“Two Ships Passing in the Night”: Missing Communication in Medical Practice
As I read the comments written to the threads on patient modesty, hysterectomy, “I hate doctors”, it seems to me that a basis for much of the tension and unhappiness with the medical profession is related specifically to a lack of communication between doctor and patient or the patient’s families. The patients fail to tell the doctor what are their goals and wishes and the doctor doesn’t ask and therefore may set goals or actions which appear appropriate to the clinical situation but in fact is not at all what the patient wants. It’s almost like two ships passing in the night, each going their own way, each with their own goals and experiences but not communicating with each other to warn, perhaps, about rough seas ahead or the conditions aboard ship.
This communication gap in medical practice, I think, is related to lack of time or simply ignorance or inattention on the part of the physician and the apparent power difference between the patient and doctor so that the patient may feel embarrassed, intimidated or unsure about the consequences of speaking out.
What are your ideas about the issue of doctor-patient communication? Don’t write about the specific views covered in the above threads, which can be more appropriately discussed by writing directly to those threads, but write here about your views of whether you see communication generally as a problem and what approaches you would offer to mitigate the problem. ..Maurice.
Graphic: Photograph by me of two snails passing and color modified by Picasa3.
posted by Maurice Bernstein, M.D. @ 10:04:00 AM
5 comments
5 Comments:
I had wrong procedure surgery recently. The surgeon (#1) had delegated the informed consent discussion to a nurse, and even though I told her that the consent form was wrong, and corrected it, I still got the wrong surgery.
It appeared to me that the surgeon delegated almost everything. The surgery was performed by a resident with him supervising, rounding was done by the resident, pre-ops were done by nurses, etc. It also seemed to me that he was doing very well financially, as far as I could tell from his facilities. I was a private patient, but the hospital did have a few residents.
A few years prior I had surgery by someone who didn't delegate much of anything. She went through my history step by step, asking questions and answering mine, for over an hour during the pre-op consultation. She also did the surgery herself and rounded herself. From what I could see of her practice, it was not nearly as financially lucrative as surgeon #1's.
I think that until physicians have a more level playing field, or are required to be more transparent up front about how they run a practice, we will be plagued with healthcare modeled on surgeon #1.
Surgeon #1's submitted fees were also much higher than #2, although they were knocked down to the same level by my insurance. So perhaps one of the only way from him to make more money was by delegation?
AG
AG, if the communication was inadequate or incorrect prior to the surgery, hopefully you communicated to the surgeon after the surgery what was "wrong", what you hadn't expected. And hopefully, the surgeon communicated back to you the explanation for the differences in what was communicated and you both were not just "two ships passing". ..Maurice.
This seems to be a perennial topic on many of the patient blogs. I don't have an answer.
It seems to me that physicians (and their staff) always give the rationale that a) they don't have time; b) they deal with dozens of patients each day so why should one patient expect "special treatment"?
I don't consider communicating with me to be "special treatment." It should be standard operating procedure. But it's hard to get past this mindset.
My dr. is actually a good communicator but he doesn't have much time to spend with me. I had cancer as a young adult and I don't feel we have a handle on some of the long-term and late effects of treatment... but when you can only bring up one problem per visit and the state of knowledge about cancer survivorship is so incomplete, I am basically left to just struggle along without much help. I'd like to think I could call or e-mail for advice, but no one at my clinic uses e-mail to communicate with patients, and phone calls are handled by a nurse who unfortunately treats everyone like they're 90 and demented.
Dog forbid you would be the victim of a medical error or injury. I know from unfortunate experience that once something goes wrong, you can expect all the lines of communication to be instantly cut.
It seems to me that it's the system that needs to change. It needs to stop being a one-way street. I'm an optimist so I keep trying to reach out, but it becomes pointless and discouraging when I'm the only one who's really making an effort.
MP
An example of the lack of communication between the healthcare providers and the patient is the subject of a Perspective article in the March 19 2009 issue of the New England Journal of Medicine (requires subscription) titled "Denial" and written by a medical oncologist from Australia, Dr. Ranjana Srivastava.
The patient was a woman in her 50's, new to this oncologist, with breast cancer who, after initial chemotherapy was to be followed with a mastectomy, radiation and hormonal therapy. However, she appeared at the oncologist's clinic 7 months after the chemotherapy, never having had the surgery or the anticipated post-op treatments. She tolerated the chemotherapy but when she called the clinic for scheduling the surgery and she was told the clinic would get back to her. However, she never got a call back. She said "..when no one called back, I figured I was done with treatment." and she resumed her usual life ignoring the developing tumor changes in her breast and neck since "..I thought that I was cured and that this was how it was supposed to look."
A medical student witnessing this interaction between the patient and the oncologist, later described the patient as in "denial". The oncologist cautioned the student against labeling patients prematurely.
What happened here truly represents a consequence of lack of communication. The lack of proper education of the patient of the need to follow through on the entire treatment plan, not just the initial chemotherapy since the chemotherapy alone would not be sufficient. The need for the clinic management to followup on the fact that no surgery had yet been scheduled and to contact the patient. Suggesting patient denial, in this case, could be an easy excuse for what was really inadequate communication. ..Maurice.
This is a complex topic, and we can't blame it just on doctors. But they have the knowledge and are perceived to be in more control (and are in actuality) of the situation that are patients. So I believe it becomes their responsibility to lead the way in communication.
Time is an issue, but I think both doctors and patients make too many assumptions about each other. Some research indicates that doctors quite often diagnose a patient in less than 30 seconds without letting the patient talk or before asking many questions. This research is available in the books "Doctors Talking with Patients, Patients Talking with Doctors" and in "How Doctors Think." I think doctors may sometimes assume too much about what's wrong with the patient and what needs to be done.
On the other hand, some patients carry with them too many assumptions about doctors in particular and the entire health care system in general. Too many patients don't take personal responsibility for their health. They expect things to be "done" to them rather than what they need to do for themselves.
Frankly, I would like to see more open forums between doctors, nurses and patients. Forums where all are equal, where the power dymanic doesn't exist, where the topic is communication, where topics like those discussed on this blog can come out into the open and be confronted. Perhaps universities can take the lead here, or other organizations. These forums shouldn't be held in hospitals. They should be held in more neutral locations wehre patients, doctors and nurses can forge relationships and communication on an equal basis.
Is this being done anywhere?
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