September 30th, 2014 at 9:00 am
The following is an interview with Dennis Rosen, author of Vital Conversations: Improving Communication Between Doctors and Patients:
Question: So what is Vital Conversations about?
Dennis Rosen: Vital Conversations is about why good communication between doctors and patients is so important to achieving better—and less expensive—health outcomes. It explores many of the reasons that this communication becomes compromised, such as cultural and socioeconomic differences; stigma and bias; and external meddling in the actual content of the medical visit that takes away from the direct face time between doctors and patients. Vital Conversations concludes with clear suggestions—for both patients and doctors—about ways each can improve the quality of their interactions in order to get more out of them. It also provides suggestions for how the health-care system can prioritize this issue in ways that will serve us all.
Q: I notice you spend a lot of time in Vital Conversations discussing how cultural differences between patient and physician influence the quality of their communication. What made you decide to focus on this?
DR: I’ve spent most of my own life moving among different cultures. I was born in the US, lived in Canada until I was 15, then in Israel for the next 19 years, and have been living in Boston since 2001. I completed my medical education and pediatric residency in Israel, and did additional training as a resident and fellow at Boston Children’s Hospital before becoming an attending physician eight years ago. I have also worked in Haiti and Guatemala several times over the last five years. All of these experiences have given me deep insight into how the ways we perceive and understand what happens to and around us influence our ability to explain it to others, and to understand their explanations in turn. When the underlying concepts are different, this can become very difficult.
Although magnified when working with people from different cultures—and let’s not forget that one quarter of American physicians were trained abroad—it is also true even when both doctor and patient are of the same culture. One issue that I explore in Vital Conversations is the differences between the objective disease, subjective illness as experienced by the patient, and sickness as defined by society. A person with a broken finger has obvious disease, and the illness process she is suffering as a result is likely to be straightforward to the physician. By virtue of this shared understanding, the doctor’s treatment recommendations are likely to be easily understood and carried out by the patient. However, a person who comes to the doctor’s office and is found to have high blood pressure may feel absolutely fine, i.e. have disease without illness. Unless the doctor is able to convince him of the need to take medications to keep the hypertension from leading to heart disease or stroke, he may be inclined to stop taking the medicine at the first sign of side effects, leading to progression of disease.
All throughout the book I’ve included numerous personal stories and vignettes from my career as a physician that illustrate these and other points I make. Even though I wish I could claim otherwise I still don’t always get it right, despite my best attempts to, as the stories make clear. As fascinating and entertaining as the stories themselves are, I think that they really drive home the central message of the book, which is that good communication between doctors and patients is vital for medical care to be effective.
Q: What about the culture of medicine? There is such a thing, right? That must also play into how doctors and patients communicate with each other.
DR: Absolutely. Doctors are trained and work within a system that is constantly in flux and changing the way it defines and treats disease because of new technologies and scientific knowledge. However, these changes are gradual, and take time to percolate through and be embraced by all. In addition, different societies make different decisions about which treatments to approve, based upon such factors as local cultural norms and cost. When a patient accustomed to receiving medical care for a specific issue in a certain way in one country finds herself in another that does things differently, the result can be a crisis in confidence. For example, vaginal births after previous caesarian delivery are much more common in Europe than in the United States, and this discrepancy arises, among other reasons, because of differences in medical culture. It is important that both doctors and patients appreciate how un-monolithic the practice of medicine can be—evidence-based-medicine guidelines notwithstanding—and that there is often more than one way to skin the proverbial cat. Openness on the part of physicians to different approaches to treating the same problem can go a long way in bringing the patient to accept the proposed treatment plan, increasing its likelihood of success.
Q: Most of the time when I visit my doctor, I feel rushed and like there’s never enough time for all my questions. What can I do to get the most out of my doctor’s visits?
DR: There’s a lot that you can do, actually. First, I’d suggest that you start thinking about your visit the night before and define what issues you hope to address and what questions you need answered during the visit itself. Summarize this in a list (increasing need to urinate during the night, prescription refills, whether you should have that new blood test you heard about on NPR last week, etc.), and bring two copies: one for you, the other for your doctor that you can hand her at the beginning of your visit. That will help you both keep the visit on track and focused on what you need. Another very important thing is to take notes during the visit, or even better, have somebody come with you who can take notes for you and free you to focus entirely on what is being discussed. That person can also ask clarifying questions that may not occur to you during the visit because of stress or discomfort. Another thing you can do is to “read back” the summary of your visit as you understand it to your doctor. This will help you both be sure that you’ve understood exactly what you’re supposed to do, when you’re supposed to do it, and under what circumstances you should call, come back, or seek further help.
Q: Do you have any suggestions in your book to doctors about improving how they communicate with their patients?
DR: The book is full of suggestions to doctors about how to improve their communication with patients, more so than for patients (even though I believe that patients will benefit from reading these as well). These relate to listening, body language, clinic room configuration, the use of medical decision-making aids and graphic images, using existing technology to increase the impact of the visit several-fold, and developing cultural competencies. Just as being a physician is a continuous process of knowledge acquisition and assimilation with experience that never really ends, so too is the development of communication skills with patients. By recognizing the areas in which improvement can—and indeed should—be made, a doctor should be able to improve his ability to guide the healing process he intends for his patients to successful results.
Q: So maybe I should buy two copies of your book: One for me, and one for my doctor?
DR: (laughs) Absolutely! I think both will really enjoy it and come away with practical guidance about how to improve their mutual relationship.