Patient Encounter and Satisfaction, Part I

The great challenge for a physician is to diagnose and provide appropriate treatment. Especially when patient care is difficult and frustrating, which for back pain is often the case, applying technical skills remains the preeminent task. It is a challenge one prepares for through dedicated, highly demanding years of training and experience. Yet every new patient faces the lurking possibility that complexity, atypicality or error may result in failure. Mistakes come at a high price in terms of patient harm; treatment disappointments; legal hassles; malpractice costs; loss of self-esteem; and damage to a physician's reputation. It is understandable, therefore, that in discussing the evaluation and care of a patient, attention always focuses overwhelmingly on the technical skills required.

Communicating with Patients

One skill essential to practice is consistently, almost universally, left out of consideration: how one uses language and the management of patient encounters to improve the likelihood of success in making the diagnosis, carrying out the treatment plan, and ensuring patient satisfaction.⁹ Like it or not, given the "pressure-cooker" or "marketplace" atmosphere of contemporary practice, physicians need to ensure that their "people skills" are up to par.^4,16 This need is now greater than ever, because, as one commentator notes, "Patients are demanding more communicative and personal physicians, similar to the 'good old days' of medicine."^3,19

In the inherent intimacy of a therapeutic encounter, a clinician must rely on well-developed interpersonal abilities not taught adequately in schools and residency programs, largely because their importance is not recognized. This is one area, among several, where anthropology can be of help, because part of what anthropologists do is document and analyze how patients and health care providers interact.^14,15 Eline Thornquist has done this at the University of Oslo. She emphasizes the importance of successful communication, even though, as she puts it, "In modern medicine, the 'art' of communication has, in principle, been considered something other than 'real' professional work, that is, a scientifically based diagnostic and therapeutic activity."²⁰

Perhaps skill in working with people has been neglected precisely because it is an art; an ability one must somehow pick up on an intuitive level. Science can be taught; art must be lived. An instructor can teach the technology of practice, but can only model that all-important art of practice that lies hidden away in deep sensitivities and intuitive leaps. Part of that art of practice comprises interpersonal capabilities that contribute to success, and one reason such capabilities cannot be directly taught is because communication is dialectic - it involves interaction between at least two people - one of whom is the physician.¹² Since each physician has a unique personality and temperament, a role model can only demonstrate communication practices that are personally (one might say "idiosyncratically") relevant. What works for him or her may not work for you. For that reason, I do not presume to outline rules for communication. I will not offer "how-to" tips. Yet, I do hope to be helpful by drawing attention to a number of social, cultural and psychological issues to keep in mind as you think about your own people skills and how they might be improved.

Setting the Stage

A metaphor that can work for or against a successful patient encounter is that of theater.^8,18 Yes, "All the world's a stage," and the doctor's office, clinic or hospital is a setting we can start with as the curtain rises on the first meeting between doctor and patient. As recommended by R. Dean Harman,DC, to begin with, the program notes should not read, "waiting room," which might seem to imply that a patient must waste time until the doctor finds it convenient to get started. Call it rather the "reception area," and consistent with that, do your best to tighten-up scheduling so that waiting is minimized.¹¹

Dr. Harman also recommends doing a bit of sociological research as you think about your work in terms of what I characterize as a theater. Ask patients about their impressions of the reception area and how they were received. Ask them, too, for suggestions about how they think your staging could be made more client-friendly, and then implement those suggestions that make sense to you. (By the way, I find that this kind of questioning works best when done informally. You can do it yourself, but a good receptionist will probably get more useful responses with more directly constructive criticism.) People don't like to sound critical when talking to their doctor. A short questionnaire, with spaces for answering open-ended questions, doesn't work as well in terms of the quality of the answers one gets, but it is an option.

It may be that neither you nor those you work with are setting the stage for optimal performances. Perhaps you should engage a consultant to provide counsel on space design: the arrangement of chairs and other furniture; lighting; the use of living plants; art objects; and so on. Apply your own ergonomic knowledge in selecting chairs that are comfortable for people with back pain and mobility disorders. Background music can do a lot for mood-setting, especially for anxious people, but it can upset those whose tastes differ from your own. Patient questioning can help in deciding the type of music to provide. Remember: The music is for them, not you. Whatever the style of music, you will probably find that patients are not too keen on radio stations that include a lot of talk.

