Confession instead of a preface
|Speaking, man is present
|in his entirety.
|Thus, everything that
|is testified to, precipitated
|deposited in language:
|everything that is human,
|all-too human, and also
|that which is inhuman.
||I have spoken rather than
||I have been given wrong
answers because I have not asked the right questions.
||I have misunderstood my
patients because I have not recognized or have confused the
various messages that they have sent to me.
||I have remained "professional"
rather than bringing empathy into the situation.
||I have rejected patients
rather than accepting them.
||Discussions with my patients
used to be unsatisfactory for both parties, because there was no correct
beginning, no clear definition of objectives and no concrete
||I have generated time
pressure and made it obvious that I was rushed.
||I have ordered rather
||I have treated patients
as if they were "difficult".
||I have overlooked anxieties,
and created them during discussions.
||I have not understood that
for the patient was not identical to that which I believed to be
||I was not aware that speech
the most useful instrument that a doctor possesses.
Briefly: I acted as do many
of my colleagues. In doing this, I have missed many opportunities, disappointed
hopes and have cheated myself out of part of the fruits of my work. I am
now aware that the right dialogue between doctor and patient can bring
about almost anything, but that incorrect dialogue achieves almost nothing.
This book is a personal attempt to demonstrate the correct way in which
discussions between doctor and patient should be carried out.
|We make speeches about
communication, but what we really need are people
|with whom we can laugh
and cry, to whom we can tell our nightmares ...
|and more than anything
else we need somebody with whom we can speak.
in DIE ZEIT
That doctors and patients talk
to one another is one of the most accepted things in the world. Would not
a complete book concerning the subject "Doctor's discourse with patients"
be superfluous? Before answering this question, I would like to share a
picture with my reader.
|I keep on noticing that
there has been no research published on the language of
A doctor enters a ward without
saying a word. A wasted man, about 70 years old, looks up at the doctor
expectantly. The doctor exposes the arm of the patient, and applies a tourniquet,
inserts a venous cannula, hangs up an infusion set and adjusts the rate
of infusion. After checking that the apparatus is functioning correctly,
he leaves, as he has come, not saying a word. This ghastly scene becomes
even more nightmarish when the drama is taken further: before the doctor
reaches the door, the patient sits up with great difficulty and says: "Excuse
me asking, doctor, but please could you tell me what you have just done?"
The doctor turns, and replies with an expressionless face: "You have got
lung cancer, and I have started an infusion to treat your tumour."
Most of my readers will find
this scene absurd. Who on earth would start a patient with cancer on an
infusion of chemotherapy without telling him what disease he has, what
the objective of the treatment is, what side-effects might arise and what
the success rate is likely to be? And what sort of doctor would approach
his patient in such an uncompromising manner, without a "how and why",
to start treating a disease which will probably result in death?
Why is it that this vision
takes on such a ghastly and apparently absurd dimension? The answer is
easy. In the initial part of the drama, the whole scene is so oppressive
and incomprehensible as not a single word passes between the patient and
the doctor. This is a vision of absolutely speechless medicine.
It represents the unease which is coming upon us with the suppression of
speech by technology in modern medical practice, described by Paul Lüth
in the following way: "Modern medical practice is dumb in areas where it
is most successful, that is in cases of extreme sickness." The spoken word
is an embellishment or by-product, and certainly not a genuine part of
the therapy. Therapy is non-verbal. This produces the uneasiness of modern,
successful medical practice.
But the second part of the
vision also has a depressing effect; in fact for the same reason. Even
here, there was no real doctor-patient discussion. What actually took place
was a communicative procedure, which broke all rules of discussion between
doctor and patient and, if the expression existed, could be best described
Of course one must ask if
this vision is not completely absurd and probably unthinkable in day-to-day
medical practice? However facts with a short selection of authentic examples
probably give the best answer, even to the question as to whether a book
about discussions between doctors and patients is really necessary.
