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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
The beginning of the discussion
Practical aspects of the initiation of discussion
The history
Basic principles
The two-person situation
 
He who misses the first buttonhole does not 
complete the buttoning.
Johann Wolfgang von Goethe
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 relationship.

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 sides.

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:
At 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.
The situation 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 of him.
The patient comes with certain expectations; these can be realistic but also completely irrational.
Initiation of 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.
A relationship 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:
The 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.
The behaviour of the doctor must show involvement, interest and friendliness right from the start.
The patient must be made to feel secure and open.
Misunderstandings (about the role of the partners in discussion, or the objectives of the discussion) must be cleared out of the way.
Non-verbal 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 not 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 link). Emotional 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:
1. Not to start from where one is oneself.
2. Recognize and accept the starting point of the other.

As well as determining the external 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 stress-reducing function.
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Practical aspects 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 following suggestions.

Introductions

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."

Reception

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 me?"
"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 tell me!".

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.
Example:
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?"
or:
"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.

Check list: causes of unsuccessful starts to the discussion
External conditions:
No hand contact (this depends on the culture)
Insufficient or excessive eye-contact
Introduction ignored (false perceptions about the role and function of the doctor)
Unfavourable ritual for the reception
Incorrect seating and/or distancing
Inadequate introductory questioning
Closed questioning technique (questioning corset?)
Incorrect language level
Inhibitions not carefully dealt with
No notice taken of non-verbal signals
Disturbing environmental factors (noise, assistants, telephone, pressure of time)
Forgetting to smile and being friendly
Technical aspects of speech and communicative aspects:
Missing the first button hole?
Not starting from where the patient is?
Finding out where the patient stands internally?
Insufficient reassurance and unfolding of the patient?
Lack of emotional support?
Induction of anxiety?
Recognizing one's own anxiety?
Insufficient presence?
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.

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").
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A "good" interview
always contains some therapy.
Rolf Adler
The history
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.

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:
1. Introduction, greeting
2. Creation of a favourable situation
3. Mapping the symptoms
4. Present complaints  
a. Onset
b. Quality
c. Intensity
d. Localization and radiation
e. Associated symptoms
f. Ameliorating, exacerbating factors
g. Other influences
Provisional diagnosis
5. Personal history
6. Family history
7. Psychological development
8. Social Total picture of the patient
9. systemic history
10. Questions and plans
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.
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Basic principles
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:
obtain information, in order to release a positive reaction, which is related to
the discovery of the individual reality of the patient, and the way in which this came about.

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" approach.

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.
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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 psychical field.

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. 

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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
URL of this page: http://www.linus-geisler.de/dp/dp10_beginning.html
 
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