Tell the Doctor All Your Problems, but Keep It to Less Than a Minute

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Tell the Doctor All Your Problems, but Keep It to Less Than a Minute

By MEREDITH LEVINE

Published: June 1, 2004

woman walks into a doctor's office. The doctor says, " What brings you here

today? " The woman starts to answer. Eighteen seconds later, the doctor

interrupts.

This may sound like the setup to a lame joke but it is a scene played out

regularly in doctors' offices across the country. Two decades ago, in 1984,

researchers showed that on average, patients were interrupted 18 seconds

into explaining their problems. Fewer than 2 percent got to finish their

explanations.

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But at the time, the office or bedside manner of doctors was considered

unworthy of research.

" We were thought of as weirdos, " said Dr. Beckman, co-author of the

study and a clinical professor of medicine at the University of Rochester.

Today, however, the rise of managed care has helped make doctor-patient

communication a major issue that is drawing increasing interest from

researchers.

Researchers have linked poor communication to misdiagnoses, the ordering of

unnecessary tests, and the failure of patients to follow treatment plans.

" When communication doesn't work and patients have good outcomes, it's by

chance, " said Dr. Sherrie H. Kaplan, an associate dean in the college of

medicine at the University of California, Irvine, and a leading researcher

in the field.

Just how often does communication between doctors and patients run amok?

Research shows that only 15 percent of patients fully understand what their

doctors tell them, and that 50 percent leave their doctors' offices

uncertain of what they are supposed to do to take care of themselves.

Studies suggest that women are better at building relationships with their

doctors than men. The typical number of questions a male patient asks during

a 15-minute doctor's visit is zero, while women average six, according to a

study by Dr. Kaplan.

Doctors as well as patients may suffer the consequences of communication

gone awry. A common theme of malpractice lawsuits is a breakdown in

communication, said Dr. Levinson, vice chairwoman of the University of

Toronto's department of medicine. What often prompts people to sue their

doctors, said Dr. Levinson, who has studied the issue extensively, " is the

feeling that they were not listened to, that they didn't have the doctor's

full attention. "

In one study, Dr. Levinson and Dr. Nalini Ambady, a psychologist at Harvard,

compared the office manner of surgeons who had been sued multiple times with

those who had never been sued. Doctors with " a more dominant tone of voice, "

they found, were more likely to have been sued by patients. Doctors whose

voices contained more warmth were less likely to have been sued.

In many instances, the lawsuits have little to do with physical harm to the

patient, the researchers said, and much to do with the relationship between

doctor and patient. Patients who sue often feel abandoned by their doctors.

Advice by experts on how doctors can most effectively communicate with

patients reads as if it came straight out of a relationship self-help book:

Listen carefully, ask open-ended questions, do not interrupt, make eye

contact and indicate that you care.

Good doctors, communication experts say, do not pepper patients with

questions; patients, studies find, do not like that.

A doctor's medical competence is of course important. And patients sometimes

stick with doctors they feel are cold or uncommunicative in the belief that

a physician's technical and diagnostic skills are more important than

bedside manner. But, Dr. Levinson said, competence and communication are

equally important.

" We should consider excellence a combination of the most technically

sophisticated skills and knowledge and the best communication skills, " she

said, " because that will get us the best outcomes from our patients. "

Research has shown that there is a clear connection between positive

doctor-patient relationships and improvements in the patients' health.

In several studies, Dr. Kaplan and her husband, Dr. Sheldon Greenfield, also

of the University of California at Irvine, found that good doctor-patient

communication resulted in lower blood sugar levels in diabetic patients, and

lower blood pressure in hypertensive patients.

Other research has demonstrated a connection between positive

patient-physician encounters and the reduction of pain in cancer patients;

improved emotional and physical health in people with a variety of

illnesses; reduced stress and anxiety; and a higher degree of adherence to

prescribed treatments.

The message, experts say, is that if patients believe they are in a good

relationship with their doctors, there is a strong chance their health will

benefit. Research indicates that this holds true even in countries like

Japan, with distinctly different cultural norms involving communication and

relationships.

It is a link that has not gone unnoticed by medical schools. Most have

introduced some form of communication training. So have the institutions

that run the continuing medical education courses required for doctors to

renew their licenses.

Even health maintenance organizations, recognizing that doctors who are good

communicators improve the bottom line (their patients generally stick with

the health insurance plan and do not doctor shop), have begun investing

significant resources into training doctors to be better communicators.

But the question of how successful these training initiatives have been is

another matter. The answer is that, so far at least, they do not appear to

have significantly improved the relationship.

In 1999 Dr. Beckman and his colleagues published a follow-up to his original

study in The Journal of the American Medical Association. Patients, they

found, were no longer interrupted, on average, at 18 seconds. Instead, it

took 23 seconds for the doctor to interrupt.

For a number of reasons, adapting school lessons to real-life medical

encounters often fails.

One continuing problem is that communication training at most medical

schools is limited to the first two years, when students are still largely

bound to the classroom and have yet to gain real clinical experience. When

the students do get into hospital wards, " their main peer models are

residents who often work very long hours under a lot of pressure and for

whom their first priority is probably not communication but learning how to

run a code so you can resuscitate a patient, " said Dr. Kravitz,

director of the University of California, , Center for Health Services

Research.

Even for experienced doctors, the workplace environment at many health care

institutions can thwart the most gallant intentions. " People are generous

when they are treated generously, " Dr. Beckman said. " In the medical

workplace, everyone is waiting to get yelled at. "

Dr. Robin DiMatteo, a professor of psychology at the University of

California, Riverside, who studies doctor-patient relationships, added that

in organizations where doctors were unhappy, " They tend to have more

problematic communication with their patients. "

Besides, in a situation where one partner denies that a problem exists and

the other does not want to talk about it, the relationship is not likely to

change.

" Most doctors think they do a good job of communicating, " Dr. Kravitz said.

" The mechanisms for feedback aren't great and patients are often the last to

tell. "

Even among doctors who do recognize that they ought to invest more in

forming good relationships with their patients, resistance is common,

usually because the doctors are concerned about adding to their already

considerable time constraints.

Dr. Levinson's research, however, indicates that allowing patients the time

to talk can lead to shorter appointments. When patient complaints are

ignored, or their expression is interrupted, there is an increased

likelihood that they will re-emerge, " just when the visit's ending, " she

said.

Yet the biggest hindrance to change may be that most training programs focus

on changing doctors' behavior, even though it takes two to make a

relationship. Studies suggest that the more equal the relationship between

doctor and patient is, the more likely it will translate into health

benefits.

But when the patient is passive, there is an increased likelihood of poor

recovery. Dr. Kaplan believes that patient passivity " should be treated as a

risk factor in chronic disease. " She advocates remedial programs that will

provide patients with the skills to ask questions and interpret the answers.

Convincing patients of the benefits of working on the relationship may prove

easier than convincing doctors, Dr. Levinson said. " If I go to a cocktail

party and tell doctors that I work on doctor-patient communication, they

kind of move onto the next conversation, " she said. " But if I say this to

the patients there, they all have a story to tell me. "