Example 1 (or: Is the
patient allowed to speak?):
H. Beckan and R. Frankel,
American sociologists from Wayne State Medical School in Detroit, secretly
videotaped 74 discussions in general practices. The results showed that
the patient was interrupted by the doctor on average within 18 seconds
of beginning to speak. Only one quarter of the patients managed to continue
describing their Symptoms until they had finished.
Example 2 (or: Why
are patients not satisfied with their doctors?):
N. Cousins from the University
of Los Angeles, who lectures in "Humanity in Medicine", wondered what grounds
patients had for changing their doctors. He questioned 1000 patients who
had changed their doctor in the 5 years previously, or who intended to
do this in the near future. He received 563 completed questionnaires. Typical
reasons for changing doctors were: "I had the impression that my doctor
did not want to listen to my symptoms; he seemed to want me to be examined
by machines as soon as possible", "I have no idea what the doctor explained
to me. I was too confused and worried to ask any questions." The art of
being able to listen is more important for the doctor than that of talking.
Example 3 (or: The
ability to speak to relatives):
The advice that was given
by a hospital doctor in 1985 to the wife of a patient with multiple sclerosis
with regard to anticipated difficulties with potency was: "Your husband
has multiple sclerosis; you should get a divorce!" (G.H. Seidler).
Example 4 (or: Are
computers better conversation partners?):
St. Silicon's Hospital in
Cleveland, Ohio, cannot be found on any map of the city. It is not a hospital
building that one can visit, but instead a computer databank, from which
patients can receive advice. It answers such questions as: "Are there various
sorts of breast cancer?", "What is atria fibrillation?", "Does electric
shock therapy help schizophrenics?" etc. Patients can type such questions
into their home computer and get an answer back from a "specialist" ("Doc
in the Box"). This programme, which is available for a small fee, has been
developed by the Case Western Reserve Medical School in Cleveland. The
patient has direct access into the information system where the questions
are stored. Doctors go through the questions every day, formulate answers
and mail these back electronically to the questioner.
Thomas Grudner, who developed
the programme, insists that the computer should never replace visits to
the doctor. In fact it offers personal tips and never real diagnoses. Nevertheless
Grudner is aware that patients ask many questions that they would not ask
a doctor, and that this service is teaching doctors how to manage patients
Example 5 (or: Is it
difficult to create a reality common to both the doctor and patient?):
Anne-Marie Tausch, a professor
in psychology who died of cancer, described (1983) the following transaction:
a patient who complained that she was losing her hair as a result of chemotherapy,
received the following reply from her doctor: "Is losing hair a loss of
your ego? I don't believe that the ego resides in the hair".
Example 6 (or: One
way of dealing with a cancer patient):
Anne-Marie Tausch describes
in her book how she was informed that she had cancer:
"I was told about the diagnosis
of cancer in hospital. The doctor, during her usual ward round, briefly
described the histological findings. She immediately started to talk about
therapy. She stood at the foot of the bed, not next to me. Then the nurse,
who was accompanying the doctor, stuck a thermometer into my mouth without
saying a word. It was more important for her to measure my temperature
according to the regulations. I was extremely aware that neither of them
were the least bit aware of my pain".
This scene from daily clinical
practice reveals nearly all of the mistakes and deadly sins that can arise
in conversation between doctors and patients. A diagnosis which decides
the fate of the patient, and may be a death sentence, is curtly given to
an unprepared patient, with no obvious sympathy. The discussion is totally
asymmetrical, as only the doctor speaks and the patient is hardly allowed
to utter a word, although many urgent questions are raised as soon as the
diagnosis of cancer is given. In addition (on a completely different level
of reality), the ritual of normal nursing procedures continues regardless.
Instead of experiencing human care, and understanding, the patient is required
to have her temperature measured. By keeping her distance, the doctor is
signalling by body language either her defensiveness or inability to get
involved with her patient.
Of course some of these are
extreme examples, and were not used in order to show common situations,
but to reveal the basic disorders in communication between doctors and
patients in a particularly strong light. The majority of difficulties in
discussion between doctors and patients are not so dramatic; that is if
considered at the superficial level. Throwing light on the background reveals
that, from the patient's point of view, they are not at all of petty importance.
