Doctor-Patient Communication
Professionals often must establish relationships with and elicit personal information from their clients. The latter may be uncomfortable for the client for at least two reasons. First, the professional is essentially a stranger to the client. Second, in some professions, such as accounting and law, clients must reveal sensitive information to the professional.
Doctors must also establish relationships with and elicit personal information from clients (i.e., patients). Only in medicine, however, must the practitioner also obtain information about the client’s most personal space— his or her own body. This task is made more difficult by the fact that medical practitioners often have to obtain this information under stressful, painful, or even life-threatening circumstances.
Establishing effective communication between doctor and patient is the first step in establishing the essential alliance that will allow the doctor to help the patient. This step is affected by many factors. For example, a patient’s earlier experiences with medical care can affect how he or she responds to the doctor. A doctor’s unconscious countertransference reactions based on past relationships can affect how he or she relates to the patient (see Chapter 8). Other factors that affect the doctor-patient relationship include the patient’s physical and mental condition, personality style and coping mechanisms (see later text), use of defense mechanisms (see Chapter 8), and cultural belief system (see Chapter 18).
Establishing an effective interaction with a patient can take time, but it is well worth the effort. Increased patient satisfaction with the physician and adherence with medical advice, as well as decreased patient complaints and malpractice claims (see Chapter 26) are closely related to the quality of the doctor-patient relationship (Tamblyn et al., 2007).
• GETTING INFORMATION FROM PATIENTS
The clinical interview is the most important tool a physician has for obtaining information about a patient. An effective interview starts with establishing trust in and rapport with the patient. Doing this involves maximizing the physical placement of the doctor and patient to facilitate effective and safe interaction (e.g., staying at eye level with the patient and avoiding desks and tables) (Fig. 24-1) and then gathering the physical, psychological, and social information needed to identify the patient’s problem.
The clinical interview
The clinical interview is used to obtain the patient’s medical and psychiatric history (see Table 10-3) and to gather other relevant information. The two major categories of questions used in the clinical interview are open-ended
and direct. Open-ended questions are unstructured, do not close off potential areas of pertinent information, and allow for a variety of responses. These questions are used in the interview to facilitate conversation and obtain information. Direct questions are those that can be answered with “yes,” “no,” or a few simple words. They are used to clarify the information obtained from open-ended questions. For example, an open-ended question such as “Describe the pain” is used to get an overview of the patient’s distress. “Does the pain wake you at night?” is a direct question about a specific area of interest.
and direct. Open-ended questions are unstructured, do not close off potential areas of pertinent information, and allow for a variety of responses. These questions are used in the interview to facilitate conversation and obtain information. Direct questions are those that can be answered with “yes,” “no,” or a few simple words. They are used to clarify the information obtained from open-ended questions. For example, an open-ended question such as “Describe the pain” is used to get an overview of the patient’s distress. “Does the pain wake you at night?” is a direct question about a specific area of interest.
 FIGURE 24-1. Seating of the participants during clinical interactions. A. Physician and patient interact in the office. Note that there is no desk or other obstacle between the participants and that the doctor and patient are at the same eye level. B. Physician, patient, and relatives of the patient interact in the patient’s hospital room. Note that the three participants sit in a triangular fashion, with the doctor to one side of the patient’s bed and the relative to the same side so that the bed is not an obstacle between any two individuals. C. Physician and potentially violent patient in the office. Note that there is no obstacle between the physician and patient, and that both participants have clear access to the door. D. Physician and patient’s family in the hospital waiting room. Note that the participants, including the doctor, sit in a circle. |
Direct questions are also used to elicit information quickly in an emergency or when a patient has a cognitive disorder (see Chapter 18). This type of question may also be preferred when a patient is sexually provocative toward the doctor or overly talkative. Whatever the situation, doctors should avoid using leading questions that suggest an answer, such as, “You really feel better, don’t you?”
Specific strategies and techniques, such as support, empathy, validation, facilitation, reflection, silence, confrontation, and recapitulation, that are used in interviewing patients are described in Case 24-1.
Defense mechanisms in illness
People unconsciously use defense mechanisms to protect themselves from realities that cause conflict and anxiety (see Chapter 8). The need for such protection is intensified by illness. Unfortunately, a patient’s use of defense mechanisms can act as a barrier to the physician in obtaining information and in gaining patient adherence.
