Tuesday, December 18, 2018

Sonoma Medicine

The magazine of the Sonoma County Medical Association

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Editorial: Doctor to Patient: Let’s Talk

Mark Sloan, MD

It's a classic New Yorker cartoon. A middle-aged man sits on the edge of an exam table, nervously buttoning his shirt. Facing him, a doctor dressed in the cartoon trademarks of his profession—white coat, stethoscope, clipboard—leans forward, his face a quick-draw study of concern. “So which do you want first,” the doctor asks, “the good news that sounds better than it is or the bad news that seems worse than expected?”

A hundred other captions could easily substitute for that one without ever changing the drawing. Doctor to man: “You’re not ill yet, Mr. Blendell, but you’ve got potential.” Man to doctor: “Give it to me straight, doc. How long do I have to ignore your advice?” 

A visit to the doctor’s office is one of the most popular New Yorker cartoon themes. It ranks with first love, dating disasters, and cocktail party faux-pas because it’s a universal experience. Everyone eventually finds him or herself in some version of that scene: a doctor, a badly fitting gown, and some news, good or bad. (Doctor to woman: “Well, as we thought, it’s something gross.”) 

Doctor-patient communication early in my career was a lot like those cartoons: me with my stethoscope, my young patient lying on the exam table, his anxious parents leaning forward to hear the verdict. I spoke, they listened, and then off I went, satisfied with my treatment plan. But misunderstandings sometimes happened—nothing major, thank goodness—and things turned out differently than planned. (Mother on phone to doctor as her worried child eyes a mound of medicine on the kitchen counter: “Now, was that ‘one tablespoonful’ or ‘one table-full’?”) It didn’t take me long to figure out that communication, especially when it involves health, is best practiced as a dialogue. 

Cultural changes and technological advances in the decades since that epiphany have forever altered the way I communicate with my patients. The worshipful, unquestioning patient of past generations is long gone. Patients are now empowered consumers, seeking value for their ever-increasing insurance premiums. They demand a physician who is accessible and accountable. Newer alternatives to the traditional telephone advice call— especially e-mail—have become a convenient and even essential way for me to stay in touch with my practice. 

And then, of course, there’s the Internet. For many people, websites and chat groups have replaced flesh-and-blood physicians as their go-to source for health information. But “e-medicine” is a two-edged sword. When the information is sound, good things can result—a well-informed patient can save time for a busy physician and undue anxiety for herself. But when the information is flawed, difficult to interpret, or simply overwhelming, trouble can start. (Doctor calling patient: “Before we try assisted suicide, Mrs. Rose, let’s give the aspirin a chance.”) The patient in our office is no longer there alone—she’s channeling a web of friends, relatives, and fellow sufferers from around the globe. To be effective, a physician has to be able to communicate with all of them. 

In this issue of Sonoma Medicine, our writers look at doctor-patient communication from several perspectives. Mark Klein offers practical tips for improving communication skills. (Man to pantomiming doctor: “Hop? Jig? You’re a dancer? Sounds like Prancer? Cancer? Cancer! I’ve got cancer??”) David Elliott writes about patients communicating with each other. (One fish to another: “Now they’re saying shiny things attached to hooks are bad for you.”) Richard Andolsen’s article deals with the fallout of poor communication. (Doctor to colleagues: “What’s the point in having malpractice insurance if you don’t malpractice once in a while?”) Keith Borglum looks at the delicate art of discussing costs with patients. (Doctor to angry woman: “You may believe you’ve been overcharged, but remember, you’re overmedicated”.) And Brien Seeley assesses the challenges of medical record-keeping in the digital age. (Doctor to patient: “Either this is the wrong chart, or—let’s just hope this is the wrong chart.”)

In this era of high-tech, impersonal medical intervention, doctor-patient communication is perhaps more critical to the practice of medicine than ever before. Done well, it’s the foundation of good health for our patients and the key to a humane journey through life’s many physical indignities. Done poorly, it can lead to a world of pain. (Doctor to wide-eyed patient: “There’s no way I can tell you this, so I’m sending you to someone who can.”)

Dr. Sloan is Santa Rosa pediatrician.

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