Communication: George Bernard Shaw's Illusion

Editor’s Note: The following is a response by Physician’s Money Digest columnist Eric Anderson, MD, to an op-ed that ran Monday in The New York Times. Join the discussion in our comment section or on our Facebook page.

I see the sign a couple of times a year. It is framed and stuck on the wall in front of my chair. It reads:

Blessed are those Who engage in lively debates With the helplessly mute For they shall be called dentists

Communication! The buzz word of the early 21^st Century. Lawyers insist on it. Information technology engineers rave about it. Couples exiting a marriage complain about it — or rather its absence.

A huge group needs it in its working day: teachers, ministers, editors — and doctors. It's the bridge doctors walk over to get the information they need from their patients. It should be easy for us. We are one-on-one in a quietened room. Pens and paper lie around us. We have wall charts and atlases, drawings and 3-dimensional models and videos.

And when we are done and patients walk away you could drive a Mack truck through the hole in their understanding. Why? Because we rate an F in the field of explaining their problems.

We can't communicate.

It's not taught in med school. We don't practice it. It's only a small part of the office visit. We're running late and we can hear the nurse ushering the next patient into the examination room next door. Plus, medicine like all professions and trades has its vocabulary, its jargon that enables us to be precise with colleagues. It's part of our very being and some of us seem unable to downsize our precious words into the simple speech of everyman.

Things may be a-changing. People are noticing this — even doctors. In a biting opinion piece in the New York Times on January 4, 2015, Nirmal Joshi, MD, an internist and infectious disease specialist called his Op-Ed piece “Doctor, Shut Up and Listen.”

Doctors, he says, are today appreciated for technical skills but not empathy.

He may have a point. I recall reading 7 years ago of a pilot study done at a university in Virginia where actors were used to show physicians how they might portray empathy. I expected the press to have a field day with that but, for once, it was surprisingly subdued in its regular complaints about America’s physicians.

In his Opinion piece, Dr. Joshi, the chief medical officer for Pinnacle Health System, discussed an update to this study where 250 physicians in Harrisburg, PA were trained by his group to listen better to patients. With a huge benefit in empathy. Impressive!

But I wonder if part of the problem isn’t simply the lack of good manners on both sides of the stethoscope. Consider what most people experience in their day-to-day living: the person ahead of you who lets a door close in your face in a public building; the person who fakes a conversation on a smart phone as he “innocently” wanders ahead of you from behind in a queue; the person who, more obviously, wants to get out of an event car park before you, because his time is more important than yours. The problem may be partly because, despite lack of manners, we are so politically correct we can’t show too much empathy.

This may be a poor argument but Joshi talks about a “passionate diabetes specialist” comforting a patient by just sitting with her hand on his shoulder. I was once interviewing physicians for an article on “How to Improve Your Office Call” after a patient told me the rheumatologist to whom I’d referred her never touched her swollen, arthritic fingers. She felt that touch might have helped him make the diagnosis. In that survey, the question came up: if medicine really is a hands-on profession, how much do you touch your patient to show empathy? Would you help someone off the examining table, for example? Most young doctors said “No,” and one male stressed the only place he would touch a young female who had difficulties getting down from the table was by the elbow. Understood, but I recall an American Pharmaceutical meeting in Toronto where one of the other speakers, a pharmacist in Los Angeles, told me he always came down from his elevated platform in his drug store to hug patients for whom he’d just filled a prescription. He called this gesture, his hugs, Vitamin H!

Yet in family practice one of the feedbacks you sometimes get after referrals is a complaint. Once I made an OB referral for an older woman who had now, unexpectedly, become pregnant for the first time. She told me when she called the OB office for an appointment saying that after many, many years of marriage she’d become pregnant, the first comment the receptionist made was “Do you have insurance?”. She did—and good insurance at that—but she would have preferred what everyone else in the service industries had been saying to her as a first response, “Pregnant! How wonderful! How are you doing?”

But the problem is more than all that. It’s too easy to become, without being aware, a bit arrogant as a doctor. We hear it when friends tell us those jokes about people in line for Heaven at St Peter’s seeing a figure breezing past the line wearing a white coat and a stethoscope. “That’s God playing at being a doctor,” the punchline goes. We see it often when doctors make restaurant reservations (or in social situations come into a group) and introduce themselves with emphasis on the Doctor. Agreed it takes a lot of financially unproductive time and money to go through medical school but do we need to flaunt our identity all the time in today’s society? A friend once told me if you are buying furniture, even a mattress, never let the salesman know you are a physician or the price will go up!

So if we can avoid the drama when we shop why not when we socialize? And if there are times when we need to let a new patient know, Yes, we’re the doctor, why can’t we introduce ourselves to a new patient when we come into an examining room? I once wrote an article on “The Five Minute Office Call” when I met several very efficient and competent physicians. One said when he came into an examining room to find it, somehow, filled with several family members, he made a point of introducing himself to everyone and asking for each to identify who they were—and he still got out in 5 minutes. He was a pediatrician and, true, they often have brief office calls.

I once had a family member who was given the task of soliciting a street collection for a community health project. The street she was given had physicians’ offices and a large building with chiropractors. She said the physicians were a bit abrupt, the chiropractors charming. “Why can’t doctors be as nice as chiropractors?” my family member asked me. I didn’t have an immediate answer.

George Bernard Shaw warned us a long time ago: “The single biggest problem in communication is the illusion that it has taken place.”

Yet, if we are to be judged by outcomes we'd better make sure our patients, our partners (how I hate that word!) understand what's going on and what our respective and mutual health decisions might be.

Such understanding comes with additional benefit: it may cut lawsuits.

Eric & Nancy Anderson, who now live in San Diego, are the resident travel & cruise columnists for Physician's Money Digest. Anderson is a charter member of the American Board of Family Practice and in 1974 was the president of the NH Academy of Family Physicians. The practice he founded in 1964 in Derry, NH has just celebrated 50 Years in continual operation and has grown to be the largest privately owned family practice in New Hampshire. Anderson, now a retired MD, was the senior contributing editor at Physician’s Management from 1989 to 1997. He has also written 5 books, the last called The Man Who Cried Orange: Stories from a Doctor's Life.