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Remember the best-selling book that claimed Men are from Mars, Women are from Venus? The same might be said of patients and physicians. In a typical encounter, patients and physicians are often attuned to different types of language and agendas, says a leading researcher of medical communication.
"By virtue of their professional training, physicians generally view patients coming in and presenting with symptoms as a disease, as a pathopathology, an imbalance," says Debra L. Roter, DrPH, a professor in the department of health policy and management at the Johns Hopkins School of Public Health in Baltimore. "Physicians are trained to first look at pathophysiology. Patients live in a world that has social relations and obligations. You live the experience of a condition; it’s an illness experience."
In a detailed analysis of medical visits, Roter identified five distinct patterns of patient-physician communication: narrowly biomedical, extended biomedical, biopsychosocial, psychosocial, and consumerist. They differ significantly in who dominates the conversation verbally, who has communication control (asking questions vs. providing information), and what type of information is exchanged, Roter reported. (For more information on these types, see story, above.)
The narrowly and extended biomedical patterns which basically involve the physician asking a series of closed-ended questions and the patient providing brief answers comprise almost two-thirds of all physician-patient encounters.1 But those are the least satisfying patterns for both patients and physicians, Roter says. The most balanced pattern is biopsychosocial, which includes both psychosocial and biomedical talk and a more even exchange between physicians and patients, she says.
There’s good news for physicians who want to change their patterns: Learning new communication skills is easy and effective, Roter found. In a randomized, controlled trial with 69 primary care physicians, two four-hour training sessions resulted in significantly more problem-defining and emotion-handling skills for physicians and reduced emotional distress for patients.2
"We need to reach more physicians to raise their awareness that [improved communication] works and can make a difference in their lives," says John W. Hawks, president of COMSORT, a Baltimore-based company that develops communications workshops and workbook programs modeled after Roter’s research.
The first minutes of a patient interview establish the pattern used by physicians, Roter and Hawk say. When the patient begins by saying, "My throat hurts," many physicians launch into a series of closed-ended questions: How long has it hurt? Where exactly does it hurt?
Those questions often close off discussion of other perhaps more important concerns the patient has. In fact, one study found that patients were able to complete their opening statement of concerns without interruption in only one-fourth of medical visits.3
"The hardest thing to sell any physician is to let the patient talk," says Hawk. "You [should] begin the interview with letting the patient tell you completely all of their issues. Most physicians think, If I do that the patient will talk for three hours.’ The truth is, they talk for a few minutes, and they have a sense of being heard."
The critical follow-up question: "Is anything else bothering you?"
"Sometimes a sore throat is just a sore throat," says Roter. "But you have to give a patient a chance to say, Yeah, that’s it.’"
Roter’s analysis showed that biopsychosocial and psychosocial patterns of communication, with more talk about the patients emotions and social supports, are not significantly longer than the biomedical type.1 Likewise, physicians who use "problem-defining" and "emotion-handling" skills, which involve more open-ended questions, did not have significantly longer patient visits.2
"You can get much more information from a well-placed open-ended question than you can for a series of closed-ended questions," says Roter. "Closed-ended questions are used to test hypotheses. That’s fine if you’re on the right track. But if you’re not, you’re wasting your time."
Hawk advises physicians to encourage patients to air their concerns with affirming statements, such as "Yes, I see, go on," or by asking directly "Why do you think this has been happening to you?" By asking probing questions, they also may discover that treatment or medication may be impacting their social or emotional lives. For example, an older person using a diuretic may begin limiting outside activities because of a frequent need to urinate.
"Even in short workshops, physicians can learn communications skills that would move them toward the more patient-centered patterns," says Roter. "I think physicians will end up being more satisfied with their practice and their patients will benefit."
[Editor’s note: For more information on the COMSORT program, "Communication Strategies in the Medical Interview," sponsored by Pfizer pharmaceuticals company or the COMSORT workbook program, call (800) 767-2764.
A reference that provides further information on physician-patient communication: Doctors Talking With Patients: Improving Communication in Medical Visits, by Debra L. Roter and Judith A. Hall, Auburn House; Westport, CT: 1992, is available in paperback ($19.95, plus $4 shipping and handling) and hardcover ($55 plus $4 shipping and handling) from the Greenwood Publishing Group. Telephone: (800) 225-5800.]