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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Dynamics of the doctor/patient discussion
History before the (initial) discussion
Opening phase
Adaption phase/thematization
Closing (termination)
Technical aspects
The closing of the discussion
Dynamics of the doctor/patient discussion
The structured interview is most likely to be favourable if the dynamics follow a regulated course (Figure).

In many cases, there is a previous history. In a situation of expectation, the most difficult part is at the opening of the discussion. Then follows a mutual adaptive phase. The objective of the discussion is a definition of the theme, and the discussion is ended by a termination. The course of the discussion is the result of interaction between the two partners. The doctor is responsible for asking questions empathetically, for listening actively and for watching for all non-verbal signals from the patient. His questions are aimed to obtain information which elucidates the individual reality of the patient, and when necessary, to steer the discussion by intervention.

Dynamics of the doctor/patient discussion
The patient acts or reacts during the discussion, by verbal and nonverbal communications, but can also "answer" with silence. The doctor interprets these signals from the patient as a "participating observer". In this way he builds up a picture of the patient, his personality, and the possible conscious and unconscious motives in a conflict situation.

Mitscherlich termed the doctor-patient discussion as "interaction of signals and their interpretation". From the interpretation, the patient receives the impression: "Here is somebody who has found out about me and does not shy away from discovering the truth with me".
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History before the (initial) discussion
The first doctor-patient dialogue does not usually arise from a vacuum. Even the means by which the consultation has come about (appointment, ward round, home visit, accident) play a decisive role in the initial discussion. The doctor has information from the patient himself, from relatives or from previous examinations. This means that certain presumptions are possible before the discussion, although these are subject to all of the dangers of prejudgment. If the patient has a choice, the fact that he has chosen one particular doctor is significant. The motives for a choice of doctor can be very variable; previous experience, particular competence, reputation, age (sex) or simply because he is easily available. Whether he was referred by another doctor, if he came of his own accord, and if he comes alone or accompanied by relatives are also relevant.
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Opening phase
The discussion is opened after an expectant phase. The importance of a good opening for discussion is dealt with in the chapter on the initiation of discussion link. Studies have shown that the relationship between doctor and patient is often established and structured during the first interview, and that this markedly determines the course of further discussions.
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Adaptation phase/thematization
The discussion partners agree "to accept each other" as discussion partners during the adaptation phase, and develop a common psychical field.

Only now is it possible to develop a theme. Here the doctor has two important tasks; the first is to recognize the true subject of the discussion, and secondly to steer the discussion so that working through this subject is as effective as possible.
Both tasks are practically impossible if the individual reality of the patient remains undetermined.
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Closing (termination)
The discussion should not be broken off at random, but should be terminated according to the particular dynamics of the course of the discussion. The length of the discussion depends on the acuteness of the situation, the subject under discussion, the extent to which both doctor and patient can manage, on the course of the discussion itself, as well as on the time available. A discussion time of more than 45 minutes will only be possible or useful in exceptional cases.

Ideally the discussion should be ended when the primary subject is closed, or has been taken far enough. The discussion should be terminated if the patient shows signs of tiredness or excessive stress, if acute resistance arises which cannot easily be resolved, or if the discussion gets into a cul-de-sac. There should always be a review or preliminary review. The patient should also always be given the opportunity to put further questions. Finally, the form of further contact between doctor and patient should be agreed.

One phenomenon which arises at the end of a discussion should be dealt with in more detail. Often patients are able to mention the subject that is really important to them only when the doctor is signaling the end of the discussion. The explanation is that the patient develops a strong defensive tendency during the conversation, which can only be broken down when, as the end of the discussion is approaching, he anticipates that he will not be able to discuss these points at all. This means that questions posed at the end of a discussion or points thrown into discussion here, can really have a very great significance.
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Technical aspects
In order that a discussion can begin at all, it is necessary that the patient is able and ready to speak, and the general situation is not unfavourable to the discussion.

Patients who make an appointment and come to a surgery or practice agree to come at a certain time themselves. On the other hand, the time of the visit of a doctor to the patient in hospital is dictated by the requirements of the doctor. It therefore has to be assessed if the patient is able to take part in a discussion at a particular time, and this is not prevented by possible symptoms, pain, hunger, thirst (being prepared for investigations), exhaustion or uncomfortable positioning.

