Understand patient expectations as part of a negotiation

Over the years, Zackary Berger, MD, PhD, has been studying gaps in the ways doctors and patients interact. As a resident at New York University, he did a study asking patients why they thought their doctors admitted them to the hospital (available online) . He then compared the patients' responses to what was recorded in the medical chart. The discrepancies he encountered between the 2 parties' disparate understandings of the reason for a hospital admission convinced him that more needed to be done to get patients and doctors talking.

Dr. Berger, an ACP Member who is an assistant professor of medicine at Johns Hopkins School of Medicine in Baltimore, has incorporated his insights into a book, “Talking to Your Doctor: A Patient's Guide to Communication in the Exam Room and Beyond.” But the message isn't just for patients, he cautioned; the physician has a role in the relationship as well.

Q: What interpersonal barriers exist between doctors and patients?

A: One predominant barrier that is addressed in the scientific literature but is relatively under-addressed in the lay literature is economic and racial disparities. When a doctor [and] patient are of different races, care is worse. That is a frequently noted and relatively clear scientific fact. There is also recent research that when doctors or patients can be taught to see themselves as part of the same team, patients have greater satisfaction and care improves.

Gender differences can also play a big role. When a woman is treating a patient, she tends to use language differently and give the patient more space to divulge their concerns than a male doctor would.

There are also preexisting notions, such as the expectation that when one sees a doctor, one is supposed to leave the room with goods and services. You're supposed to leave with something in hand, be it a prescription, an order, or a referral. That can be a barrier because everyone knows the patient wants to get something. I don't think that's an unreasonable expectation. Medicine is a service profession. But that doesn't have to result in a prescription for a medicine that might not help.

Q: What are the systemic barriers to doctor-patient communication?

A: Time. Doctors and patients use it as an excuse—not to say that time isn't a real issue in the encounter and that time is limited. But there are studies in the literature that show we can't always place the blame at the feet of the clock. There are possibilities that the visit results in patient satisfaction, even when the time is limited.

The reason people use time as an excuse is because it plays with the notion of what the hierarchy has been in the medical encounter. A patient goes into the visit and the doctor says yes or no—the top-down relationship, and supposedly there's not enough time for dialogue. That's a real systematic barrier, this notion that the patient proposes and the doctor disposes. I do believe that there are certain instances or circumstances where the hierarchy is a useful thing. That's important to medicine, but recognizing the patient as an equal human being and being on the same page with them requires a certain leveling of the hierarchy.

Q: What has been the impact of electronic health records?

A: There are some before-and-after studies showing that with electronic health records (EHRs), doctors are spending comparatively less time with patients and more time entering information. On the other hand, there are instances that show that in complex conditions, better care can be delivered with the EHR. The focus on EHRs from a regulatory perspective is not on patient-centered care. It's on [the] population level; it's on improving outcomes. From a national perspective, how can we make care more patient-centered?

Q: What has been the impact of public reporting?

A: The claim made for public reporting from a patient-centered point of view is that it can be for the good. If someone is able to pick their doctor according to characteristics that they find important, that would lead them to have greater satisfaction in that doctor. The physician-centered argument is that doctors realize that they are going to have to compete, and so they will improve because of market pressures or because of incentives. The question is, are we incentivizing the outcomes that actually matter to patients? That's not necessarily the case.

One example is, we want to get HbA1c under 8% for patients with diabetes. We can discuss what number is best for patients. We can say that most people with diabetes should be at 7%. But we should also realize that every treatment is a tradeoff. And I have patients who keep their blood sugar at a level they consider controlled enough for them. They don't like a higher dose of insulin, even though it would help keep their sugar under 7%, because it makes them feel a certain way. And that's a difference between what doctors think is a good idea and what patients think is a good idea.

Q: What solutions do you propose to overcome these hurdles?

A: There are certain deceptively simple things that many providers don't do. Education in medical school is improving, and communication is now well represented at least as a theoretical element on the care front. Physicians need to recognize the individuality of the patient in front of them. And that means being able to ask the patient, “What questions do you have?” or “What brings you here today?”

It's also about finding opportunities for emotional connection with the patient. To be able to express empathy, to realize that there is someone in pain, and that the pain can be rated on a numerical scale. It's also important to recognize that someone has an individual experience with that pain. And it's also a recognition that the person's individuality can also help us realize the difference between what our clinical indications say to do and what the patient wants to do.

Doctors have things they want to address, but patients have things they want to address. One of my favorite phrases is when housestaff present a patient, and they say so-and-so “is just here for follow-up and doesn't have any particular reasons for the visit.” In the great majority of cases, there was a reason for the visit. People come to doctors for reasons, whether that reason is easy for them to express, whether they feel comfortable mentioning it, whether they couch it in other terms. So the patient should list what he or she wants to do. And the doctor should list what he or she wants to do. And there should be an explicit negotiation about the agenda of the visit. Both parties should realize that there's going to be a negotiation, and that means that neither party is going to be completely satisfied.