Evelyn Osorio is a fifty-six-year-old woman in my practice. Her diabetes and hypertension are relatively well-controlled but she’s still twenty pounds heavier than she’d like to be. Her gym membership remains more theoretical than actual, though she now eats salad most days for lunch instead of pizza. She describes her life as stressful, though she’s been good about keeping her appointments. She’s someone who’d probably be described as a very average patient in a medical practice—a few mild-to-moderate illnesses, not excessively complicated from a medical perspective.
Nevertheless, my brain is racing during our visit. Even with a patient who is not especially ill there are dozens of thoughts scrambling in my head as we settle into our visit and begin talking.
• Blood sugar is a little better than last time. Have we checked her kidney function? Has she been to the eye doctor? The podiatrist?
• Cholesterol isn’t ideal. Need to think about starting a statin, but she hates the idea of more meds.
• Darn, I forgot to return that phone call to Mr. Dayton. He’s already left me three messages!
• Ms. Osorio’s blood pressure is 148/93 today—okay but not great. Should we add another BP med? Will the greater number of pills risk less adherence?
• The computer is moving like oatmeal today. The traffic entering the Midtown Tunnel up the road is a veritable fleet of flitting gazelles by comparison. If I try to update the med list while I’m ordering labs the computer will probably flatline.
• Didn’t Ms. Osorio mention last time that her husband was struggling at his job, maybe drinking a little more? Is she feeling just the regular stress of life, or might there be a clinical depression lurking underneath?
• Have we covered all of Ms. Osorio’s health maintenance issues? When was her last mammogram? Has she had a colonoscopy since she turned fifty? Has she had a tetanus booster in the past ten years?
• These lousy keyboards inflame my carpal tunnel syndrome. If my right wrist conks out I’ll never get through the next six patients. Plus my cello lesson is tomorrow. If I can’t hold the bow properly I’ll garble the Bach enough to cause all twenty of his offspring to yell for mercy from their graves.
Ms. Osorio interrupts my train of thought to tell me her back has been aching for the past few weeks. She’s not interrupting, of course, she’s just talking, but my brain has been bustling on overdrive so it feels like an interruption. From her perspective, this is the most important item in our visit, but unfortunately she’s caught one of my neurons in midfire (the one that’s thinking about her blood pressure, which is segueing into the neuron that’s preparing the diet-and-exercise discussion, which is intersecting with the one that’s debating whether the defibrillator on the crash cart might be an effective tool to goose up my crotchety computer).
My instinct is to put up one hand—the one without carpal tunnel—to keep all interruptions at bay till I’ve sorted everything out. It’s not that I don’t want to hear what she has to say, but the sensation that I’m juggling so many thoughts and need to resolve them all before the clock runs out keeps me in a moderate state of constant panic. What if I drop one? What if one of these critical thoughts evaporates while I address another concern and then I do something dangerous like prescribe a medication she’s allergic to or miss an abnormal lab result?
I’m trying to type as fast as I can—for the very sake of not letting any thoughts escape—but every time I turn to the computer to write, I’m not making eye contact with Ms. Osorio. I know that eye contact is critically important for good communication and I don’t want her to think the computer is more important than she is, but I have no choice but to keep looking toward the screen to dig out her blood tests, check the dates of her immunizations, type in the progress of her illnesses, order the labs for next time, refill her prescriptions, see what the gynecologist recommended.
Then she pulls out a form from her bag; her insurance company needs this form for some reason or another. An innocent—and completely justified—request, but this could be the straw that breaks the camel’s back. The precarious balance of all that I’m keeping in the air could be unhinged by the appearance of an unassuming 8½-by-11-inch sheet of paper.
I try not to let my eyes widen with dismay, and indicate that we’ll get to it after the physical exam. I barrel through the basics and quickly check for any red-flag signs that might suggest her back pain is anything more than a routine muscle strain. I hustle back to the computer to input all the information, mentally running though my checklist, anxious that nothing important slip from my brain’s increasingly tenuous holding bay.
I want to do everything properly and cover all our bases, but the more effort I place on accurate and thorough documentation, the less time I have to actually interact with my patient. A glance at the clock tells me we’ve gone well overtime. I struggle to wrap everything up, hoping I haven’t forgotten anything important. I stand up and hand Mrs. Osorio her prescriptions, feeling more out of breath than an office visit should warrant.
“What about my insurance form?” she asks. “It needs to be in by Friday, otherwise I might lose my coverage.”
I clap my hand against my forehead; I’ve completely forgotten about the form she’d asked about. It was hardly six minutes ago but my hippocampus evidently had hung out the next-cashier-please sign.