Two of the most common defense mechanisms used by people when they are ill are denial and regression (see Table 8-2). In denial, a patient unconsciously refuses to admit to being ill or to acknowledge the severity of the illness. Use of this defense mechanism can be helpful initially because it can protect the individual from the physical and
emotional consequences of intense fear. However, denial can be destructive in the long term if it hinders the patient from seeking treatment. For example, if a patient in the initial stages of a myocardial infarction attributes his severe chest pain to a minor problem like indigestion, his physiological fear responses (e.g., increased heart rate and blood pressure) will be attenuated. However, if the patient persists in this denial and fails to seek treatment, he increases his risk of dying.
emotional consequences of intense fear. However, denial can be destructive in the long term if it hinders the patient from seeking treatment. For example, if a patient in the initial stages of a myocardial infarction attributes his severe chest pain to a minor problem like indigestion, his physiological fear responses (e.g., increased heart rate and blood pressure) will be attenuated. However, if the patient persists in this denial and fails to seek treatment, he increases his risk of dying.
case 24.1
THE PATIENT
Ms. Gardner, an 80-year-old nursing home patient, is brought to the hospital after a fall. The emergency room physician introduces himself to the patient by saying, “Ms. Gardner, I am Dr. Smith.” He then outlines what he will do: “I am going to ask you a few questions now, and then I will examine you.” Dr. Smith then pulls a chair up to the bed and sits down. As he begins to talk to her, Dr. Smith notes that Ms. Gardner is oriented and alert, but seems suspicious and agitated. She also appears to be in pain. Dr. Smith asks, “Ms. Gardner, how are you feeling?” The patient says that she is “fine” and then starts crying.
COMMENT
Dr. Smith correctly addresses the patient by her family name and sits at eye level with her during the interview. Although the patient says she is “fine,” her behavior suggests that she is not. Before confronting this discrepancy, however, the doctor must establish a relationship with this patient. Although this situation is an emergency, the doctor can express interest and concern for the patient using support and empathy and give credence to her feelings using validation. For example, to show support and empathy, he can say, “That fall must have been a frightening experience for you.” He can use validation to confirm to the patient that her feelings are normal and to be expected under the circumstances by stating, “Many people would feel scared if they had been injured as you were.”
Once a relationship has been established, the doctor can maximize information gathering by encouraging the patient to elaborate on her responses using interview techniques such as facilitation and reflection. An example of facilitation would be a simple statement such as, “Tell me more.” Reflection entails using what the patient has just said to encourage her to continue talking, such as asking, “You said that your pain increased during the ambulance trip?” Both techniques can increase the flow of information from the patient. Silence is the most powerful interview technique for obtaining information from patients. Therefore, when this patient begins to cry, the physician should remain attentive and concerned but should not speak. This use of silence allows the patient to gather her thoughts and composure so that the conversation can continue. Effective use of silence requires practice on the part of the physician. It is a natural human response to try to make a person feel better when he or she shows evidence of sadness. However, statements such as “Everything will be okay” or “Don’t worry,” which are used in ordinary conversation, are not usually appropriate in a doctor-patient interview because they stop the flow of information from the patient. These comments also may not be true and can be interpreted as patronizing.
MANAGEMENT
Before treating Ms. Gardner, Dr. Smith must clarify the information he has received from her. Information can be clarified by calling the patient’s attention to inconsistencies in her responses or body language using confrontation and by summarizing the information obtained during the interview using recapitulation. However, the doctor should be careful not to judge a patient who is not forthcoming. In confrontation, the doctor might say, “Ms. Gardner, you say that you feel fine but you seem to be in pain.” A statement such as this allows the patient to confirm or correct the doctor’s observation. The final step in an interview is for the doctor to use recapitulation to summarize what the patient has said. For example, the doctor can say, “Let’s go over what happened this morning. You fell in the shower and hurt your leg. When you realized that you could not move it, the emergency squad was called. The paramedics then brought you to the hospital where I met you. Have I gotten it right?” This gives the patient the opportunity to either confirm the doctor’s comprehension or correct his misunderstanding of the story.
In regression, the ill patient reverts to a more childlike pattern of behavior that may involve a desire for more attention and time from the physician. This response can make it more difficult for the physician to interact with and treat the patient effectively.
