and bases of discussion
Correct discussion technique
is the "tool" which is necessary to lead an interview. However this alone
does not guarantee that a satisfactory discussion will develop between
the two people involved. This is because discussions never take place in
a "vacuum", but in a certain setting which always contributes to
the success of a discussion. This concerns the often simple (and therefore
often neglected) conditions and surroundings of the discussion, such as
the place and time of day, the positions and the distance between the two
people, the time that is available (time pressure) and influences which
are difficult to examine objectively, such as the effect of the "climate"
of the conversation.
A basic requisite
for the success of an interview is that the person who is leading it (in
this case the doctor) develops a series of abilities which are vital
for understanding, effective discussion; the ability to listen actively
to the patient, to meet him with empathy (understanding his feelings),
to move over to him and to recognize that discovering a common reality
is the bedrock of communication between doctor and patient.
The setting of the discussion
One of the prerequisites for
the success of the discussion between doctor and patient is that it takes
place in an appropriate setting. This determines the atmosphere of the
discussion and whether or not a positive key-note can be achieved. The
right setting creates a trustful atmosphere, makes it possible to be open
and approachable without being interrupted, and allows a free-flowing conversation
and concentration on what is most significant. The ideal conversation is
characterized by concentration on the other person, active listening, friendly
approachability and obvious interest. This is the opposite of what could
be described as the "poker-face syndrome". If the situation is balanced
against the patient because noise and hectic activity have taken the upper
hand, the doctor is not "really there", under pressure of time, or there
are constant interruptions, which only allow snatches of conversation,
with obvious time pressure, the conversation is bound to failure. The setting
(surgery, ward round, house visit, emergency room)
||the time available
||the climate of discussion
The physical environment
Wherever it takes place (interview
room, bedroom, ward), and under all conditions, efforts must be made to
ensure that the discussion can be carried out undisturbed. This is one
of the most crucial criteria for encouraging discussion. All interruptions
from colleagues, clerks, nursing staff, telephone calls, "beeps" or loudspeakers,
or other patients, have to be eliminated or minimized. "Deadly sins" of
communication include discussion somewhere on the corridor, by an open
door, or "just in passing". Nevertheless, they are daily occurrences.
Anne-Marie Tausch gives many
authentic snippets of conversation in her book about conversations to relieve
anxiety, written as though they were on a tape recording or film script.
The following is a typical example from a patient with cancer: "My professor
let me know when the door was open: ".... by the way, I've just got your
report. You will have to have an Operation on Monday, as one of your breasts
must be removed." I said: "Please? What's the matter with it?" "Yes, you've
got cancer." Then the other patients started talking to me about it in
the corridor. They had heard everything." There is no justification for
this sort of information transfer through an open door.
The correct positioning and
distance is described in another chapter .
Obviously, the doctor must not only be physically there, but also actually
with his thoughts, senses and emotions.
The time factor
The sensation of time pressure
should not be allowed to arise, even in cases where the discussion actually
is being carried out under shortness of time. There is no doubt that lack
of time and the associated time pressure is one of the major practical
problems in the daily life of doctors, and certainly stand in the way of
good interviewing. It is precisely because of this, that it is extremely
important to look at every aspect of medical practice and to differentiate
between real, presumed unavoidable and avoidable time pressure.
Time pressure on
the doctor - an insoluble problem?
Ways to save time
"I just haven't got the time!"
could be the immediate response of many doctors, as a reaction to the suggestion
that they should follow the concepts laid down in this book. However, the
quality of discussions between doctor and patient is not a function of
time, but of the ability to understand the feelings of the other, as well
as employing correct interview techniques. A good discussion certainly
does not imply a long discussion, neither does a long conversation guarantee
a successful interview. Many doctors will probably only be convinced than
understanding discussion does not waste time, when they have had experience
in this area.
Nevertheless there need be
no discussion about the lack of time that most doctors have for the fulfilling
of their duties. There are two roots for this deficit of time: the
objective, immediate multitude of tasks, but also the uneconomical use
of time that is available. Ways of saving time will now be described, in
order that one can have more time for the primary task of being a doctor,
especially that spent in consultations with patients. Most of the recommendations
and tips that follow are based on the work of G.F. Gross and R.H. Ruhleder.
