On one of my recent trips, I went to a famous bookstore in Delhi with a far wider than average selection in order to browse. There are so few bookstores in India where you can actually do that. Most places have little to offer, no interesting choices to explore, just the bestsellers which overall become dumber every year, with the rare and occasional exception. I was actually looking for a gift for my niece and nephew in the kids’ section, but then going through the medical section one title caught my eye, HOW DOCTORS THINK by Jerome Groopman MD. I had to have it, and I am happy that I followed my intuition and actually bought it, as it confirmed me in my own approach of how I tend to interact with a client.
It is good to be confirmed by top people when you are a general practitioner and a mostly self-taught expert in preventive and detoxification medicine trying to find your own way because, for sure, in medical college they did not teach you a thing about working with a client or patient. In this respect, here in India we live still pretty much in the dark ages although exceptions to the rule will always exist. Yet, the fact remains that in my college time less than a decade ago I did not have to fulfill any requirements regarding interpersonal communication, for example. I simply was not coached in how to deal with a patient.
The stereotype still being that an Indian doctor is expected to project the ‘I-know-it-all’ aura of infallibility and may therefore be very well in the habit of almost barking at his or her patients in a commanding voice; whereas the patient is expected to behave meekly and like a mere receptacle for the doctor’s wisdom – and prescriptions. As I have treated a good number of European and American patients who come to see me for my special skills, I have also heard many a tale about the insensitivity of Indian doctors. Well, I am one of them, but in this regard, not quite like that. I know that I would be less than half as successful than I am, if I did not listen to what my patients have to tell me, or if I talked to them without paying attention to my own words and body language; if I did not make an effort to address each and everyone in a way that they can understand in their individual ways. So, I was not surprised to read in the book that I had bought in Delhi what I hope will be food for thought for some of the readers of this post.
“How a doctor thinks can first be discerned by how he speaks and how he listens. In addition to words spoken and heard, there is nonverbal communication, his attention to the body language of his patient as well as his own body language – his expressions, his posture, his gestures. Debra Roter, a professor of health policy and management at Johns Hopkins University, works as a team with Judith Hall, a professor of social psychology at Northeastern University. They are among the most productive and insightful researchers studying medical communication…. They have shown that how a doctor asks questions and how he responds to his patient’s emotions are both key to what they term ‘patient activation and engagement’. The idea, as Roter put it when we spoke, is ‘to wake someone up’ so that the patient feels free, if not eager, to speak and participate in a dialogue. That freedom of patient speech is necessary if the doctor is to get clues about the medical enigma before him. If the patient is inhibited, or cut off prematurely, or constrained into one path of discussion, then the doctor may not be told something vital. Observers have notes that, on average, physicians interrupt patients within eighteen seconds of when they begin telling their story.”
The art then, is to not so much take at face value the conclusion that the patient himself may draw, but to listen to and observe the actual narrative. In the way the story is told clues can be found that point to the patient’s problem. These clues are vital because in many cases even the clearest test results say nothing about the condition and the suffering of a patient. After all how revealing can a particular test be when it has zero bearing on a particular case? When you wrongly test for irritable bowel syndrome in a case of celiac disease, the negative test results will lead you to the wrong conclusion that your patient has merely a psychological problem – and you will never be able to be of any useful assistance. That’s why listening and looking for clues is so important.
Therefore, Roter and Hall come to the conclusion that successful diagnosis and good manners and listening and observation skills go together. They are not separate issues. “Most of what doctors do is talk and the communication piece is not separable from doing quality medicine. You need information to get at the diagnosis, and the best way to get that information is by establishing rapport with the patient. Competency is not separable from communication skills. It is not a tradeoff.”