Numerous studies have debunked the myth of multitasking in humans. The concept of multitasking evolved from the computer field to explain a microprocessor performing two jobs at one time. It turns out that microprocessors are mostly linear and so are really performing only one task at a time. Computers give the illusion of simultaneous action by jumping between competing activities in a complex and rapid-paced algorithm.
Like microprocessors, we humans can’t actually concentrate on two thoughts at the same exact time. We merely zip back and forth between them—with none of the algorithmic sophistication or breakneck speed of microprocessors—generally losing accuracy in the process. At most, we can juggle only a handful of thoughts in this desultory manner.
The more thoughts we juggle, the less we are able to attune fully to any given one. To me, this is a recipe for disaster. This time with Ms. Osorio I only forgot an insurance form. But what if I’d written the wrong dose on her prescription or refilled only five of her six medicines? What if I’d forgotten to fully explain the side effects of one of her meds? The list goes on, as does my fear of causing harm.
Interactions like this were one of the reasons I started writing this book. Ms. Osorio had several things she wanted to tell me, but I was hardly hearing them because of all the noise in my head. To be sure, most of that noise was about Ms. Osorio’s medical care—with a few stray thoughts about phone messages, flitting gazelles, and the progeny of Bach—but I knew I wasn’t fully attuned to what she was saying. At best, I could only keep half an ear on what she was saying, while my brain scurried around trying to stitch together the myriad elements of her medical care. And Ms. Osorio is a relatively uncomplicated patient; my sicker patients generate exponentially more balls in the air and the consequences of dropping any one are far graver.
The more researchers, patients, and doctors I spoke to for this book, the more I realized that our current setup in medicine seems designed to thwart good communication. There are so many odds stacked against it: a patient in pain or consumed with worry, a doctor with way too many tasks for the given time, uneven power dynamics, stereotypes, racial and gender disparities, assumptions, knowledge gaps. Add in ever more complex illnesses, exploding amounts of data for each patient, rigid documentation requirements, and ever-changing insurance company labyrinths to battle, and it’s no wonder that a meaningful and well-understood conversation in the doctor’s office is rarer than a decent cup of coffee from the hospital cafeteria.
The knowledge base and treatment options in medicine have exploded in the past half century of medicine, yet we still have the same fifteen-minute visit in which to accomplish everything. (And somehow, in this proliferative half century of scientific progress, we have never managed to improve upon the paper towel that passes for a gown.)
I know that my ideal world of luxurious hour-long visits will never come to pass. I’ll never be able to fully barricade the exasperating bureaucracies, tyrannical telephones, and pseudo-time-saving technologies outside the door. (Though it sure is nice to fantasize . . .) But I remain convinced that it is possible to protect and even enhance doctor-patient communication, despite the multitude of factors conspiring against it.
Anatole Broyard observed, “Virginia Woolf [in her essay ‘On Being Ill’] wondered why we don’t have a greater literature of illness. The answer may be that doctors discourage our stories.”1 I’ve debated Broyard’s harsh assessment and I’m not sure that doctors are as actively pernicious as he makes them out to be. I don’t think doctors intend to discourage stories, but rather it is our system that makes full stories nearly impossible. By no means am I excusing doctors who don’t at least make the effort, but I recognize that the problem is more than just doctors being paternalistic or wearing blinders.
The biggest take-home message for me, after wading through the research and interviewing people on all sides of the issue, is that both doctors and patients need to give communication its just due. Rather than seeing the conversation between doctor and patient as the utilitarian humdrum of a visit, the conversation should be viewed as the single most important tool of medical care. It should be given the deference and attention that we lavish upon the swankiest of medical technologies. If you consider the amount of information that can be gleaned from a doctor-patient conversation, the diagnoses that can be made, the analyses that can be elaborated, the treatments that can be rendered, the human connections that can be cultivated—the simple conversation is, in fact, a highly sophisticated technology. It’s far more intricate, powerful, and flexible than most of our other medical technologies, which generally do only one thing in only one way. Plus, conversation is way cheaper and it doesn’t decimate your sex drive or make you puke. (Except if you start talking about local politics . . .) The mere act of both parties taking this conversation more seriously will enhance communication and improve medical care. It’s heartening to recognize that effective communication needn’t take an unconscionably long time; it just needs full and intense focus. Such a focus, even for just a few minutes, can yield an abundance of information.
In his characteristic blunt yet philosophical style, Broyard put it this way: “I see no reason or need for my doctor to love me—nor would I expect him to suffer with me. I wouldn’t demand a lot of my doctor’s time: I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.”2
The giving of the whole mind is the key. For doctors, this means shunting aside competing thoughts, however virtuous and clinically relevant. I don’t underestimate how onerous this task is, but doctors need to be fully focused on what the patient is saying because that’s where nearly everything medically relevant resides.
