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Another look at talking with doctors.

June 6, 2012

In my post last week, Why is it so hard to talk to doctors?, I tried to capture the essence of the experience I and others I know have had.  I feel like I was partially successful, but I wasn’t able to adequately convey everything I wanted to. I’m going to give it another shot and see if I can get closer to my experience and feelings.

In the last post, I talked about problems in the system that interfere with doctor-patient communication.  Today I think I’ll focus more on the actual relationship between doctor and patient and how the doctor’s ability to connect with another human being impacts the conversation.  One thing I don’t think the general public realizes is that doctors are not normal people for the most part.  I don’t mean they don’t have the same problems we do or that they are alien in some way.  What I mean is they have different priorities in life than average people.  Most people offered a choice of pursuing a profession that requires 7 to 15 years of post graduate education, with a punishing level of competition and work demands far in excess of what most consider reasonable OR a profession that requires somewhat less time in school with less cutthroat competition and a work load that allows time to be with family and pursue other interests would pick the latter.  You have to be an extremely ambitious, focused person to even be attracted to the field of medicine.  Often these characteristics come at the expense of communication skills.  As one nurse I knew put it, “Doctors are nerds.”  I don’t want that to be taken in the pejorative sense.  Think of someone so wrapped up in study that they didn’t interact with others enough to gain normal conversation skills, someone who was sheltered in academia for 11 to 15 or more years before entering the workforce independently.

Communication requires people listen to each other.  Therapeutic communication requires even more from the listener.  We have to school ourselves not to interrupt, to actually listen to what is being said rather than racing ahead in our minds to what we are going to say next or what we think the patient is going to say next.  It is a challenging skill that requires much practice.  Doctors have been run through a mill that forces them to think and spit out answers as quickly as possible, often in competition with their fellow students.  In everyday practice, this spitting out answers as quickly as possible cuts off the communication with the patient.  Also, patients may not be able to articulate what is going on with them in a concise way.  They know something is wrong and they have some symptoms troubling them, but they may not prioritize them the same way a medical professional might.  We can’t expect patients who have not had medical training to understand what’s going on well enough to present their problems in the orderly fashion the teachers in med school did.

I believe there is also an aspect of differences in communication style between men and women.  (This applies to the women in my audience, sorry guys.)  See this article on curiosity.com for a more detailed discussion.  Men tend to be problem oriented and are all about fixing it.  Women tend to discuss things in a broader way and may feel a need to include more detail and nuance.  Women also tend to express emotions more freely than men.  Up until recently, the vast majority of doctors were men.  Also men are more numerous in certain specialties, such as surgery.  I have often had conversations with male doctors who become impatient and refuse to listen to what I consider to be important details, both professionally and as a patient.

Relating all this to my experience, there were problems in my communication with my first cardiologist.  I kept returning to the office with worsening symptoms of chest pain and fatigue.  He would say I was on “maximal medical management,” make a minor med change if I insisted, and tell me to come back in 6 months.  My average time between visits was less than 3 months because of hospitalizations or making appointments early because of worsening symptoms.  That phrase “maximal medical management” tended to shut down conversation and caused me to put up with symptoms that were quite incapacitating longer than I should have.  There were always different courses we could follow for medications, I think he just didn’t believe it would make a difference or he truly did not understand the impact of my symptoms on every aspect of my life.  How could he when he didn’t ask and didn’t allow me to explain?  When I would start to say I had been having chest pain, he would interrupt before I finished the sentence, “You’re having angina?”  Then he would look concerned but ask almost no questions about when it was occurring, what was the quality of the pain, other associated symptoms, how frequent were episodes, how much nitroglycerin was I using?  He never explored fatigue even though this symptom was (and is) quite severe.

Another big problem is the “one symptom only” office visit.  Rarely do people only have one thing wrong, yet often they are told they can only talk about one problem at a visit.  This is driven by reimbursement (or lack thereof).  This requirement is quite deleterious to the doctor-patient experience, causing great frustrations on both sides.  Sometimes patients just don’t go to the doctor because they feel they can’t get help.  Sometimes doctors leave their practice to start seeing patients cash only in a “boutique practice” where they can actually get to know their patients and treat them appropriately without insurance companies hanging over their shoulders dictating treatment.  Unfortunately most patients cannot afford to see a doctor in this type of practice.

I’m sure these problems occur daily in hundreds (or thousands) of doctors’ offices.  So often at the doctor, people do not get help for what is bothering them most.  Even as an experienced health care provider, I had this experience.  What is happening to people who have little medical knowledge?

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