The beginning of the discussion
The beginning of the discussion,
when the doctor and patient meet for the first time, is often the most
difficult phase of their relationship. This is the discussion upon which
the shape of all future discussions depend. Similar to the "first impressions"
which decide the further course of relationships, so it is that the effect
of the "first words" can direct the course of the development of the doctor-patient
|He who misses the first
buttonhole does not
|complete the buttoning.
There is no other real parallel
for communication between doctor and patient. In the case of the doctor,
he is expected to have extensive sensitivity, competence and to be able
to support a great deal. The patient on the other hand must reveal, to
an considerable degree, his problems, difficulties and anxieties to the
unknown person in front of him; a situation which hardly ever arises elsewhere.
The relationship between the doctor and the patient is not a "social relationship
in the usual sense", and certainly does not follow the classical business
contract, even though there are wide-reaching legal implications on both
What happens when the doctor
and patient first come into contact? The answer to this question contains
the key to the correct initiation of the discussion:
first two strangers are meeting, who must find, probably as rapidly
as possible, a mutual basis of trust, which will allow the solution of
very personal problems.
is not without tension; the patient wonders if he will receive help
and what form it will take and the doctor wonders what will be required
||The patient comes
with certain expectations; these can be realistic but also completely
the discussion is often marked by anxiety and inhibitions;
anxiety of the patient about what will happen to him, and inhibitions with
regard to very personal, difficult or taboo problems; the doctor may doubt
if he is able to fulfil the requirements expected of him.
starts to develop, but its significance is not yet obvious. All eventualities
ranging from a brief and quickly forgotten meeting to a doctor-patient
relationship of fateful importance are wide-open at this point.
The following shows what
must come over during the initial phase:
feeling of being a stranger must be overcome as rapidly as possible.
The patient must have the feeling that he is welcome. The first contact
is made smoother by a "warming-up" touch, and verbal "ice-breaker".
||The patient must
be given time during which he can express himself.
of the doctor must show involvement, interest and friendliness right
from the start.
||The patient must
be made to feel secure and open.
(about the role of the partners in discussion, or the objectives of the
discussion) must be cleared out of the way.
indications of anxiety and inhibition must be recognized
and dealt with as soon as possible.
The "constructive start"
is the best device for initiation of discussion (R. Bang). With the exception
of the emergency situation, obtaining information or solving problems is
the primary consideration of the start of the discussion, but rather the
construction of a stable relationship between the doctor and patient. This
also creates the basis of "keeping in touch". The importance of
keeping in touch should not be underestimated, as in all dialectic situations.
For example, it is not possible to continue major international politics
if the parties do not remain in contact. This has been shown by the fact
that it was better to continue with disarmament meetings year after year,
even though this was ineffective to all intents and purposes, than to get
into the difficult rigidity of "cold war". This is not in contradiction
to the basic task of the consultation, which is problem-solving.
The more the doctor is able
to encourage the patient to speak freely, the more the discussion
will be productive. How can this be achieved? The answer includes presence,
calmness, empathy and emotional support.
Presence ("being all there")
shows the patient that the doctor is interested, involved and understanding
of him and his problems. Calmness increases the security of the
patient and thereby his feelings of self-worth. Empathy signifies
uncritical recognition of the sensibility and feelings of the patient,
even though the doctor does not get involved in them (see chapter on empathy ).
support lets the patient know that the doctor is both competent and
warm-hearted. This is not to be confused with sentimentality, sympathy
or compassion. This emotional support should not be regarded as "professional
neighborly love", as this is a contradiction in terms, just as true love
has little to do with professional love.
Emotional support can be
achieved with verbal and non-verbal means. The simplest non-verbal form
of emotional support is that of smiling. This is the opposite of
the "poker-face" or "straight-faced" behaviour. It is one of the appropriate
icebreakers at the start of discussions. There is a creative force in a
smile. Not only does smiling relax the person who smiles, but it is an
antagonist to hecticness. Smiling has a markedly infectious effect, and
is emotionally convincing. "Nobody smiles at someone whom he rejects or
distrusts, who is not accepted for being a person, or who appears to be
an undesirable failure. If the helper smiles, he is credible, demonstrating
his interest and compassion, even when no word passes between them" (R.
