Doc Talk by Stuart Foxman
There is a lot of technology in the practise of medicine. Yet with all of the advances in tests and treatments, the most valuable tool at a doctor’s disposal remains the conversation.
Sounds fundamental. Still, internist and author Dr. Danielle Ofri suggests there’s often a great divide between the participants. Patients can sense an urgency to make their case. Doctors, feeling pressures of their own, might focus on the facts and miss the underlying message.
“The story the patient tells constitutes the primary data — and it’s really the only thing they have. It’s what they’re experiencing as part of the story of their life,” says Dr. Ofri. “Our issue is that we don’t see it as a story. We see it as chest pain or shortness of breath.”
Dr. Ofri, who works at Bellevue Hospital in New York City, has written six books about the art of medicine. She also has a Canadian connection, completing her undergraduate degree at McGill. In an interview with Dialogue, she talked about the pillars of the doctor-patient relationship.
It should centre around the human connection. Yet the framework of a doctor-patient encounter is telling.
“We’re there for the chief complaint, they’re there to tell a story. We’re speaking different languages,” says Dr. Ofri. “We’re socialized to organize data, and much is lost in that process.”
What can go wrong?
In her book, What Patients Say, What Doctors Hear, Dr. Ofri describes an encounter with a patient named Oumar (a pseudonym), age 43 with cardiomyopathy. He tended to call the clinic often, and show up without an appointment.
Oumar phoned one Thursday evening as Dr. Ofri was leaving. He wasn’t feeling well and wanted to see her. Dr. Ofri admits her reserve of patience was depleted. As Oumar had no specific symptoms, she told him to come Friday to urgent care. She explained that she’d be away.
Returning to work Monday, Dr. Ofri found an indignant voicemail from Oumar. He had come by Friday, but left when she wasn’t there. “I need to see you,” he said in the recording. For the next several days, Dr. Ofri and Oumar traded messages. If he was feeling sick, she said, come to urgent care. If not, make an appointment.
In his voicemails, Oumar just said he had to see Dr. Ofri, not acknowledging her messages. Finally, after a week, he dropped by the clinic. It was lunch hour. Dr. Ofri had five minutes to grab a bite. She was surprised to see Oumar, and irked. Did he have a free pass to be so demanding?
Oumar took a few steps, then collapsed. Dr. Ofri checked for a pulse. He was breathing rapidly, and his fingers were cold. She called for oxygen and a stretcher. On route to the ER, Dr. Ofri held Oumar’s hand. While he was hooked to an IV, she apologized for the week of miscommunication. He opened his eyes and nodded, too out of breath to talk.
Later, Dr. Ofri wondered if Oumar had been too exacting, and if she had been too stubborn. Perhaps the problem was even more basic.
“Maybe we just weren’t hearing each other,” she said. “For all of his pushiness, [he] was trying to say ‘help me’. Deep down, no doubt, he was terrified that his heart could give out. This informed his actions. Seen in this light, his relentlessness was understandable. His life hung in the balance. I could no longer hear what he was saying because I was busy reacting. I could not make the connection that the very annoyance of his behavior was a plea for help, a declaration of fear and vulnerability.”
That was Oumar’s story. And Dr. Ofri missed it.
Letting patients talk
Many things interfere with a productive conversation. Lack of awareness is one. Dr. Ofri cites research that shows not just the prevalence of miscommunication in medical visits, but a failure by both parties to even recognize this problem.
Other times, doctors cut off or redirect a conversation. How long would patients talk if they weren’t interrupted? Dr. Ofri asked colleagues. Some said 5 minutes, some 10 minutes, and others said the entire visit. She compares patient monologues to waiting for a bus or subway; it seems to take forever, but actually it’s quick.
Some Swiss researchers tested that idea. They asked doctors at a clinic to pose an initial question (like, “What can I help you with today?”), and then remain silent until the patient stopped talking. On average, patients talked for just 92 seconds.
Letting patients just talk is only part of the solution. To get on the same page, doctors can become co-narrators. That means cueing the patient with statements like, “Tell me more about…”, “What do you think about…” or “ Let me see if I’ve got this right…” Doing so draws out a story, builds rapport, and shows the patient that you’re listening.
“Our issue is that we don’t see it as a story. We see it as chest pain or shortness of breath.”
Genuine listening is critical. Dr. Ofri describes an experiment from the University of Victoria. Volunteers were paired off. In each pair, one person had to tell a detailed, dramatic and personal story. The other person had to simply listen. However, some of the listeners got an additional task. While they heard the stories, they either had to count in their head the number of official holidays in the year, or press a button every time the speaker used a word starting with “t”.
Here’s what happened. The listeners who counted holidays were preoccupied and had trouble paying attention. They made few gestures or expressions that showed they were following the threads of the story. In contrast, the other group had to listen intently to note the “t” words. But they, too, had a hard time tracking the conversation. Everyone listened, but they weren’t really hearing.
The real impact was on the speakers. Recognizing that the listeners were distracted, the speakers started to either run on or pause. Their stories became disjointed and a bit repetitive. The speakers were thrown off in particular by the “t” word counters, who seemed as if they were listening intently but who were disengaged.
“If we look like we’re listening but not actually listening, that bothers people. They can sense that,” says Dr. Ofri.
Curing and healing
Listening skills are critical for the sake of a patient’s storytelling. Especially when patients are working their way to reveal their underlying or unexpected agendas.
In another study, researchers interviewed patients before and after their doctor visits. For about one in six patients, the real reason for the visit had to be teased out. Why were some doctors better than others at getting at the crux of the issue?
It had nothing to do with the doctor’s age or experience, the gender of the doctor or patient, or even the amount of time the doctor gave to the patient. What mattered most? Doctors who spent a higher percentage of time listening found that their patients revealed more.
That shouldn’t be surprising. “Give the patient room,” says Dr. Ofri. She says doctors tend to focus on what’s “categorizable and solvable,” all of the things that check the boxes. That can be gratifying, but it lends itself to a more just-the-facts conversation than a deeper dialogue.
In one of her other books, What Doctors Feel, Dr. Ofri described the difference between curing and healing. It’s essential, she says, to understand the relative importance of both and achieve a balance. Curing is an outcome, and healing is a process — one that covers a patient’s physical, emotional and psychological state. Dr. Ofri suggests that patients get that instinctively, while some doctors can struggle with that concept.
Reflecting on her interactions with Oumar, she wrote, “the geometry of our conversation went awry as we pursued divergent dialogues.” In her irritation at what she felt was a difficult patient, she didn’t step into his shoes.
Oumar recovered. He had excess fluid drained from his lungs, and his pacemaker replaced. The next time he saw Dr. Ofri, they both felt relief. And she pledged to herself to pay more attention to how she spoke and listened.
“One of our biggest jobs is to bear witness,” says Dr. Ofri. “Let the patient tell their story. We may be the only person they tell that story to.”
Resources
- Getting Communications Right with Your Patients, College of Physicians and Surgeons of Ontario
- Good Practices Guide: Communication, The Canadian Medical Protective Association
- Successful Patient Interactions, Saegis
- Brown, J.B., Ryan, B.L., & Thorpe, C. (2016). Processes of patient-centred care in Family Health Teams: a qualitative study. CMAJ Open, 4(2), E271-E276.
- Stewart, M., Ryan, B.L., & Bodea, C. (2011). Is patient-centred care associated with lower diagnostic costs? Healthcare Policy, 6(4), 27-31.
- McMaster Health Forum, October 2016: Enhancing access to patient-centred primary care in Ontario
- The College of Family Physicians of Canada, October 2014: Patient-centred care in a patient’s medical home
