The power of conversation, according to Danielle Ofri

Jordi Varela
Editor

 

Danielle Ofri, an internist at Bellevue Hospital and professor of medicine at New York University, is recognized for her work on the emotional aspect of clinical practice and its impact on the diagnostic process and the effectiveness of treatments. Danielle Ofri has already deserved the care of our blog on several previous occasions and now we return to her with her latest book, What Patients Say, What Doctors Hear.

According to the author, the conversation between the patient and the doctor is a more compelling diagnostic tool than the physical examination or the sophisticated diagnostic tests that we have today. Despite the key role of the clinical interview -she affirms-, in the real world, words do not usually travel in a fluid or transparent way between the two sides of the table, this fact being the origin of misunderstandings and diagnostic errors. Danielle Ofri insists that effective communication between doctors and patients is not just a matter of good manners, but is often the linchpin between a good or bad clinical outcome, between life and death, and to prove it she has selected several studies that have shown how beneficial the word becomes to improve adherence to treatments (DiMatteo 2004, Zolnierek 2009), to reduce pain, including surgical pain (Egbert 1964, Amanzio 2001, Fuentes 2014) or to improve clinical outcomes (Hojat 2011, Rakel 2011).

What do patients want?

Patients want to trust their doctors, but most of all they want to be heard. All patients have a story to tell or a worry that haunts them, but doctors, on the other hand, have some forms to fill out and, even more important, a reason for the consultation to code. As the title of the book points out, a disappointing communication gap is often generated in medical consultations.

Doctors, more or less, are aware of the problem, but cannot stop it, since listening well is not a subject that is learned in a course, but a matter of attitude full of small details, such as being attentive to know if patients have been recognized them, knowing how to look (genuinely) into people's eyes when they speak, avoiding distractions from breaking the atmosphere of the conversation, not interrupting the story except to be interested in some detail, being attentive to emotions when they appear, adjusting language at the level of understanding of each patient, confirm that patients understand the proposals in addition to asking their opinion on the matter and, finally, not forgetting to ask if there is something that has remained in the pipeline.

Danielle Ofri says that many doctors do not like to ask this last question for fear that the visit will be prolonged, but not asking has consequences, because often in that question that the patient asks when he already has his hand on the doorknob, the case plunger is hidden. This does not seem to be a minor issue when a study has found that "unexpected agendas" appear in one of every six or seven visits.

The different types of medical consultation

Debra Roter (Johns Hopkins), in 1982 created Roter Interaction Analysis System (RIAS), a very useful tool - according to Ofri - to understand how patients and doctors communicate. Roter's research team analyzed more than 500 clinic visits and, after filtering them with the RIAS scale, she concluded that, in summary, there were 4 types:

1. The strict biomedical visit. They are inquiries of the type: "My chest hurts" or "My legs swell up." These visits, according to the study, represent a third of the consultations, in which both patients and doctors act diligently. Psychological or social issues are not usually entered, and closed questions (yes / no type) are the most common.

2. The extended biomedical visit. These consultations also have a biomedical basis, in the style "My head is spinning", but due to their characteristics they allow them to open up the questions and treat, even briefly, the psychological and social perspective that surrounds the problem. According to the study, expanded biomedical visits account for another third of visits.

3. The bio-psycho-social visit. They are consultations originated by more diffuse motivations, in which a balance is observed between the part of the medical conversation and the psychological and social one. These conversations tend to be more balanced between the interlocutors and, perhaps for this reason, once asked about the satisfaction that the consultation has caused them, both doctors and patients agree that the one they like the most is the bio-psycho visit -social, although it’s only practised 20% of the time.

4. The consumer visit. In these consultations, the patient's position is that of the consumer requesting a service: the knowledge of the doctor or the prescription of a test or treatment. Given the situation, the initiative for these interviews belongs to the patient, while the doctor limits himself to responding as he can and, logically, there is usually not much interest in the psychological or social environment. These visits represent a tenth of the global.

The limited communication skills of physicians

In a study made from several registered medical visits, it was observed that the most common communication strategy of doctors was the repetition of concepts and recommendations, often with repeated explanations aimed at extolling the rationality of a clinical decision. In no case did the researchers detect any doctor who used somewhat more elaborate communication strategies, such as suggesting (or even helping) patients take notes or record the conversation and then be able to listen to it again at home as many times as necessary or ask them to explain the conclusions of the visit to them in their own words.

As the evidence shows, effective communication is not just a matter of good manners, but the basis of quality medicine, so it’s surprising how, even today, most doctors have so few skills and strategies to focus conversations with their patients in a sincere, open and decisive way.