Bang). This is however no reason for referring to the medical profession
as "the smiling profession".
The projection of empathy
and understanding does not mean that one has to agree factually
with the patient. Remarks such as: "I completely understand" can give the
impression that one agrees, although this is not the case. Therefore terms
such as: "I can understand from your point of view, why you reacted in
this way" or: "It appears to me that your reaction was understandable,
in the circumstances you described" can be used to give emotional support
and project understanding.
One of the most crucial rules
for the initiation of the discussion is provided by Ruth Bang as: "Start,
from where the other is!" This means both:
to start from where one is oneself.
accept the starting point of the other.
As well as determining the
starting position (social status, educational level etc.) it is important
to determine the internal starting point. What are the wishes, expectations,
thoughts, feelings and weighty issues for the patient? How is he experiencing
this illness? How does he see it in retrospect and anticipate its effect
in the future? What areas of his life are affected by this illness?
The more that the internal
standpoint of the patient is revealed, the less danger exists that the
discussion will continue in the dark. Of course, finding the internal starting
point of the patient can be made very difficult by his defense mechanisms,
lack of understanding and the use of conventional hackneyed phrases.
The second most important
principle for opening the conversation is to allow the patient to
have an active role in the discussion from the very beginning. This
is easier if use is made of the "open start" method.
The basic requirement for
the open start is a questioning technique using mostly open questions,
although closed questions, appropriate to the general direction of the
discussion, can be interjected economically. A bombardment of closed question
can rapidly lead to rigidity, internal retreat or skating over the surface.
Such a "questioning corset" (L.R. Schmidt) confines the patient and robs
him of the possibility of presenting his own point of view. Allowing the
patient to use his own words reduces the danger of him delivering a description
deemed appropriate for doctors' ears but containing information of questionable
worth. In addition, describing a problem in one's own words has a considerable
of the initiation of discussion
Rules for the opening of discussion
can only be given under great reserve. The doctor needs considerable room
for maneuvering especially at the start of discussions, and the individual
situations are extremely variable. It is therefore completely legitimate
(and in fact even necessary in some circumstances) to ignore some of the
If there is any possibility
that the patient might not know who the doctor is and what he does, the
doctor should introduce himself clearly by name and describe his function.
This especially applies to hospitals in which patients are usually confronted
with a variety of doctors. Studies have shown that patients in hospital
very often do not know the name of their doctors or their responsibilities.
The description of function
should be as simple as possible, such as "Mrs. Smith, my name is Dr. ...,
and my job is to give you the anaesthetic tomorrow". ".. .1 am the x-ray
doctor, and would like to have a good look at your kidneys by lying you
here and injecting this fluid into a vein in your arm..." This is better
than "I am the anesthetist, radiologist etc.". The doctor who is responsible
for a particular patient on a ward, should present this fact during his
introduction: "Mr. Smith, I am Dr...., and am the houseman responsible
for this ward and the doctor who looks after you and your concerns."
How should the doctor receive
a patient during surgery time? Certainly not by remaining in his chair
making notes about the previous patient, and saying: "You can sit down"
without even looking up to make eye-contact. He should at least rise from
his chair, give the patient a friendly glance, welcoming him in with a
gesture of an open hand. A barrier can be created if he remains behind
his desk. The reception is more friendly if the doctor leaves his "own
territory" and moves away from the desk. It is even more effective to move
a few steps forward towards the patient. Only then should the patient be
offered a seat and asked to sit down, and he should sit before the doctor
takes his place.
If the doctor does not know
the patient, or why he has requested an appointment, the discussion can
be opened using familiar general questions, which should underlined at
the same time by willingness to discuss and availability such as:
"What can I do for you?"
"What led you to come to
"What is it that you would
like to discuss?"
"How can I help you?"
Many individual modifications
are possible. A question such as "What's wrong?" is not particularly useful.
