Some talk about talking

I don't often write about my own work here, for various reasons, but today I am inspired to say a few words about some problems and issues that I see in communication between doctors and patients. Most formal research in this area is carried out in medical schools, financed by agencies that mostly fund biomedical research -- principally the National Institutes of Health -- and in fact is conducted mostly by M.D.s rather than social scientists. Inevitably, it is grounded in the physician's point of view and the problem definitions are written by physicians, mostly taking the form of "How can we get people to do what we want them to do?" These are hardly original observations but I hope they are salutary reminders.

I trust my colleagues won't mind if I refer to some ongoing research in very general terms. In a study to evaluate an intervention intended to give doctors specific, comparatively accurate information about their patients' adherence to drug regimens, we are finding that while the intervention did indeed prompt doctors to talk about adherence more, all that talk didn't have any evident effect. About midway through my own analysis of the transcripts of these conversations, I'm starting to get a pretty good idea of why that is.

The doctors scold, exhort, convince, invoke the dire consequences of non-adherence, encourage, plead, you name it. But the people already know what the instructions are, they already know what the rationale is, they already know what the doctor wants them to do. If that isn't enough for them to take the pills on schedule in the first place, it isn't going to magically become enough by repeating it.

There are reasons why the people aren't taking the pills, but these don't get talked about, and nothing gets done about them. They don't get talked about because:

1) Doctors have too much cultural authority, and the people aren't even going to mention it if they just don't agree with or believe in something the doctor is telling them. They'll just sit there and nod, and then go home and do what they think they ought to be doing. It doesn't help matters that the doctors know, beyond a shadow of a doubt, that they are right, and would meet any challenge with scorn and contempt.

2) There is a huge social difference, in many if not most cases, between doctors and patients. Doctors just do not grasp the realities of their patients lives and for the most part haven't got a clue how to help people solve problems that may interfere with health promoting behavior.

3) Doctors and patients don't necessarily have the same goals. Taking the pills, regardless of the statistical likelihood that they will have some benefit in terms of longevity or avoidance of symptoms, may just not be as important to the people as some other consideration, such as not having to think about bad stuff all the time, or more concrete considerations.

Again, there is really nothing original about these observations. To a medical sociologist, they are utterly banal. Yet we are spending I don't know how many millions of dollars every year on adherence related research with little consciousness of the basic problem, and no meaningful effort to do anything about it. Even the current superstar docs who are doing professional self-criticism, such as Jerome Groopman, aren't really looking at these basic issues. Groopman blames himself for biased thinking, but he still assumes that he should be doing all the thinking. (Props however to our friend Alan Showalter who does have an informed perspective.)

What is at issue here is the fundamental culture of medicine. Doctors have to stop telling people what to do, and learn how to form effective partnerships. Lots of people pay lip service to this simple idea, which has transformed the way people talk about medical communication, and even the conventional ethical framework for medical practice, but it's still just a lot of talk. The behavior has scarcely changed.

In coming weeks, I will present some specific case studies. As I say, nothing original here, but maybe some illustrations will get through where abstraction can't.