Both patients and physicians need to communicate in the exam room

Today’s healthcare consumers are increasingly asked to take a more participatory role in their care. For many this is a daunting task, even if the patient relishes the role. There are a myriad of issues undermining patient-physician communication – such as time constraints, lack of comfort with the subject matter, lack of shared language, or even fear – that can make the task of being an empowered patient akin to trying to assemble a puzzle with several pieces missing.

In the recent New York Times article “Afraid to Speak Up at the Doctor’s Office”, Pauline Chen, MD, suggests that patients often feel “trapped” in communication patterns with their physicians. This phenomenon is not unique to patient and physician. As a graduate student, I taught a freshman-level communication class in which we called these ongoing communication challenges URPs – or Undesirable Repetitive Patterns. Addressing and correcting the common patient/physician URPs are important factors to improving communication.

In my professional experience, I consistently encounter an interesting “he said/she said” type of scenario with regard to patient/physician relations. On the patient side, I have never conducted a patient focus group when at least one did not say something to the effect of:

“It feels like my doctor doesn’t listen to me. All s/he wants to do is write me a prescription for something.”

Conversely, in focus groups with physicians, it is rare that I do not hear one say:

“Patients really don’t seem to be listening. All they want is for me to write them a prescription that they don’t really need.”

Although, the sentiments are simplified a bit here, the intent – and underlying issue – does not change. In this case, a lack of a shared perspective is leading to more medications begin prescribed than maybe anybody really wants or needs. Both patients and physicians have a role to play to help prevent this.

From my own experience as a patient, I know that trying to achieve a common ground can take a lot of, well, work.  Case in point: I am now one year out from my own cancer diagnosis and I still don’t really know what my care plan is. I know the plan exists, because several providers have made reference to it. The important parts seem to get dribbled out in bits and pieces in various doctor appointments, so I’ve pieced together the big picture, but I don’t have anything in writing. As a result, I don’t really have a sense of cohesiveness, or a nuanced understanding of what I might experience along the way, or even what’s expected of me as a patient.

I know better than this. I’ve asked about it a couple of times, but know that I should be pushing harder. But, that would probably require multiple phone calls and the navigation of umpteen voice mail systems and, quite frankly, it’s just easier to do a little internet research on a rainy Saturday to find out whether such-and-so is a medication side effect or if I should call the doctor about a new symptom I’m having or just deal with it. I’m soon to arrive at a key decision point in my care, and although I’ll be actively involved in making a choice, I’m not sure it could truly be called “shared decision making.” My choice will be made based on possibly incomplete information received in disparate office visits and data I’ve culled from various sources that may or may not be applicable to me. What’s really being “shared” here?  There is value to patients in gathering information from multiple sources. Physicians continually glean knowledge from new research or the experience of their own patients. These asynchronous discussions need to be linked to ensure a collaborative process.

How can we break out of these URPs at the physician’s office? Not unlike the patient, the doctor will often favor the path of least resistance. When I probe further about patients asking for unnecessary prescriptions, physicians describe it as the challenge of “getting to ‘no’.” For a busy physician, it is more efficient to write the prescription than it is to help the patient understand why s/he doesn’t need it.

Communication is always a two-way street. For patients, this might mean working to overcome the fear of asking questions and being persistent about getting the answers when necessary. For physicians, this might mean identifying a mechanism for patients to ask questions and acquire the information they need (which may translate to leveraging other members of the care team). We stay in URPs because it’s what we know. It’s always going to be easier to do it the way we’ve always done it. In an environment where both physician and patients can commit to doing it differently, new and beneficial communication patterns can emerge.

Beth Austin is a patient and consumer engagement advocate who blogs at Crescendo Consulting Group blog

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  • David Voran, MD

    Exam room conversations is a complicated and nuanced subject involving lack of time, poor communicating environments, processes that don’t encourage relaxation and systems that don’t prepare either the patient or the physician adequately.
    Many times the patient and physician are new to each other and need to get to learn to trust each other. If you look at interactions with new people there’s usually a need for small talk before settling down to business. A 10-15 minute visit doesn’t allow for any of the small talk that preps the participants and establishes the foundation for trust.
    I often tell those who are willing to listen that exam room interactions are similar in many respects to 10-15 minute business meetings in which the interviewer must be their own secretary where in addition to conducting the meeting the physician needs to take notes and document the visit (both of these activities interfere with concentrating and listening activities. First, you don’t find scheduled 10-15 business meetings. They are all 30-60 minute intervals. Second, the first few minutes of every meeting involve small talk and it’s usually only in the middle to latter stages of the meeting where the meat of the meeting is discussed. Finally there’s usually a secretary keeping notes so the participants can focus on communication. None of these facilitating features are present in the exam room.
    Extending the exam room time wouldn’t be profitable as most physicians need to see 20-24 patients a day in order to cover their costs. Redesigning the exam room is as difficult as any of the other measures and also cuts into the relatively low profit margins.
    There are many other issues but suffice it to say that the exam room is precisely NOT where much of the good decision making needs to take place.

  • Maurice Bernstein MD

    With regard to physicians’ failure to provide the patient with a “road map” of therapy, one must consider that such a “map” may not be within their knowledge or skills since each road may have an unpredictable and unknown ending and what both the patient and doctor find as they travel down that road will determine whether it will finally take them to the desired destination or whether it is necessary to move to another route. That is why, though the doctors know where they have started and where the desired destination is located, it may be necessary for the doctors’ presentation of the route to be ” dribbled out in bits and pieces” as each road is entered and its course examined. What is critical is that the patient passenger on this bus trip must be sitting up in the front next to the physician driver rather than way in the back of the bus. It is the duty of the driver to explain the turns and why the turns were necessary. Sometimes, based on the desires of the patient passenger another route may be suggested and even the destination may have to be changed. Treatment plans and their outcomes for a patient can’t always be printed out with the clarity of a map. ..Maurice.

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