Map of life expectancy at birth from Global Education Project.

Monday, August 13, 2007

Right Speech

The whole field of rigorous study of physician-patient communication is essentially 40 years old. It got started with the availability of affordable, portable recording equipment, which Barbara Korsch first put to work to study interactions between pediatricians and mothers. Her most important observation was that the doctors would throw around a lot of medical jargon that the mothers didn't understand, but they would not speak up and ask questions.

On the one hand, we've come a long way since then, on the other, we're pretty well stuck. We've come a long way in that people have developed all sorts of approaches to coding and analyzing these interactions, and we do have some consistent observations about them. We're stuck because we still don't have a cogent idea of what approaches to physician patient communication are likely to result in the best medical outcomes, and we have even less idea how to teach doctors and patients to be more effective in communicating with each other.

The dominant paradigm is called patient-centered communication. Doctors are supposed to understand patient's health-related preferences and goals; factors in their life worlds that effect their health, ability to follow medical advice, and priorities regarding the risks, benefits and costs of various approaches to health care; and patients' health literacy levels and knowledge about medical issues, so they can explain medical concepts effectively. The dialogue is supposed to include opportunities for patients to ask questions, state their preferences, and clarify their understanding. And treatment decision making is supposed to be shared, based on a process in which physician expertise and patient values and feelings are equally considered, resulting in informed choice on the part of the patient.

Unfortunately, the evidence relating this paradigm to medical outcomes is mixed. There are fundamental difficulties, obviously, in deciding whether you have correctly measured whether these criteria are met. Even so, what is right for one patient and one doctor isn't necessarily going to be right for the next pair, and what is right in one situation isn't going to be right in another. Some patients don't want to make informed choices, some don't care to understand the doctor's explanation for their condition, they just want to be told what to do. It's less work, they have other things to worry about, and what is the doctor being paid for anyway, but to make medical decisions?

Of course, these same people might accept the prescription but not take the pills, but they also might just do what the doctor thinks best. The empowered patient who asks questions and makes informed choices might make bad ones, that result in poor medical outcomes; or might also be just as likely to accept the prescription but then not actually take it.

We can find statistical relationships between certain patterns of physician behavior and endpoints like medication adherence or glycemic control in diabetes, but these aren't necessarily much help to doctors who are trying to maintain relationships with individual patients, each of whom is different from all the others.

On the other hand we can apply fundamental ethical frameworks to the issue. We might feel that it's just the right thing to do to at least give people the opportunity to be informed, active partners in their health care. But then we need to figure out how to make that happen. I'll tell you right now that it's the exception. However you try to characterize physician patient communication, it tends to be radically asymmetrical and physician-dominated. Prescribing seldom incorporates even the basic elements of informed choice, or even informed consent, which is a weaker standard. Patients seldom ask questions about their health or health care, and in my own research, physicians actually make more statements about their goals, preferences and feelings than do patients.

I know that a lot of people, including me (see two posts back) often have complaints about their relationships with physicians, although most people say they like their own physicians personally and are happy with them.

Why do you think it is that medical communication is so asymmetrical? Do you speak up with your own doctor when you don't understand something, or you are reluctant to do what she or he wants? If not, why not?

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