The won­ders of an em­pa­thetic ear in the doc­tor’s of­fice

The Washington Post Sunday - - BOOK WORLD - RE­VIEW BY LIBBY COPELAND Libby Copeland is a for­mer Wash­ing­ton Post re­porter who writes on cul­ture and hu­man be­hav­ior.

If you’ve switched physi­cians in search of some­one more car­ing or left an exam feel­ing un­seen and un­heard, you will find much to ap­pre­ci­ate in Danielle Ofri’s per­cep­tive book “What Pa­tients Say, What Doc­tors Hear.” The short­com­ings of the pa­tient-doc­tor re­la­tion­ship are on full dis­play as Ofri probes what goes wrong in the exam room and tal­lies the im­pact on the care we get.

We of­ten think of medicine in terms of num­bers and statis­tics. How many pos­si­ble di­ag­noses are there for this mys­tery ail­ment? What’s the suc­cess rate for this surgery, or the like­li­hood of re­mis­sion af­ter chemo­ther­apy? We rightly want our doc­tors knowl­edge­able about the lat­est treat­ments and side ef­fects.

But Ofri makes a com­pelling case that pa­tient-doc­tor com­mu­ni­ca­tion in the exam room is as cru­cial to di­ag­no­sis and treat­ment as ex­pen­sive tests and pro­ce­dures. Of­fer­ing em­pa­thy, ask­ing open-ended ques­tions, in­volv­ing the pa­tient in a treat­ment plan and check­ing again and again to make sure pa­tients un­der­stand are all key to mak­ing the sick bet­ter, she writes.

Ofri, a physi­cian at New York’s Belle­vue Hospi­tal and a pro­fes­sor at the New York Univer­sity School of Medicine, delves into med­i­cal re­search and draws on her years of prac­tice and ob­ser­va­tion to il­lu­mi­nate vi­tal as­pects of the pa­tient-doc­tor re­la­tion­ship: Good com­mu­ni­ca­tion low­ers anx­i­ety, raises pa­tient con­fi­dence and makes us more likely to ad­here to treat­ment plans. Longer vis­its with pri­ma­rycare doc­tors are cor­re­lated with fewer mal­prac­tice suits. Doc­tors who lis­ten well are more likely to un­cover hid­den causes of ill­ness, such as sex­u­ally trans­mit­ted dis­eases. In one study, back pain pa­tients re­ceiv­ing elec­tri­cal stim­u­la­tion ex­pe­ri­enced far more pain re­lief when ac­com­pa­nied by a phys­i­cal ther­a­pist who was a good lis­tener. Re­search shows that pa­tients who visit more em­pa­thetic doc­tors even shorten the du­ra­tion of their colds by more than a day.

We’ve known for decades that doc­tors who of­fer em­pa­thy, build trust and set ex­pec­ta­tions help their pa­tients fare bet­ter. As far back as 1964, a study con­ducted with ab­dom­i­nal-surgery pa­tients il­lus­trated what Ofri calls the “demon­stra­ble ef­fect of the sim­ple act of talk­ing.” Be­fore surgery, half of the pa­tients were vis­ited by an anes­thetist who said pain af­ter­ward would be nor­mal and would last a lim­ited amount of time, and ex­plained how pa­tients could re­lax their mus­cles to lessen the pain. These pa­tients needed half the pain med­i­ca­tion of oth­ers who didn’t re­ceive a pain talk. If we are an over­med­i­cated na­tion, bet­ter com­mu­ni­ca­tion would seem an easy and cheap way to re­lieve that bur­den — ex­cept that lis­ten­ing takes time, and doc­tors don’t usu­ally have that.

Ofri’s in­sights are par­tic­u­larly in­struc­tive as the med­i­cal pro­fes­sion in­creas­ingly suf­fers from tight sched­ules, packed wait­ing rooms and tight­wad in­sur­ance com­pa­nies. With pa­tient-doc­tor com­mu­ni­ca­tion more im­por­tant than ever, Ofri shows how it gets fouled up, point­ing to un­spo­ken as­sump­tions, rhetor­i­cal dif­fer­ences and lan­guage bar­ri­ers. (And she’s not talk­ing about non­na­tive speak­ers of English; med­i­calese is its own lan­guage, im­pen­e­tra­ble to laypeo­ple.) When pa­tients go to the doc­tor, Ofri writes, they’re in­clined to tell the “story” of their ill­ness, from be­gin­ning to end, while doc­tors are trained to look for the “chief com­plaint.” Lit­tle won­der, then, that re­search shows “doc­tors typ­i­cally in­ter­rupt pa­tients within 12 sec­onds.” The dif­fer­ence in speak­ing styles sets up an ex­pe­ri­ence in which pa­tients feel rushed and un­heard, and doc­tors feel im­pa­tient about their ram­bling pa­tients. Too of­ten in exam rooms, we are speak­ing past each other.

An open, wel­com­ing physi­cian can draw out cru­cial in­for­ma­tion that oth­er­wise might lie hid­den. Ofri re­counts ex­am­in­ing a woman with a tense smile who de­scribed the pains she had in var­i­ous parts of her body. Af­ter the woman left the exam room, she re­turned and, clutch­ing the door­knob, said, “Doc­tor?” She hes­i­tated. “‘Do you think it’s pos­si­ble . . .’ She hes­i­tated again. ‘Do you think it’s at all im­por­tant that these are the same spots where my boyfriend shot me with a dart gun?’ ” The “hand-on-the­do­or­knob phe­nom­e­non is . . . well known to all doc­tors,” Ofri writes. “A physi­cian can pro­ceed as­sid­u­ously through a de­tailed his­tory and phys­i­cal with a pa­tient, but it is only when the pa­tient is half­way out the door that the im­por­tant in­for­ma­tion spills out.” Ofri in­vited the woman back into her of­fice so they could con­tinue talk­ing, clock be damned.

Ofri seeks to hu­man­ize a pro­fes­sion of­ten seen as haughty, priv­i­leged, un­com­mu­nica­tive and in­dif­fer­ent to crit­i­cism. She’s also sen­si­tive to her col­leagues’ re­sis­tance to “hok­ier-sound­ing soft stuff” such as com­mu­ni­ca­tion, em­pa­thy and con­nec­tion. “Some­thing that sim­ple and in­tu­itive, some­thing that doesn’t re­quire spe­cial­ized knowl­edge, can feel threat­en­ing to a physi­cian who has spent a decade train­ing to ac­quire unique med­i­cal knowl­edge . . . . There’s some­thing vaguely dis­com­fit­ing to re­al­ize that the tech­niques shamans used cen­turies ago can some­times be as ef­fec­tive as our phar­ma­ceu­ti­cals backed by mil­lion-dol­lar mega-tri­als.”

But, as Ofri’s com­pelling ar­gu­ment makes clear, mod­ern medicine could ben­e­fit from a bet­ter un­der­stand­ing of how hu­man be­ings like to be treated when they’re at their most vul­ner­a­ble — sick and con­fused and naked save for a thin pa­per gown. If only doc­tors could bill for lis­ten­ing.

WHAT PA­TIENTS SAY, WHAT DOC­TORS HEAR By Danielle Ofri Bea­con. 242 pp. $24.95

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