Initially however one important
remark: Time pressure creates shortness of time. Time pressure is
infectious and can itself create further lack of time. Time pressure lowers
It is not possible to measure
time pressure objectively, as it is the subjective experience of limited
supplies of time. This also means that I can influence how I experience
time pressure and cope with it. This in turns means that I can train myself
to tolerate time pressure, instead of constantly feeling impotent under
its influence. Whoever learns to tolerate shortness of time and time pressure
will not mention his limited time again and again, thereby releasing the
feeling of time pressure in the person he is talking to, and not disturb
something very important that has just come up in the discussion.
It has become fashionable
not to have much time; full diaries and overcrowded, loaded desks are supposed
to be a status symbol; however they are certainly not evidence of an economical
way of dealing with the time available. It is also not a sign of composure
to brag about one's lack of time and to wear time pressure like a badge
People vary to a great extent
in the way that they relate to their time. Some manage to live better
without a watch, whilst others always know exactly what time it is, to
the minute, and are still always watching the clock. Check whether in fact
you are looking at the clock more than is really necessary. Stick a red
point on your watch or clock, and make an exact note of the number of times
you glance at the time. Something is wrong if this is more than 5 times
in half an hour: this can be either your attitude to time or your way of
dealing with it.
The most important time-saving
factors in discussion are those which, at the same time, are essential
to a good discussion: active listening, empathy, an adequate interview
technique and the ability to find a mutual reality.
The amount of time which
is potentially available is laid down. If there is any possibility of using
this time more economically, a task analysis is its prime
requisite, to look at what should actually be achieved within a particular
time period. It helps to divide tasks into one of three groups as
either "vital", "necessary" and "unnecessary". Even at this point, it can
be seen that unnecessary work is the classic time-stealer and that usually
much more time is devoted to these tasks than to those which are truly
necessary or vital.
Uncompleted tasks set off
restlessness and stress. It is only a completely finished assignment which
releases this burden. Because of this, it is advisable to complete one
task after another, rather than to try to take on too many at one time.
In fact, a completed task brings one much further on than 10 which are
incomplete. A task which, in principle, will be repeated many times should
be carried out the very first time in such a way (even if it takes longer)
that the procedure can be used in similar tasks in the future, and then
involve the use of less time.
Tasks should be put into
It is an uneconomical use of time to telephone, to talk to a patient, to
visit the laboratory, to chat to a colleague and then leaf through a journal
in colourful succession. Putting these tasks into blocks of time means
that continuous and effective work can be performed in each of these areas.
Putting off a more difficult task by appearing busy (clearing up, reorganization
etc) is only a substitute for work, and actually only puts off achievement
of the major task.
The amount of reading
material, which is showered upon the doctor is increasing continually.
A closer analysis reveals that only a fraction is really worth reading.
It is therefore necessary to employ the classical system, differentiating
reading matter and
||Reading matter, which can
be immediately thrown away unread.
In the grey zone between
the two there may be, for example, one article in a journal that
does not necessarily have to be read now but which is not completely uninteresting.
One can keep this to read for a brief, limited time (not more than one
week), but should not store it for longer. The final possibility is to
properly file those works, publications or articles which appear interesting
or important, but which can not be read immediately (but they need to be
disposed of after 6 months).
Nobody has continuous competency
or efficiency throughout the day. Analyzing one's personal efficiency
curve makes it possible to synchronize difficult tasks to the time
when proficiency is maximum, and to perform easier jobs or those that are
purely routine, at a time of low efficiency. A doctor, who knows he is
"never awake in the early morning", should not arrange a difficult discussion
with patients or relatives at 8 am.
The surroundings in
which we work play a role in our efficiency, and thereby also in the way
we deal with time. The personal environment should if possible only contain
that which improves one's mood, increases proficiency, or will be of use
for getting on in the future. The permanent stack of unread medical journals
is a continual reminder of time-pressure. It can be therefore very useful
to undertake a thought-out "spring-clean".
