Why Can't My Doctor Hear What I'm Saying?
The snarky picture displayed above can be said to represent one type of doctor-patient relationship in our century. The patient comes in with a vague hint that something might be wrong with him, or the patient comes in having self-diagnosed. When that patient has already been diagnosed with a serious illness such as cancer, a doctor should be listening intently. But sometimes this dynamic does not play out well, and there are several reasons behind its failure. In addition, there are several things both doctor and patient can do to draw the trained doctor and the frightened patient into a more level relationship of person to person.
1. Interns are expected by both patients and themselves to function like experienced doctors:
Consider the new intern, well-trained in his prestigious medical school, but not at all sure how to draw blood on his first day with a real, living patient. His book knowledge has not transferred over into the realities of treating. Consider that conducting honest inquiry into the patient's social-emotional-spiritual-bodily functioning has not even been taught at the intern's medical school. One can picture such an intern speaking as the doctor in the picture above.
2. Traditional medical conduct involves "silent care."
Not engaging in personal conversations with the patient and limiting them to one-way requests for biological/physical symptomology permits the physician to act on the patient as if he were a superior version of a car mechanic. Denying that the patient is experiencing dread, fear of death, excruciating pain, or a diagnosis that cannot be made, puts the doctor in complete control. The patient wants to be seen as a "good patient", and fails to push for recognition of symptoms or conditions that are not being addressed.
4. Both doctors and patients are sensitive to feeling they have failed the other.
Take the patient who comes into his doctor complaining of "pins and needles in his toes." But the patient has brought in something more; he has come in with a specific narrative in mind to share with his physician. And where did that narrative originate? From his beliefs, fears, conversations with friends and family, and his culture. Let's say that this patient had been a cancer patient now in remission or adjudged cancer-free after surgery and chemotherapy.
Chemo can create neuropathy in the feet. So can diabetes. So can plantar fasciitis. So can badly fitting shoes or vascular issues. Or perhaps he was sitting too long at yesterday's meeting. The doctor can send his patient for a variety of tests, but what if he doesn't come up with a diagnosis? The doctor may feel that he has failed his patient, and the patient may feel that the doctor doesn't believe him.
Dr. Rob Lamberts has a perspective on this possibility:
"She looked at me, eyes pleading, telling me without needing to say a word: I am not lying to you. I am not crazy. I am not making this up.
I sighed. “We’ve done the work-up and know this is not your heart. I don’t think there are a lot more tests that can be run.” I studied her expression, trying to discern what she wanted to hear from me.
I’ve come to understand that there are two questions my patients are looking for me to answer:
- Is there anything serious?
- Can you make me feel better?
Doctors don’t seem to know this list, instead either focusing on a third question, What is wrong with me?, or failing to answer one of these two questions. I’ve heard countless tales of frustration over hours spent at the doctor’s office only to hear the final judgment of “nothing is wrong.” These doctors have answered question #1 without addressing #2, leaving the patient to feel like they aren’t believed by the doctor. In the best case, this is a well-minded doctor who simply doesn’t consider the patents’ perspective; in the worst case, the doctor questions the validity of the patient’s story."
As Dr. Julie Craig notes in her blog, "Embrace the narrative. Withhold judgment. Explore the story in all its complexities, contradictions, and outrageousness. Because therein lies the humanity".
5. Patients often feel that they have to present "interesting" symptoms to get their doctors invested in their care.
I recall going to my doctor after my cancer treatment ended and feeling reluctant to tell her that I felt tired, really bone-weary. Had I come with too vague a sort of symptoms? Did this warrant her valuable time being taken away from other, sicker patients? In other words, did I have the right to be sitting on the examining table?
If we had not reduced medical care to diagnostic codes, perhaps I wouldn't have had these concerns. What if there was no box she could check after she examined me? Would my insurance cover this visit?
6. Doctors and patients each have perspectives about the other that are never discussed.
A fascinating report by the Health Foundation in England summarized this phenomenon as follows:
Different perspectives most often are not discussed or unearthed during the brief time that clinician and patient interact. Perhaps patient has really come to discuss her desire to go out on disability due to her illness, but all she communicates is that after her treatment has ceased, she feels tired.
Another issue concerning differing perspectives hinges on whether the medical issue is a "tame" vs. a "wicked" problem. Treatment for common breast cancers are considered "tame." There are acceptable courses of treatments and probable outcomes. The situation is fairly static. A "wicked" medical problem is one "where there are multiple and often competing definitions of the problem itself and where any solutions are likely to have unknowable and possibly unintended consequences." http://www.health.org.uk/public/cms Many medical problems, and many serious conditions such as complex or late-stage cancers fit this definition.
The proposed solution to this and many of the factors retarding doctor-patient conversations might take on the structure mentioned by the Health Foundation.
7. Both patient and doctor need to clarify their respective perspectives at each meeting.
Is Dr. Smith going to suggest a mastectomy but Patient Jones knows in her heart she will doctor-shop until she finds one to perform a lumpectomy? Both of them need to be more forthcoming about the presumed courses of treatment, why they were selected, and what the patient's initial reaction might be to each.
If Patient Jones is presenting with a wicked medical situation, then Dr. Smith and Jones need to negotiate their positions so that both are satisfied to a rational point with the outcome.
There are times where Dr. Smith is faced with a novel medical situation Smith has no way to attack, and Jones is dissatisfied by what course of treatment is currently available. Such a truly wicked case requires that Dr. and Patient agree to co-evolve their approaches to the case as the situation clarifies and warrants.
We have a long way to go to correct the current state of doctor-patient conversation. But both parties can begin to alter the environment so that both achieve satisfaction of being heard.
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