Problems also arise with discussion during an examination. Occasionally, discussion can be helped by closer physical contact during an investigation (ultrasound, for example). It is very unfortunate when a good discussion is interrupted by a physical examination, and the patient is left wondering whether or not he will have an opportunity to discuss this subject again.

Opening of the interview and further steering of the discussion should follow the so-called funnel technique (Figure). 

The method of an open introduction with a broad unfolding is appropriate. Further questioning runs on sequential principle. Initially the patient is allowed the largest amount of room in which he can formulate his answers. As the discussion advances, the contents of his answers are made more precise and clearer by decreasing the room left for responses. This achieves a focusing of the subject matter.

'Funnel principle' of leading discussions
As regards the questioning technique, the start of the discussion is accompanied by open questions ("How do you feel?", "What mood are you in?"). There are more answers that can be given to the question: "How are you getting on?" than to the closed question "Are things okay?" The information which is obtained is examined more precisely by the use of an increasing proportion of closed questions. In this way the subject is brought more and more within boundaries. As this proceeds directive questions can be interjected, which serve to plumb certain points ("Can you tell me more about the course of the first attack?").

The doctor should anticipate the patient's manner of telling his story. This depends partly on the subject and its subjective importance for the patient, and partly on his personality structure and character. Enough time must be available for the discussion if details of the life history of the patient need to be discussed.

Those who are "long-winded" can pose a particular problem. In order to intervene, the doctor must determine why the patient behaves in this way. There are two main reasons. One is that some people have a natural tendency to speak associatively. This means that they find it difficult to stay with the point under discussion, and what they say depends on the immediate situation or key-word which crops up. With these people, intervention with directive and closed questions is usually effective.

More problems are raised in the second type of long-windedness, in which the same subject crops up continually. Often this behaviour hides the patient's concern that he will not be understood. Due to this, he attempts to ensure understanding by continually repeating himself. In these cases, the following options for intervention are available. Firstly the patient can be given strong clear signals that his request has been understood. This can be achieved verbally ("I am convinced that I now completely understand your problem"), by the use of a series of questions which convince him that he has been understood, or by using "echoing" questions ("This groin pain only happens when you have eaten a lot of fibre?"). Another possibility is to choose a single point as soon as convenient and go into it in detail as there is usually less to discuss "in depth" than superficially.

A complete chapter has been devoted to active listening link as this is the most important but also the most difficult ability for leading discussion. The art of active listening does not only apply to what the other is recounting, but also how he saying it and what he does not tell.

Meerwein points out the doctor should also ask himself, whilst listening actively, what is happening to him:
What mood is the patient putting me into?
Am I speaking too much, too little or too impulsively?
Am I free to speak or inhibited by this patient?
Do I really want to see this patient again, or do I hope that he will never appear again?

In other words, the doctor must be prepared to listen not only to the patient but also to himself.

However, leading a discussion is not limited to listening and questioning. It is necessary for the doctor to repeatedly intervene in the conversation. One reason for intervention can be that the course of the discussion is heading in the wrong direction, or that it appears useless. At this point, it is helpful to introduce a fresh, more attractive subject into the discussion in order to regain an interactive pattern. A further reason for intervention can be to head-off rising anxiety on the part of the patient (see chapter on anxiety link).

Unwillingness to speak may indicate defensiveness, which again requires intervention. However the initial step is to confirm whether or not this is really defensive behaviour. Although a break in the discussion may be interpreted as "refusal to speak", it may in fact be a pause for decision or working through of a point (see chapter on the pause in discussion link).

If it appears from the "offer of disease" and the preceding discussion that a conflict situation is at the root of the physical symptoms, certain key questions serve to elucidate the problem. Basically, a spontaneous exposure of the conflict and working through it occurs much too infrequently in daily practice. The grounds for this is that the patient is not really conscious of the conflict and the doctor is not really prepared go into it. Studies from the Heidelberg psychosomatic clinic showed that out of 100 patients referred to the clinic, only 2 to 5 had really developed a truly conscious appreciation of the conflicts (De Boor and Künzler). Guyotat could show that, on the other hand, only 10 out of 75 doctors actively approached the conflicts in their patients.

An important key question which brings the internal conflicts into consciousness is to ask the patient what he himself thinks are the reasons for his illness. Von Weizsäcker formulated this question in the following way: "What do you yourself believe to be the cause of your illness?". Meerwein recommends the following question: "Why do you think that you are ill?". A further aid can be to ask the patient for his own suggestions for treatment for his illness.