The second thing doctors need to do is to shut up, at least a bit. The dogged detective instincts ingrained from medical training too often fly into overdrive, cutting off patients before they’ve hit their second syllable, racing down diagnostic pathways before the data have been fully collected. Misdiagnoses and medical errors flower in this wake. Holding back that first question bursting to erupt is agonizing for doctors; I feel your pain on this one. But if you can hold it for a minute, even thirty seconds, you’ll be richly rewarded with better information, more accurate diagnoses, more efficient testing, improved adherence, and enhanced patient trust. And you’ll probably even save time in the long run.
For the patient—who’s often coming into the visit already feeling at a disadvantage—it’s helpful to realize just how powerful the conversation is. In some ways, you hold all the cards; the story that you bring to your doctor is the essence of the medical visit. Insist that you be given time to tell your story. If your doctor jumps in too quickly, feel free to politely deflect. “Would it be okay if I had another minute to finish what I’m saying?” should do the trick.
If your doctor is excessively trigger happy with the questions, you could say something more direct like, “I need to finish telling you this. I’ll keep it concise and as soon as I’m done, the floor is yours.” And if she’s completely tone deaf, you might have to look at her square in the face and say, “Listen, if you truly want to be efficient, just listen for two minutes so I can get my whole story out. You’ll avoid diagnostic errors, and I’ll avoid unnecessary tests.”
Recognize, though, the reality of time and the limitations of how much can be accomplished in a single office visit. Invest some of your own time in advance preparation. Prioritize what you want to talk about and be realistic. If you press your doctors to address more than two or three issues in one visit, the focus and depth will necessarily be diluted. In fact, one of the things Corine Jansen now spends her time doing is helping patients—especially those with complicated illnesses—to develop an efficient, coherent narrative that clocks in at under three minutes. This allows both doctor and patient to focus fully on the main story, without competing distractions.
Before writing this book, I viewed communication little differently than I viewed breathing—both occurred automatically and I only really paid attention if they ceased. Communication wasn’t on my to-do list for keeping up with medical advances. Whenever my periodic fits of medical spring cleaning occurred—those sporadic frenzies of self-improvement—I’d brush up on a couple of obscure physical exam skills, which of course I’d promptly never use in my daily practice. Or I’d spend a few weeks actually reading my medical journals rather than trying to osmose a smattering of facts by scanning the table of contents, feeling virtuous until the fever broke. But it never dawned on me to think critically and consciously about how I speak with my patients. I’d always thought I was a reasonably decent communicator (and frankly a pretty good breather as well).
When I turned the lens on my own practice, I observed that I fall short much more than I’d ever care to admit. I redirect the conversation within nanoseconds of the patient’s chief complaint. My approach to improving adherence is always education and reeducation, reading the chronic-disease riot act at nearly every visit. Although my modus operandi is generally to be pleasant in conversational tone, there’s no doubt I verbally dominate nearly every patient visit, shepherding the conversation along the most expeditious path possible. And I’ve never really stopped to think honestly about the biases that I bring into the exam room.
Each time I wrote about an experiment in this book, I tried to do a version of it in my own clinic sessions. It was about as effortless (and as comfortable) as resetting my breathing pattern to a polka rhythm. Every time was awkward and it often felt downright ridiculous. And I didn’t necessarily see obvious results. I didn’t suddenly turn into an orator extraordinaire, nor did my patients’ blood pressures, glucose levels, and BMIs miraculously corral into glorious normalcy. But it turned out that the process, not the product, was the most valuable part.
My ingrained habits didn’t rectify overnight but I did start noticing some of them. Usually it was only in retrospect, after the visit was over, that I recognized my blunders. But occasionally I could catch myself in the act. When my better angels were on duty I might actually be able to stop myself mid-harangue about becoming blind, impotent, amputated, and on dialysis (the monologue that my diabetic patients can no doubt recite from memory). It was no easy task to zip it up, for sure. But if I had my wits about me I could force the apocalypse faucet closed and simply ask, “What is the most challenging part of diabetes for you?” Nearly every time I had the presence of mind to switch gears like that, the patient came up with something specific, rather than the abstract horrors I was honking on about ad nauseam. I could then note down that challenge in the chart, and we’d have something real to focus on. And beyond providing a more practical direction for our medical efforts, the exchange offered me singular insights into this individual’s life with diabetes. Disease is never abstract for a patient, and it’s only by foraying into the particulars that a doctor can ever begin to fathom the unique trek of illness that each patient must navigate.