Patients sometimes understandably reply: "I thought you would be able to
To ask: "What are the problems
that made you want to see me", is also not very useful. Many patients are
really not aware that problems have led them to the doctor, and their symptoms
are, as it were, just "packaging". In other cases "problem" is a trigger
word, releasing defensive reactions.
Sometimes patients have already
described their symptoms to the receptionist, or have asked the doctor
for an appointment by phone. In these cases, nevertheless a careful approach
is advisable, as one cannot be sure whether these complaints are the real
reason for the consultation or they are only acting as an "ticket" for
the appointment (Froelich and Bishop).
Inhibitions preventing discussion
about very personal problems, or even difficulties in articulating the
most important factors in a limited time, can be hidden by the use of generalizations
especially at the beginning of the discussion. In these cases, the doctor
must attempt, by encouragement and obvious availability, to help to define
the patient's concerns.
Doctor: "What was it that
brought you to me, Mrs. Jones?"
Patient: "I simply can't
manage any more."
Doctor: "That sounds bad;
can you tell me more about it?"
"Please tell me more in
detail what you mean?"
Other calming and encouraging
phrases that could be used are:
"We can talk about it, even
if it seems difficult for you." "Simply tell me what seems to be the most
important for you." "Try to be calm and tell me all about why you have
come - I'll just listen."
The correct eye contact
also counts as one of the most encouraging nonverbal signals and is an
expression of open availability at the same time.
The correct level is
that of the orbit. The person who looks at the ground creates the impression
of absence and unreadability. Looking upwards (a common phenomenon of poor
speakers, seen especially in politicians) creates the impression of arrogance;
the conversation partner feels that he is being "overlooked". One should
look at the other person whilst he is speaking. Whilst speaking,
a prolonged eye contact is disturbing. It is better to avert the eyes,
i.e. onto the hands or the desk.
causes of unsuccessful starts to the discussion
hand contact (this depends on the culture)
or excessive eye-contact
ignored (false perceptions about the role and function of the doctor)
for the reception
seating and/or distancing
technique (questioning corset?)
not carefully dealt with
||No notice taken
of non-verbal signals
environmental factors (noise, assistants, telephone, pressure of time)
and being friendly
aspects of speech and communicative aspects:
the first button hole?
from where the patient is?
||Finding out where
the patient stands internally?
and unfolding of the patient?
||Lack of emotional
Whether or not the doctor
should start taking notes from the very beginning of the discussion
is a question with several answers. The patient who requires quite a lot
of encouragement and support in the initial phases, can get the impression
that the doctor is not concentrating on him if he is busy making notes.
In general it is usually better if notes are not made immediately,
but all attention is paid to the patient. On the other hand breaking off
the conversation, turning away the eyes and jotting down notes can give
a breathing space to a patient who is momentarily overcome by a wave of
inhibition, or needs time to compose his emotions ("communicative pauses").
As the history is usually taken
at the onset of the discussion, it will be dealt with here. In the monograph
on the practice and theory of history taking, R. Adler and W. Hemmeler
described history taking as the "impossible" task. This is the contention
of the essay of R.R. Greenson, "The Impossible Profession" for psychoanalysis,
in which he explains that it is extremely difficult to reconcile the two
diametrically opposed characteristics of, on the one hand, understanding
the patient and being in tune with his feelings, and on the other hand,
to think logically and precisely.
|A "good" interview
|always contains some
What follows is not an external
schema for history taking, leading from the present history into previous
history, family history etc. which every doctor does automatically. Rather
it is an attempt to outline the internal schema during history taking.
This allows a more overall picture of the patient, somewhat similar to
the "bio-psycho-social concept" as conceived by Adler and Hemmeler.
Adler and Hemmeler described
the basic difficulties of obtaining a rounded history, which should reflect
the factors of the individual reality of the patient: "During history taking,
the doctor has to pick out facts which he can link with anatomical, pathophysiological
and biochemical considerations. He has acquired this framework by logical
thinking during his studies. On the other hand he must draw out facts which
are concerned with human behaviour. .. and verbal statements which he cannot
take at face-value, but for which he should seek hidden and covert meanings.
