Talking to Patients in the 21st Century

Abstract

STYLES OF PARENTING AND PRACTICING MEDICINE HAVE followed remarkably similar trajectories over the last half-century, with authoritarian tones firmly banished from both arenas, and the old phrases of admonition and advice overhauled to communicate cheerful encouragement, mutual understanding, and respect. It is only a matter of time before “Good job!” and its equivalents are heard as often in the nation’s examination rooms as on its playgrounds. There are signs that the parenting pendulum may be reaching the end of its swing: Amy Chua’s 2011 memoir Battle Hymn of the Tiger Mother elicited a vigorous national debate over the comparative merits of different child-rearing styles. No such reactionary murmurings have surfaced in medicine, however, and experts continue to rewrite scripts for this newly democratic, time-challenged, increasingly electronic profession. Four Viewpoints in this issue of JAMA address some of the changes in physicians’ speaking and writing habits that will be necessary to accommodate new models of practice. Judson and colleagues emphasize that even today medicine retains an “asymmetry of power” likely to skew every exchange between physician and patient. Just as “whitecoat hypertension” may complicate a cardiac evaluation, so the entity they term white-coat silence probably attends even the most basic clinical conversation. How often do patients smile and nod as they think to themselves, “I have no idea what this person is talking about”? Any physician with firsthand experience of the layered misunderstandings that can accumulate in clinical care will realize that silence equals befuddlement on a regular basis. What to do? Judson et al enumerate a variety of tools for prodding patients to ask questions. Some are pedagogic, like the teach-back method that urges patients to summarize what they have heard. Some are self-evident, like allocating more time to each patient visit (although this simple and appealing intervention has, bizarrely, become prohibitively expensive). In the end, none of the fixes considered by Judson et al is entirely satisfactory, and they conclude that a fundamental reengineering of the clinical experience is required to make patients comfortable enough to ask all the questions they should. White and Danis suggest one way of reengineering the clinical experience, by simply rearranging the office furniture. Computers have become the newest barrier between physician and patient, in both the figurative and literal sense. Computers store and dispense all information, and when they stop working, so does all work. Even so, no one has figured out a good place to put these machines. In the inpatient setting, computers are often on wheels; in the office, they wind up on a desk. Either way, computers are generally positioned so that the patient faces the physician and the physician faces the screen. Why not change everyone’s perspective, White and Danis suggest, by opening up those tight triangular configurations? Let physician and patient look at the screen together, just as they might watch television together. The physician will still be the navigator, but relevant data will be reviewed jointly, an activity bound to foster communication and collaboration. It is also, they note, an activity bound to create new and different misunderstandings unless physicians learn the specific language skills required to pilot patients through their own health records. The patient chart is not the only digital image likely to appear on a jointly viewed screen. As McAfee points out, the world is now brimming with “direct-to-patient” communications that are increasingly televisionor Internetbased. These communications may originate from pharmaceutical companies, hospitals, media-based physicians, public health authorities, or from a large array of alternative medicine proponents. The temptation to shut this cacophony out of the examination room is very strong. Doing so, however, is not only difficult but, as in the case of the tobacco-related public service announcements McAfee discusses, really quite foolish. All this material can and should be productively integrated into the patientphysician dialogue. Finally, Tinetti and Basch propose a revolutionary new clinical agenda. They suggest that it is time for the sacrosanct realms of medical research to be opened to patient input, and for physicians to help their patients’ voices be