When I’m not too overwhelmed with the logistical tribulations of the day, I try to experiment with some of the other techniques I read about: asking a patient to “share back” what we’ve just discussed, adding in an extra dose of optimism about a treatment, matching my medical terminology to my patient’s, stepping back from my natural tendency to steer the visit in the way my inner racehorse deems most time-efficient. They don’t all work all the time, and there’s no magic, but stirring the pot in a variety of ways almost always brings something of import to our medical encounter. And if nothing else, the conversation is far more interesting for both of us.
The hardest thing by far is trying to rout out my biases. No doubt they are so ingrained culturally and personally that I’m not even aware of most of them. But I’m making an effort to notice them, and to confront them when I find them. When I read a patient’s name on the chart, for example, I try to pay attention as to whether my mind is racing ahead with predictions and assumptions before I’ve actually met the person. I can’t always stop these snap judgments, but I can administer a mental kick in the shins if needed. I’m also trying to consider more explicitly which biases my patients may have faced in prior medical experiences and how these might impact my encounter with them. Some of my patients have suffered concrete offenses at the hands of the medical system, and the resulting wariness is often interpreted as “noncompliance.” I can’t undo all the societal injustices out there but I can think carefully about whether I’m promulgating them.
Thankfully, we seem to be evolving from the old-school view that considered communication merely an affable bonus that a few kindly doctors possess. You’ll still occasionally hear that so-and-so is an excellent doctor even though he has a bedside manner that rivals a roll of surgical tape. But increasingly we are recognizing that this is a contradiction: you can’t be an excellent doctor if you have a lousy bedside manner. Communication is not an extraneous perk but rather the bedrock of high-quality medical care. Without good communication between doctors and patients, the chances of achieving effective medical outcomes plummet.
Human connection is a seedling that needs to be cultivated, and good communication is the loam in which it is nurtured. The doctor-patient relationship is a particular human connection, one that carries uniquely high stakes—health and even life can hang in the balance. Communication between doctor and patient, therefore, assumes these stakes.
If well tended with appropriate respect, attention, and time, this communication will take root, nourishing a sturdy doctor-patient relationship. What can be reaped—easing of suffering, improvement of health, solidification of connection—helps enhance our lives on both sides of the stethoscope.
When I think back to my communicative mishaps with Oumar Amadou, my patient from the opening of the book, I can see more clearly how and why it was so exasperating. The geometry of our conversation went awry as we pursued divergent dialogues. Although I appreciated the severity of his cardiac disease, I was irritated by the muscularity of his insistence and quickly pegged him as a “difficult patient.” In retrospect, I can see that my labeling of him created a bias that distorted what I heard. In his persistent demands for my time, I discerned entitlement. I became resentful and grew impatient with him.
Had I stopped talking for a bit, stopped arguing about appointments and phone calls, I might have been able to intuit the animating impulse of his desperation. Mr. Amadou was wrestling with the very real demons that his heart disease dealt out and he was in a justified existential panic.
Those of us whose luck has kept us from facing down death can’t really appreciate the exquisite vulnerability that serious disease engenders. Raw fear is a motivating force like no other. When I try to imagine what it would feel like to be Mr. Amadou—navigating a complex and unforgiving medical system, negotiating in an unfamiliar language, all with a heart that had proved itself unreliable long before its warranty was up—I can begin to understand his approach. Why wouldn’t he—like Morgan Amanda—insist on what he perceived as necessary? Why wouldn’t he refuse to take no for an answer? But I wasn’t able to fully comprehend that until his body crumpled in my office and I felt the life wicking away from him.
After his faulty pacemaker was replaced and the excess fluid drained from his lungs, Mr. Amadou came for a post-discharge appointment. It was an almost intolerable relief to see his lanky frame in his trusty tracksuit filling my doorway. When I shook his hand—the hand that had been chillingly frigid the last time I’d held it—I basked in its ardent warmth. I had no illusions, of course, and neither did he. The recent tune-up did not impart any fairy dust of additional cardiac reserve. Mr. Amadou would not be doing the two-hundred-meter dash down Lexington Avenue anytime soon.
But we’d dodged the bullet, this time at least, and we both exhaled cautious sighs of relief. Mr. Amadou’s first question, of course, was when our next appointment would be. Normally, this would irritate me, but now his voice unfurled almost like a benediction, so relieved was I that he had survived.
I couldn’t promise that we’d never have any miscommunications in the future, or that I—or he—wouldn’t get aggravated when things didn’t work out as swimmingly as we’d like. But I could promise that I would pay more attention to how I listened and how I spoke. I couldn’t realign his obstreperous cardiac myocytes, but I could commit to more conscientious communication.
When poet John Stone offered the graduating medical students his indelible commencement poem, he told them: “You will learn to see most acutely out of the corner of your eye, to hear best with your inner ear.”3 A more astute lesson in communication I could hardly imagine.