenced by mood, coping skills, and social support, yet the predominant approach in medicine is to treat people with physical and chemical treatments that neglect the mental, emotional, and behavioral dimensions of illness,” Sobel writes.
It’s clear that if doctors do what’s needed to be considered a trusted ally, they can elevate patient confidence. And the studies and data cited in Sobel’s paper emphasize again and again that, “what goes on in a person’s head — the thoughts and emotions — can have a dramatic effect on the onset of some diseases, the course of many and the management of nearly all,” Sobel says.
Share in the Responsibility for Change
If the burden of effective communication is shared across all stakeholders — physician, patient, medical facility and administrators — the chance of improving the doctor-patient relationship surges. Plus, if the medical community can do more to create an environment of shared expectations, influencing patient behavior can be a secondary outcome of that effort.
“More and more studies point to simple, safe, and relatively inexpensive interventions that can dramatically improve health outcomes and reduce the need for more expensive medical treatments,” writes Sobel.“Far from a new miracle drug or medical technology, the treatment is simply the targeted use of educational, behavioral, and psychological interventions in a medical setting.”
So if the focus becomes less about a physician’s spoken communication and ability to build rapport during a doctor’s visit and more about propping up these visits with adequate education and shared expectations before and after those visits, then improving the doctor-patient relationship becomes manageable.
This is not a quick fix. It’s getting that first foothold in a long climb toward change. And the first footholds should be the practical, actionable tasks. Leave the culture-changing chores alone (learning empathy, ending the 15-minute doctor’s visit, and so on). Instead, it’s about small interventions.
Sobel says education through brochures, videos, classes, self-help groups, alongside individual counseling sessions are accompanied by strategies that increase confidence, reduce isolation, and encourage patients to play an active role in their own health care. Again, it’s sharing the burden.
For me, the doctor-patient relationship where many small interventions were at play was during maternity, childbirth and the early days of my son’s life. There were tons of brochures, information sheets, and packets throughout the process. Sure, I can Google stuff, just like everyone else. But the printed materials provided to me by my physician were endorsed by someone I knew.
Ultimately, I began to trust and buy in. And it wasn’t because my doctor developed a gentle bedside manner. It was because she had all these support pieces in place, a team. So soon enough, I began to believe she would not let me fail.
Along the journey, there were birthing classes, more handouts, lactation consultants on-site after labor and lactation consultants on the phone checking in after I returned home. This wasn’t a series of doctor’s visits but, instead, a process of interventions that complemented the care and communication my physician provided. Information was delivered over time through various mediums. It required a team of active participants.
This is important. Rapport grew overtime because the process from start to finish leveraged many avenues to offer communication and education. While I didn’t have a connection with my doctor early on, I didn’t feel isolated because I was engaging with many stakeholders. Ultimately, I began to trust and buy-in. And it wasn’t because my doctor developed a gentle bedside manner. It was because of her expertise and dedicated investment. She had all these support pieces in place, a team. So soon enough, I began to believe she would not let me fail.
Many of the educational and psychological interventions Sobel cites and I experienced are pretty actionable. Some are easy to implement and cost-effective. While intervention is a process with many mediums, the printed materials stand out for this reason: 65 percent of the general population are visual learners and only 30 percent are considered auditory learners.
In light of these numbers, it’s incredible to think about the verbal communication that dominates a doctor’s visit, especially given the biology and medical language necessary to explain the causes of symptoms or explanations of diagnoses.
Disconnecting As a Survival Tool
Emotional dissociation is not only common among medical students, it’s encouraged as a survival tool. Too much investment in patients can distract from the work itself.
“One way we cope is to become emotionally dissociated,” writes Dr. Lee Lipsenthal in his book, Finding Balance in a Medical Life. “It begins in anatomy lab. No one enjoys the smell of formaldehyde or confronting mortality. So we learn to shut off our emotions, keeping the ‘scientist’ mindset. Later, when managing an emergency, we’re taught to shut off our emotions and be as objective as we can be. We are told this will serve our patients best.”
Lipsenthal also believes conventional medical training exaggerates competitiveness, perfectionism, multitasking, unreasonably long hours and overwork at the expense of compassion, sensitivity, and social connection.
Yet empathy, which embodies compassion, sensitivity, and social connection, is a wonderful solvent for broken relationships, namely the doctor-patient relationship. According to Loran Nordgren, an associate professor at Northwestern University, empathy is the oil that keeps relationships flowing smoothly. “It creates bonds of trust, which result in higher-quality teamwork.” And some in the medical community believe empathy can be taught. Narrative Medicine, an educational program at Columbia University, helps “all those interested in the intersection between narrative and medicine improve the effectiveness of care by developing these skills with patients and colleagues.”
Another program known as Vitaltalk cites research that proves communication skills like empathy are learnable. The program's courses were created to teach clinicians to communicate effectively and in a style that allows patients to retain more information, improve trust and ensure a better quality of life.
While these programs are promising and Perhaps empathy can be taught, how long will it take for the culture to shift? How long before doctors become active listeners, time is less constrained and visits aren’t limited to 15 minutes?
In the meantime, there are opportunities for change that don’t require wholesale cultural shifts, like the interventions that reach a patient through multiple communication channels. As simplistic as it sounds, these small footholds are increasingly valuable when loftier goals prove slow and problematic. Whether such efforts would bear measurable change is unknown, but it’s one step toward a series of interventions that spreads the burden across stakeholders, envelopes the patient with support, and puts physicians in a better position to succeed.
