Wolf Langewitz, M.D. is Professor and Medical Director of the Psychosomatic Medicine Department at Basel University Hospital. We hosted a comment on his work “Spontaneous talking time at start of consultation in outpatient clinic: cohort study”, and we want – by this interview – to deepen some aspects of communication strategies in doctor-patient consultation.
Q. What did lead you to “Spontaneous talking time at start of consultation in outpatient clinic: cohort study” research hypothesis?
W.L. The reason was that when we trained residents to listen to patients, and to offer open space to patients, so that they can talk freely, we were usually sensing one major problem: physicians said “I’ll not do it, because patients will be talking so long that I’m violating the time schedule”. So the research hypothesis was, first of all, if is this claim justified – that patients talk without end if you let them talk – and therefore we were primarily interested in verifying whether doctors’ assumption was true or not.
Q. What can we learn from the results of this research?
W.L. What we concluded was that in general a physician does not risk very much, if she/he allows the patient to present her/his complains in detail, because on average it won’t take much longer than two minutes. What we also found however, was that some patients talk much longer, up to 15 minutes, and therefore we followed a two-sided strategy: on the one hand, reassure physicians that, in general, patients do not talk very long if you let them, they want the doctor to continue within two minutes; on the other hand, we thought that we had to give physicians a technique, how to prevent patients from statements that disrupt the physicians’ schedule. So what we teach medical students and physicians in postgraduate trainings is a combination of closing this space, reducing room for the patient, room explicit structuring, and on the other hand open spaces within these initially defined boundaries. This works like we ask physicians, doctors, nurses as well, to first of all tell a patient what that time-schedule is, so that patients can arrange themselves within this timeframe. And we ask doctors to first of all come to an agreement on the items that are to be dealt with during this consultation. Which goes like, doctor says “Dear Mrs. Gianfranca, I have two items to talk about today: one is your blood pressure, and the other one is your complain about the pain in your right knee. What would you like to discuss with me?”, and then the patient brings forward her/his items. In the next step, they share the decision on what they are going to talk about today, and what they postpone for the next appointment. This is our basic idea of combining techniques that open space and tools that narrow space.
Q. Which advantages could have focusing the attention on patient and not on his/her disease?
W.L. This is a very fundamental question because it includes the distinction between disease and illness, which means that disease is what one objectively states – someone suffers for a certain disease because she/he fulfills certain criteria, and it is observed in objective facts. If I say you that you’re suffering for diabetes, I could justify this label by quoting certain laboratory findings, and every physician in the world would come to the same conclusion. So, disease is in objective findings. However if I am interested in learning how you get along with your disease, I’m interested in illness: and illness is something which is not objectively based, but is based on your subjective appraisals of living with a certain disease. So illness is subjective, disease is objective. I would say all chronic diseases, as to the treatment of chronic diseases, relies on the patient’s willingness to follow a certain therapeutic regimen – that means what the physician proposes to a patient must be met by at least similar assumptions from the patient’s side. Otherwise, she/he would not follow the doctor’s advices. Therefore, in order to treat someone with a chronic disease I must understand how she/he perceives her/his illness. And this is something that goes beyond the objective statement of this patient is suffering for a certain disease.
Q. Do you think that more attention on communication elements could be useful during medical training?
W.L. Yes, of course. And it will ever be more important because the aging of society is one driving force that leads to more people with more complex diseases, which means that therapy become all the more complex. Therefore, it is ever more difficult to explain to a patient how therapy looks like, and it is becoming more difficult to find his/her agreement, one certain behavior modifications including taking pills. Next point is that medicine offers a continuously increasing variety of therapeutic options, therefore I can’t just tell the patient “Take the red pill, and you will get better”, but I have to offer the red, the pink, and the green pill, because nowadays are three therapeutic options. The patient should come to a decision, whether or not the pink one is ideal for him/her; I have to explain the difference the red, the pink, and the green pill. This makes communication good.
Q. Which practical tools and suggestions could help doctor-patient communication, according to you?
W.L. According to what I believe, and what I teach, it is practical tools, communication techniques, so to say, and they are the one that I mentioned above – techniques that reduce space, among them the most important is explicit structure, and those that open space, which can probably easier be summarized under the term “reflecting back”. These are techniques that do not by which the doctor does not introduce new material into the discourse by either asking questions or by providing information. Using reflecting back the doctor hangs back the lead of the interaction to the patient. And this is a wise technique if the doctor does not really know where to go. If the doctor knows where to go, it’s not useful to communicate in a purely patient-centered way, because this generates more information. The doctor needs the patient to clarify the problem and to develop ideas for that solution, if he knows (or thinks he knows) where the problem is, and what solutions might be, he has to take action and reduce space by telling himself what he thinks he has to say.