Interviewing children and adolescents
Like adults, children and adolescents respond best during a clinical interview when they feel comfortable with the doctor. In contrast, the type of
questions most effective in interviews with adults may not be appropriate for children. For example, young children may have difficulty responding to open-ended questions. A 6-year-old child may not know how to respond to a question such as “Tell me about yourself,” but she may be able to answer a specific and direct question such as, “What grade are you in?” Other children may not respond well even to direct questions. Methods of obtaining information from children (if they are old enough to understand) include asking the child to draw a picture (e.g., “Can you draw a picture of yourself?”) and asking questions in the third person (e.g., “Why do you think the little boy in the picture looks sad?”) Getting the child to use his imagination can be fun for the child and can provide information for the doctor (e.g., “Let’s pretend that you have two wishes. What would they be?”) Gaining parental permission to speak to teachers and babysitters can also be helpful in getting information about a child.
questions most effective in interviews with adults may not be appropriate for children. For example, young children may have difficulty responding to open-ended questions. A 6-year-old child may not know how to respond to a question such as “Tell me about yourself,” but she may be able to answer a specific and direct question such as, “What grade are you in?” Other children may not respond well even to direct questions. Methods of obtaining information from children (if they are old enough to understand) include asking the child to draw a picture (e.g., “Can you draw a picture of yourself?”) and asking questions in the third person (e.g., “Why do you think the little boy in the picture looks sad?”) Getting the child to use his imagination can be fun for the child and can provide information for the doctor (e.g., “Let’s pretend that you have two wishes. What would they be?”) Gaining parental permission to speak to teachers and babysitters can also be helpful in getting information about a child.
Typically, adolescents worry about appearance, sexual orientation, sexually transmitted diseases, and substance abuse, concerns they may find difficult to discuss with their parents. Often, all that is required of the doctor is that she be nonjudgmental and able to reassure the adolescent that his or her thoughts are normal and common in people in this age group. With the exception of certain breaches of confidentiality (see Chapter 26), it is also appropriate for the doctor to reassure the patient that such information will not be shared with his or her parents. Parents usually understand this need for privacy.
case 24.2
THE PATIENT
During his regular office visit, a 54-year-old male patient who has been taking propranolol (Inderal) for hypertension for the past 6 months says to the doctor, “Could you please tell me again the side effects of the medication I am taking for my blood pressure?” The patient then stops speaking.
COMMENT
Some antihypertensives cause sexual difficulties, such as erectile dysfunction (see Table 21-4). This patient is most likely to be uncomfortable mentioning his sexual problems. The doctor should raise the issue with a statement such as, “Sexual side effects are common with antihypertensive medication. Please tell me about the effects you have been experiencing.” The doctor should not simply repeat the known side effects or tell the patient that the side effects are not medically significant.
MANAGEMENT
If the doctor determines that this patient is experiencing sexual dysfunction because of the antihypertensive medication, she can recommend switching to a medication with fewer sexual side effects. Among the antihypertensives, angiotensin converting enzyme (ACE) inhibitors (e.g., captopril) are less likely than β-blockers (e.g., propranolol), to have sexual side effects (see Chapter 21).
• GIVING INFORMATION TO PATIENTS
Patients are understandably reticent to ask questions about issues that are potentially embarrassing, such as sexual problems, or potentially fear provoking, such as laboratory test results. A doctor should anticipate such unspoken questions, verbalize them, and then answer them truthfully and completely.
Giving information to adult patients
In the United States, it is customary for adult patients to be told the complete truth about the diagnosis and prognosis of their illness. For example, if a dying patient asks the doctor how long he has to live, the doctor should answer truthfully. An accurate statement such as, “I do not know for sure, but most people at this stage of the illness usually live from 1 to 3 months,” is an appropriate response. A falsely reassuring response to this patient’s question (e.g., “Do not worry, we will take good care of you”) is paternalistic (Kaba & Sooriakumaran, 2007) and not appropriate. The doctor should also avoid philosophical or religious statements that could be interpreted as patronizing (e.g., “No matter how long you live, you have had a very productive life”). Table 24-1 provides a six-step strategy for giving bad news to patients (Baile et al., 2000).
In some cultural groups, adult children protect elderly relatives from negative medical diagnoses and make medical decisions about their care (see Chapter 20). Nevertheless, in the United States, information about a competent patient’s illness should be given directly to the patient and
not relayed through relatives. With the patient’s permission, the physician can tell relatives this information in conjunction with or after telling the patient, especially because relieving the fears of close relatives can bolster the patient’s support system.
not relayed through relatives. With the patient’s permission, the physician can tell relatives this information in conjunction with or after telling the patient, especially because relieving the fears of close relatives can bolster the patient’s support system.
table 24.1 SPIKES: A SIX-STEP PROTOCOL FOR GIVING PATIENTS BAD NEWS | ||||||||||
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