These sorts of discussion actually take place every day.
Benjamin gives a particularly
pertinent example in his book "The Helping Interview".
"'Why have you not taken
your tablets? Didn't I tell you how important it is that you take them?'
Mrs Bell struggled not to cry. She knew that her doctor meant well; she
also knew that he had a lot to do, and just how long it would take her,
if she even tried to explain the reasons to him. She knew well enough why
she had not taken the tablets. She did not know if it was right or wrong,
but she didn't bother about that. She knew that it really didn't matter
if she got better again. In fact she was much better cared for if she was
ill. She knew something ... about the children and grandchildren and why
they had stuck her in this home. And about this home ... she knew a lot
about this. But the doctor wanted to know why she had not taken the tablets,
and so she replied briefly: "I'll take them now, you'll see." The doctor
was satisfied. He smiled, shook her hand and opened the door for her. He
really didn't want to know why. He only wanted her to take her medicine.
He did like the old lady, but he was much too busy to make more time for
Disorders in communication
between doctor and patient are as old as medicine itself, as speaking with
another inevitably entails basic misunderstandings. However, misunderstandings
between doctor and patient have a particular significance. As the potential
of medicine, especially technical and pharmacological knowledge, increases
so does the danger of extensive disorders of communication. More and more
specialists are appearing in all areas of medicine. However many doctors
do not go beyond the level of a self-taught amateur with regard to their
ability to speak to patients. There are of course some doctors who have
a natural talent for guiding conversation. However there are very few who
Thomas Bliesener (1986) writes
about one of the basic causes of the problems that doctors have in dealing
with patients: "Whoever wants to sell a computer, shares or a beta-blocker,
receives a much better training in leading discussions than the doctor
who is attempting to help his patient towards health. Salesmen, representatives
and public relations staff from all product areas receive highly specialized
training in speaking. There is no such speech training for the doctor.
He remains almost completely isolated with his problems in managing consultations."
The ritual of the brief,
friendly but factual discussion apparently completely devoid of problems,
takes place every day at innumerable times in surgeries or during ward-rounds.
This ritual however is particularly good at hiding the true communication
disorder between doctors and patients. M. Hertl: "How often does the doctor
induce a feeling in the patient that he can only answer the question "How
are you?" briefly and rapidly with "Okay!", in order not to create even
more disturbance for the busy doctor. If he tells the truth, which is that
he is not feeling well, then the doctor will have to stop and talk about
it, ask more questions, think about it and get help. The patient doubts
if the doctor will carry on being in a good mood if he is required to spend
his valuable time doing this. So it is that the greetings between doctor
and patient, which appear superficially to be creating friendly communication,
are in fact lies and have no hope of success."
In an essay entitled "There
is no substitute for discussion", W. Cyran critically analyses the way
medicine is being lead astray by technology, and the consequences: "In
an attempt to attain complete objectivity, it has become forgotten in the
welter of results delivered from the machines and laboratory tests, that
life is equally both objective and subjective. It is not only in medical
practice that this Illusion of objectivity leads to destructive and dehumanizing
results, because everything that is subjective or emotional is considered
unimportant ... The mechanistic machine model should also not be employed
for the diagnosis of disorders of bodily function because this leads to
even more unselected data gathering. It is curious that the model of the
machine, which first arose from the study of physics in the 19th century,
is still maintained in modern medicine, even though modern physics has
moved on to a completely different position. A major part of this is certainly
due to medicine becoming more technological; but a result of all of this
is the emotional speechlessness of the doctor mirrored by the desperation
of the patient."