Safeguard yourself from the
thief". Folk who belong to this group mention that they want to "come
by and see you", and "only need 3 minutes", but this goes on to 30 minutes.
Whoever really needs 3 minutes should of course have them, but not a minute
longer. The more that one is known, the more people want to steal your
time. They initially appear with great show of admiration and affection.
You are apparently the only person in the world to whom they can turn to
perform the task that they are burdening you with. You are "The expert"
or "The opinion-former". There is certainly no obligation on you to do
what they ask immediately; this appointment lies a very long way in the
It is human weakness to succumb
to these attacks on your time, if it first appears that your immediate
time is not interfered with. The decision to undertake such tasks usually
comes back to you with a vengeance and leads to the most unpleasant form
of achieving work, which is to do it under major time pressure at the last
minute. It is usually illusory to think that this task could perhaps be
delegated to somebody else (assistant, laboratory technician or consultant).
From this it can be seen
that one of the important abilities that one needs in order to save
time is that of being able to say no, only saying "yes" when you
really mean it. Much time can be saved with an unmistakable and reasoned
As you deal with patients
who give you the impression that they are taking too much time,
try to analyse what the reasons are. These are often so called difficult
patients (see chapter on this subject )
and it is only by analyzing and dealing with the reasons for their behaviour
(unspoken anxiety which could be dealt with etc) which results in your
time not being involved excessively.
Many people demand your time,
but you yourself can not extend your time by a millisecond. One way out
of this situation is to make a clear offer of time, and stick to
it whatever happens. This forces the other person to make his objectives
and requirements clear without beating around the bush. If you have made
it clear to your discussion partner that you have only 10 minutes available,
it is not impolite to signal the dose of the discussion at the end of this
time. It is much more difficult if you did not make this clear before the
discussion commenced. This is one of the ways in which you can determine
your own time schedule, and not let others do it for you.
Many tasks which you believe
you have to do yourself could be delegated. Most people are unwilling
to delegate work, either because they do not trust those with whom they
work or haven't trained them well enough, or because they have the attitude
that they are the only person would could do it all correctly. In fact
new tasks can often motivate those that work for you and can be an incentive
for a more responsible way of working. Not only the task, but also
the responsibility for it should be delegated. The stress is removed
when both are passed on. There are however two classical objections which
can be raised by those involved when a new way of working is suggested,
both of which are only sham arguments: "We have always done it this way"
or "We have never done it that way".
Finally, a very important factor
for efficiency and the associated way of working is the degree of your
motivation. Tasks which are approached with less enthusiasm and motivation
need an over-proportional amount of time. However pleasure in the work
is the result of experiencing satisfaction with the results of one's own
work. This completes the circle: the discussion which is successful is
the one which is understanding" therefore an understanding discussion is
not one that steals time. In fact the successful discussion between doctor
and patient represents the optimal economy of time.
your own attitude to time
to tolerate lack of time
infect others with your time-pressure
tasks into vital, important, and unimportant
better to complete
one task than start ten
an efficient system of reading
put off tasks by substituting bustle
tasks to your own
daily efficiency profile
to say "No"
defined offers of time
let others interfere with your time plan
how to delegate both a task and responsibility for it
time-saver is the successful discussion between doctor
The climate of the
The bases for a fruitful climate
of discussion are: a trusting atmosphere, openness and willingness to listen,
as well as the ability to relate to the patient and to be on the "same
wavelength". No aggression arises in such a discussion, which is factual
and not driven by emotions, allows recognition of resonance and does not
create anxiety. Respect and appreciation characterize the relationship
between the two people, and the discussion proceeds symmetrically.
Where the conversation is
optimal, both partners are at the same level in discussion of the subject
matter, and are communicating emotionally on the same level. Both sides
profit from such a discussion: the patient because he feels that his problem
has been accepted and the doctor, who finds it easier to obtain the necessary
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
of this page: http://www.linus-geisler.de/dp/dp02_setting.html