Imagine that an employer and employee meet one-on-one. Suppose that the conversation goes like this:
Employer: Let's see how you're doing. (Flips through some papers.) Well, I think we need to change some things here. (Scribbles on a piece of paper and hands it to the employee.) Here. And in two weeks I'm sending you on a trip for three days; my assistant will give you the details later.
Employee: Wait a minute - what trip? What for?
Employer: All you need to know is that I think it's best.
Employer: If you don't want to do as I say, you can find another employer.
Employer: That will be all.
Many people would find that conversation annoying. Even if employers have the right to call the shots in attempting to meet their goals, it rankles when they don't keep employees in the loop, particularly when it's the employees who have to change what they're doing.
How would you feel about that conversation if you knew that it reflected typical exchanges between doctors and patients?
A study by Dr. Clarence Braddock appearing in the Journal of General Internal Medicine reported the following exchange recorded between a doctor and a patient:
MD: I'll give you this, and something in addition ... something else that should help.
Patient: Which one is that?
Patient: You don't know what it is?
MD: I know what it is.
Patient: I just want to see if I've had it before.
MD: You haven't had it before.
Patient: Is it Metoclopramide?
Jordan Dolin, writing in the Chicago Tribune, reports on a conversation he observed between his mother and her heart doctor as the doctor started to schedule her for surgery. The doctor hadn't said anything about the reason for the procedure, nor about its benefits or risks.
His mother started to ask questions.
The surgeon did not answer any of her questions. What did he say instead? "Honey, all you need to worry about is if I am going to listen to opera or Steely Dan during the procedure."
A doctor writing in the New York Times explained, "The physician-patient compact basically states that a doctor will care for a patient in exchange for compensation, and that the patient will heed the doctor's advice. Patients who disagree with their physicians are free to go elsewhere."
Many research studies have concluded that communication between doctors and patients is often largely one-way.
When the conversation that opened this column was described as an employer directing an employee, you may have thought that it was irritating but understandable. After all, employers pay employees to do what the employers tell them to do.
What's the justification for communication that goes only one way in healthcare - from the doctor to the patient? Who is the "boss" here? Who is writing the checks to whom? Who is supposed to be serving whom? Whose interests, priorities and goals should drive the conversation?
Many studies (including a recent one in the Journal of the American Medical Association) report that doctors are often poor at communicating with patients. The problem, though, runs much deeper than that. It isn't simply that many doctors would benefit from training in active listening. The real problem is the assumption about who should call the shots.
Imagine that you have concluded that you need a new car. Imagine that you go to a car dealer and after waiting a while to see a salesman, the conversation goes like this:
Sales Rep: What are you driving now?
You: A 2002 Honda Civic.
SR: I've got the perfect car for you: a brand-new Nissan Leaf!
(This small car has an all-electric motor and a range of about 75 miles before it needs to be recharged.)
You: We want something we can put a trailer hitch on, because -
SR: Oh, listen! This is the latest thing! Environmentally friendly, inexpensive to operate - it's perfect!
You: I belong to the Sierra Club. I'm a big supporter of environmental causes. But we drive cross-country -
SR: Don't you deserve the best? Why would you settle for old technology? This is the new standard. I'll schedule you to come get your new car next Wednesday at 11 a.m.
You would probably find a way to extricate yourself from that conversation and go find another car dealer. But people often behave differently when it comes to health care. Many would echo the views of one reader who wrote to me that she had "grown up at a time when it was expected that a medical doctor's word was gospel."
Does it make sense to go see doctors if you have a serious medical condition and listen carefully to what they have to say? Absolutely. Does it make sense, outside of life-threatening emergencies, to let someone who sees you for 5-10 minutes decide what happens to your body without your having any say? Probably not.