Why discussions misfire
between doctors and patients are not exceptions but, if considered critically,
a daily occurrence. Bliesener neatly refers to the ward round as "handicapped
dialogue". Nearly all communication disorders in medicine can be
traced back to 3 basic causes:
speech is the most important instrument possessed by the
||Poor discussion technique,
||Disorders in the doctor-patient
Based on these 3 causes,
a list of reasons can be drawn up, which is certainly not complete,
but which can all lead to misfiring of discussions between doctors and
of the discussion
||Incorrect closing of the
||Inability to listen actively
||Language which is incomprehensible
||Inappropriate frame for
discussion (place, time, surroundings)
||Vague diction as a result
of vague notions
||Discussion not encouraged;
||Use of generalizations,
communication and "killer phrases",
||Not picking up the various
messages in a communication
||Orders instead of motivation
||Induction of anxiety
||Regarding the other person
||Lack of metacommunication
||Inability to construct a
Many doctor are only vaguely
aware that their discussions are not really running satisfactorily, that
is unsatisfactorily for them as well as the patient. A consultation can
be unsatisfactory for the patient if he feels that his problems,
situation, or conflicts are not understood or accepted. He may be aware
that his doctor sees his illness in another way to that which he is himself
experiencing it, and that his world and that of the doctor cannot be reconciled.
The doctor is also left feeling dissatisfied; he was unable to make
the patient really aware of his view of the patient's illness. As
a result, the patient did not completely follow what he was saying, he
refused obviously necessary investigations and therapy, and his compliance
left much to be desired. These discussions are very trying to the doctor,
leaving him tired, unenthusiastic and/or aggressive, for he, too, knows
or is aware deep down that the reality of his patient is not identical
to his own reality. He then finds that discussion is a heavy burden
which he must take up again and again, day after day. He never realizes
that speech is the most important instrument he has; that to speak and
to hear and understand what is said, is a unique privilege of being human;
that medical practice which does not use all of the possibilities is futile,
and that speechless medicine is ultimately inhuman medicine.
A brilliant exposure of the
power of speech, in the example of manipulation by words is found in George
Orwell's novel "Nineteen Eighty-four":
The vocabulary of Newspeak
"was so constructed as to give exact and often very subtle expression to
every meaning that a Party member could properly wish to express, while
excluding all other meanings and also the possibility of arriving at them
by indirect methods. This was done partly by the invention of new words,
but chiefly by eliminating undesirable words and by stripping
such words as remained of unorthodox meanings, and so far as possible
of all secondary meanings whatever. To give a single example. The word
still existed in Newspeak, but it could only be used in such statements
as 'This dog is free from lice' or 'This field is free from weeds'. It
could not be used in its old sense of 'politically free' or 'intellectually
free', since political and intellectual freedom no longer existed even
as concepts, and were therefore of necessity nameless".
Syme says to the protagonist
of the novel, Winston Smith:
"Don't you see that the whole
aim of Newspeak is to narrow the range of thought? In the end we shall
make thought crime literally impossible, because there will be no words
in which to express it. Every concept that can ever be needed, will be
expressed by exactly one word, with its meaning rigidly defined
and all its subsidiary meanings rubbed out and forgotten... Every year
fewer and fewer words, and the range of consciousness always a little smaller."
"Speech" according to the
renowned American linguist, Benjamin Lee Whorf, is the "best skill that
mankind has. It is completely his "scene" on the stage of evolution, in
which he appears from the wings of the cosmos and really plays his part."
Speech is the reference
system within which people think and within which they experience their
own reality, within which they meet one another and come into contact with
the other's reality. Wittgenstein summed it up in a few words: "The limits
of my language are the limits of my world".
What this book attempts
This book shows simple methods
which make it possible for doctor and patient to speak to each other better
than is usually the case. Improved discussion have been shown by personal
experience to lead to fewer unsatisfactory consultations and ultimately
more successful discussions.
The success of satisfactory
discussions between doctor and patient depend on three skills:
to the patient,
||The use of an adequate discussion
||Both doctor and patient
finding a common reality.
If these requirements are
fulfilled, it is possible to have that type of discussion which is related
to successful medicine, which is understanding discussion.
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
of this page: http://www.linus-geisler.de/dp/dp01_introduction.html