These features lie diametrically opposed to one another; one involves logic,
abstraction and objectivity and the other, the ability to identify with
the feelings of the patient, and to perceive what is described as scenes
and acts of a dramatic production. It is a difficult task for one person
to integrate these during one session; it is a task that is never completely
solved, and recurs every time a history is taken."
There are 10 steps in
the interview according to the authors:
In many cases the steps 1-4
allow a provisional diagnosis to be made. Steps 5-8 should build up a picture
of the patient. The objective of the extensive comprehensive history
is not only to collect data but also to determine the individual reality
of the patient. This "scheme" is only a guide-line. The less experienced
the interviewer, the more he should try to follow these steps. The more
experienced doctor can deviate from the scheme.
||Creation of a
||Mapping the symptoms
|g. Other influences
picture of the patient
Taking a history is understood
here to be more than a method of dialogue which allows the doctor to gain
as much information about the patient in as short a time as possible, in
order to come to a (physical) diagnosis as quickly as possible.
There are certainly many
situations in daily clinical practice in which this sort of history taking
is sufficient. The physician is mainly concerned with the bodily functions
of the patient, the body being considered the "object under investigation".
This is a "single-person" situation. Most doctors take this exploratory
style for granted as the most economical way of working.
However the limits are reached
at the point at which the psychosocial situation of the patient
demands it. Whether this is necessary, and to what extent, is often discovered
only during the discussion itself. In this sense doctor-patient discussions
are primarily "understanding discussions" (F. Meerwein). This sort of discussion
goes beyond the physical in order to find possible "areas of conflict".
Whenever more information
is needed than that revealed by symptom-analysis, more than the classical
history is required, that is to say, a type of questioning that includes
the patient's psychological make-up as well as his past history. It is
a structured interview that aims to:
information, in order to release a positive reaction, which is related
of the individual reality of the patient, and the way in which this
The patient comes to his
doctor with the offer of a disease. This expression comes from Balint,
who says that physical symptoms and signs of disease, and the way in which
they are presented, can be a request for involvement. This step is however
ambivalent, as he is notifying the doctor of a request (which is not
discussed) wrapped up as a symptom. The job of the doctor is to accept
this offer, as it is presented, but at the same time to take care to unwrap
it in such as way that it is possible to put it into words. Von Weizsäcker
has described what is required of the doctor as "yes, but not like that"
The extended history in the
form of a structured interview should not be taken to mean that every doctor
has to be involved in psychotherapy. Bellak and Small correctly noted that
"brief psychotherapy" is often more difficult than extensive psychotherapy,
and needs just as much commitment. The structured interview should not
be considered a form of discussion which wastes the doctor's time in clinical
practice. Bally put it that "the doctor does not have to devote more time
to the patient, but should listen to him in such a way that time is saved".
This is best achieved by active, understanding listening,
in association with economical, targeted intervention.
The two-person situation
Even in the one-person situation,
the doctor talks to the patient. This "talking" however serves to inform
both sides about objective facts necessary for orientation within the factual
world of the physician (Meerwein). In the two-person situation the
objective of the discussion is to develop a therapeutic instrument
out of the relationship between the doctor and the patient. The patient
and the doctor no longer wander around in a sort of emotional nomansland
during their discussion. Instead they meet each other in a psychical field.
This psychical field depends upon certain prerequisites, which begin with
the arrangement of the room, and extend to whether the doctor can project
emotional warmth. The attitude of the patient to the doctor also plays
a role. This means that the psychical field depends on the personalities
of the doctor and the patient, in addition to their individual objectives.
It is only possible to have a two-person discussion within this sort of
A successful discussion can
only be achieved when this psychical field seems favourable to both. If
deeply entrenched difficulties arise (for example, because the doctor is
not able to create emotional warmth or to show empathy), it is unlikely
that this discussion will be successful. In fact it has been shown that
there is no true substitute for this warmth and genuine understanding.
The majority of patients intuitively recognize if they are in a situation
in which "friendliness is forced". It is not possible to correct such difficulties
in a doctor-patient relationship with words, which are white-wash.
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
of this page: http://www.linus-geisler.de/dp/dp10_beginning.html