What Patients Say What Doctors Hear
Author: Danielle Ofri
This book is a detailed inquiry into that most important foundation of medical practice, the doctor-patient interaction. It investigates the architecture of this fundamental but fragile relationship, scrutinising the delicate factors that may strengthen or weaken the bonds between physician and patient. The author paints the picture of a very complex partnership made up of ‘many layers of emotion, frustration, logistics, and desperation‘, with each party bringing to it their own ‘biases, history, strengths, and liabilities‘. She shows how healer and sufferer, using their knowledge, experience, and understanding, try to negotiate the uncharted territory between them, the patients trying to tell their stories, and the doctors ‘scoping out a chief complaint‘ (pages 6 and 17). With illustrative personal anecdotes and excellent research work, the book explores why ‘the story the patient tells and the story the doctor hears are often not the same thing’. It also prescribes what physicians can do to nurture the critical interactions they have with their patients (page 23).
The book is based on the correct premises that communication is ‘the single most important diagnostic tool in medicine’, and ‘the single most important tool of medical care‘. It also argues that patients understand the importance of establishing good rapport with their doctors, and they usually go out of their way to make a successful connection with their physician (pages 14, 17, and 221). It is on these assumptions that the author lays the responsibility for establishing and sustaining effective communications heavily on the physician (page 6). The author emphasises this when she pointed out that good patient-doctor interactions depend on key physician behaviours such as attentive listening, frequently asking the patient’s opinion, using a warm tone of voice, and employing humour and laughter (pages 15-16 and 133-134).
The author dedicated a major part of the book to uncovering why the patient-doctor interaction often breaks down, when both sides want it to work well. Of the many elements that impair communication, she particularly highlights the role played by time pressure in pushing doctors to shorten their consultations, often cutting-off their patients shortly after they start speaking (pages 17 and 24). The negative physician behaviours also exert detrimental influences on the conversations they have with their patients, and these include ineffective listening styles, poor delivery of information, misunderstanding the patients perspectives, and adhering to the traditional doctor-patient boundaries and roles (pages 113-132 and 67). Doctors’ reliance on ‘the swankiest of medical technologies‘ also impairs the quality of their conversations by undermining the ‘deference and attention‘ that they would otherwise have given it (page 221). Other factors that impair the patient-doctor interaction however go much deeper than the individual doctor, and the author reviews these systemic matters when she explored how ‘our current setup in medicine seems designed to thwart good communication’ (page 220).
A major theme of the book is the overriding importance of getting the doctor-physician conversation right, and perhaps the most critical in this regard is its indispensability in making accurate diagnoses. The benefits however go much further, and the author demonstrated this with several examples such as how a good rapport succeeds in unearthing the ‘unexpected agendas‘ that often threaten the medical consultation (pages 5 and 157-158). The book also emphasises the imperative of effective communication in ensuring adherence to treatment. Citing linguistics researcher Heidi Hamilton, she argued for communication styles that take into consideration the patient’s personal and psychosocial circumstances; she said these are much better than the traditional data recitation and emotional persuasion in making patients conform to treatment (pages 58-59). The author discussed many other benefits of skilful communication, such as the therapeutic value of just letting the patient speak, and the placebo effect of conversations on symptoms such as pain and anxiety (pages 27 and 72-80).
The most practical messages of the book are the helpful recommendations the author makes on improving communication with patients. Perhaps the most important advice she offered doctors is to listen to their patients uninterrupted, pointing out that this takes much less time than doctors perceive (page 24). Many tips the author gave were simple measures that enhance the effectiveness of communication, and these included asking open-ended questions, eliciting patients concerns, expressing more empathy, summarising key points, encouraging patients to take notes, and simply always asking ‘what else?‘ (pages 88, 123, and 164). Supporting her recommendation to doctors ‘to be fully focused on what the patient is saying’, the author outlined many listening skills tips such as the technique of grounding, ‘the periodic acknowledgement to the speaker that he or she is being heard‘ (pages 222 and 115). Referring to the work of Debra Roter, the author also advocated the use of activation and partnership statements, utterances that clarify, enhance, and shape the patient’s story, and thereby consolidate the patient-doctor relationship (page 40). Referring to physician Donald Boudreau, she also explored unconventional enhanced listening techniques (pages 197-198).
Typical of her writing style, the author deployed many illustrative anecdotes to support her arguments. Central to her narrative in this regard is the story of Morgan Amanda Fritzlen, an ‘empowered patient’ with a complex medical condition and very strong views. The author depicted how Morgan Amanda stretched the patience and resources of her care givers, perceiving them as ‘dismissive and somewhat paternalistic‘, whilst they saw her as ‘defensive and somewhat stubborn‘ (page 18). Another instructive story relates to her patient, Mr. Amodou, whose forceful and annoying behaviour turned out to be a plea for help, ‘a declaration of fear and vulnerability‘ (page 5). In this very human book, the author also freely expressed her own emotions, such as when she referred to her ‘depleted reserves of patience’ when confronted by a patient speaking to her in an irritating tone of voice (pages 1-2). Amongst the wider range of relevant subjects the author discussed are empathy, apology, disclosure, euphemisms, implicit bias, breaking bad news, and the biopsychosocial model of communication (pages 85-88, 140-148, 184, 203-206, and 43).
This book addresses a fundamental activity of medicine, how patients and doctors communicate. It highlights how this often goes so awfully wrong, resulting in poor patient satisfaction and increasing the risk of diagnostic error. An exhaustively researched book, it struck the right balance between anecdotal reports and research evidence. The author’s non-judgmental and self-deprecating style is most refreshing and encouraging. Whilst her descriptions of patients were occasionally excessive, and occasionally not directly relevant to the subject matter, I thought these did not diminish the quality of the narrative, or the lessons of the book.
The doctor-patient communication is critical to healthcare, and this book goes a long way to highlight its pitfalls and offer effective remedies. The writing is lucid, and the narrative very clear. The author’s practical recommendations are invaluable and overdue, and I recommend the book to all doctors.
Publisher, Place, Year: Beacon Press Books, Massachusetts, 2017
Number of chapters: 16
Number of pages: 242
Star rating: 4