It can also be important to question, when it is clear than the patient's explanation has left "omissions and loop-holes". Freud points out that one should "approach material at deeper levels behind these weak points". Such holes and omissions can for example concern certain people around the patient or his sexual life.

Nevertheless it would be a mistake to mention conflicts too early in the discussion, and to refer to the connection with physical symptoms. The patient does not usually come to the doctor either aware of internal conflicts or with the willingness to face these conflicts in discussion. When asked if they would be prepared to speak to their doctor about personal problems, if these had nothing to do with their illness, 73% replied "no", and only 22% "yes" (Delay and Pichot).

The basic rule of structuring and intervention in discussion between doctor and patients has been explained by Meerwein as follows: "None of these suggestions for intervention in the course of discussion should deviate from the basic principle that it is associations of the patient that define the discussion and not the questions posed by the doctor. The questions and intervention of the doctor arise when rationalization, omissions, contradictions, statements suggesting anxiety and defensiveness, confrontation against the doctor and similar forms of behaviour, influence or inhibit the development of the discussion. The doctor needs to recognize these difficulties for what they are, and to use them for understanding more of the illness". The final step in the consultation interview is to establish a diagnosis and if necessary its interpretation. The interpretation "reveals illness as being not just a physical phenomenon but a crisis in human relationship - a conflict. If correct and presented in a way acceptable to the patient, its result is insight and benefit" (Meerwein). The interpretation allows worries and uncertainties to rise to the surface, and to be put into words. This reduces anxiety "as we rise above what we can express in words" (Nietzsche).

It can be difficult to make a diagnosis, but even more difficult to give it an interpretation. Meerwein lists rules which should be applied to every discussion between doctor and patient, in which not only the diagnosis, but also the interpretation of the disease is required:
The interpretation should extrapolate from what the patient himself expressed. Therefore the patient's words, and not lofty language, should be used.
Interpretations which under certain circumstances could hurt the patient should be avoided.
The interpretation of external conflicts should precede the interpretation of internal conflict. Inner conflicts are rarely verbalized in conversation with doctors, if the patient does not raise them himself.
The interpretation is the doctor's service, with which he compensates the patient's willingness to converse. It encourages and reinforces the understanding that the patient has of himself. As a result of it, the patient feels understood and supported. This is where its therapeutic function resides.
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The closing of the discussion
Many discussions in daily clinical practice end as they started: unstructured and unsystematic. The end of the conversation is far more likely to be caused by external factors (such as situations in discussion or time-pressure) than by logical and psychological dynamics. Nevertheless, the termination of the discussion is just as essential a constituent as the other phases in discussion. No business discussion about a purchase or contract would end without a clearly-defined termination. Many discussions are "crowned" by the termination.

The end of the discussion can be divided into 3 phases:
1. Discussion of the conclusions
2. Constructive plan
3. Parting

Discussion of the conclusions has more than one function: a "balance sheet" created initially. It should make it clear to both partners what has been achieved by the discussion. It is just as important to describe what has not been achieved, as further discussion will depend on this, as well as the further steps which are necessary. As at the start of the conversation, an internal and external recognition of the other's position is once again necessary, and should be actively sought. Summarizing at the end of the discussion has an important control function; it reveals whether the discussion was based on mutual reality. One objective of the summary is to round off the discussion psychologically. Discussions which do not have recognizable conclusions and are open-ended leave both discussion partners with a feeling of emptiness and uncertainty. On the other hand, discussions from which conclusions can be drawn give both parties a feeling that they have had a quantifiable success in their discussion of a problem, that the contract between them works, and that it is worth-while to have a discussion. The best motivation for further discussions between doctor and patients is a successful previous discussion.

The summary of the discussion is a condition for the "constructive plan", which includes the following points:
Prescriptions, advice, suggestions, and encouragement for the patient
Indications and help as to how the "therapy" can be achieved
Possibly a further appointment

Of course the concept of a discussion cannot as a whole apply in every situation of daily clinical practice (emergency situations, conversations with patients who are not able to discuss). However wherever discussion serves as a decisive instrument for dealing with and solving problems and conflicts, the highest degree of efficiency is achieved with a formal, structured discussion which is closed as regards content and subject matter.

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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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