While it might be wise to solicit professional help in designing the reception area, you should make your own decisions about how to set the stage in the office where you first meet with patients to get acquainted and take a history, because the arrangement of office furniture constitutes an important clinical act. Talking across a desk, for example, is the single most common practice in medical offices, with the doctor swiveling in a large desk chair to greet a patient confined to a smaller chair that, to further stigmatize the relationship, has him or her sitting at a lower level. This typical arrangement is practical for the physician, since it provides a flat surface for filling out forms, reading printouts and using a computer, but by its very nature, it constitutes distancing behavior in terms of the doctor-patient relationship. In symbolic terms, it implies an authoritative role for the care provider and a submissive one for the care-seeker.

For some patients, talking across a desk works well. These patients want an authoritative, technocratic or parental figure to take charge. Also, it can serve especially well if you are with a client who may be attempting to become unduly personal or outright sensuous. Many practitioners complain of problems they have encountered with "patients who want more time than the physician has to give; patients who are overly friendly, seductive, or curious about the physician's personal life; and (who initiate excessive) gift-giving."⁵ Your desk can help to protect you from these doctor-patient boundary transgressions.

But this arrangement does imply a hierarchical relationship, which produces discomfort in many patients, particularly those who in their own jobs are esteemed and powerful. Quite ordinary folk also enter a doctor's office with a strong sense of personal dignity that is vulnerable to symbolic put-downs. These patients may respect the doctor, yet feel strongly that respect requires an egalitarian relationship. They respond to distancing behavior with hurt feelings and deep resentment. Ask around, and you will notice the prevalence of negative emotions engendered unconsciously in the staging of the therapeutic encounter.

This potential impediment to effective doctor-patient relations can be avoided in simple ways. Merely by relocating the patient's chair to the end of the desk instead of across from it makes face-to-face interaction much more direct. This setup moves the patient into your conversational space, with physical barriers effectively removed. Other possibilities include sitting at two ends of a couch, or in identical armchairs positioned across a coffee table. No doubt you can think of still other ways, if you put your mind to it.

Body Language

We've all been trained to observe and interpret how a patient's posture and movement can provide clues to the diagnosis. You know how to look for subliminal messages in facial grimaces; you habitually observe how a patient walks. In the presence of limping, you know you must rule out a limb-length difference; fixed deformity; flexion deformity of the hip; antalgic reaction to a painful disk protrusion; or psychosocially inspired pain behavior. The observation of antalgic asymmetry of the sort one sees with sciatica, the stooped but bilaterally symmetrical habitus typical of ankylosing stenosis, or other subtle indications are also taken into account. However, most of us were never trained, at least not adequately so, to look for body language that speaks to the quality of the interpersonal encounter, in terms of how we feel about each other.

In this, other aspects of the patient's behavior become meaningful. More importantly, the physician needs to observe self-behavior and what it says to the patient about the doctor! It is that aspect of body language that most doctors neglect.

Communication is not solely a matter of the spoken word, of verbal exchanges. It is far more complex. It flows along multiple channels simultaneously, complementing language with the subliminal cues of posture; movement; proximity; gaze; touch; and attire.^10,2,20,5 For improving all of these, a useful technique is to arrange to be videotaped with a patient or two (with the patient's consent, of course). Later, review the tape with someone you can trust to be frank, but supportive, and discuss what your sheer physicality seems to be "saying." Are these messages consistent with your verbal exchanges? Are they messages that make you more effective? Keep in mind that all actions convey messages, including the following:

• Posture. Do you look attentive? Is your body directed toward the patient? Are you slumping, as though too tired to care? What about the set of your jaw and facial expression?


• Movement. Are your movements quick, suggesting you have little time to devote to the encounter, that you are impatient? Do you and the patient move in synchrony, like dance partners? To do so is probably better than to have your body "out-of-step" with the small movements of the patient.


• Proximity. You should be far enough from the patient for both of you to feel comfortable as you converse, except when doing the physical examination, in which case extreme closeness is understandable. A distance of less than about two-and-a-half feet can make a patient feel uncomfortable, because it implies bodily intimacy; more than three-and-a-half feet has the opposite effect. In psychological terms, this is "distancing."


• Gaze. Maintain eye contact. Talking to a patient while looking away can suggest a lack of caring, hypocritical personal involvement, or being distracted. Avoid what most commonly occurs: unfocused attention and middle-stance gaze. On the other hand, do not stare down your patient. A hard stare is intimidating. The preferred strategy for dealing with a patient who may be abusive is not a hard stare, but to articulate clearly what you expect and the limits you set on your relationship.


• Touching. I remember being told always to shake hands with a patient entering the office, because doing so provides clues about the patient's emotional state, based on the firmness of the grasp and the dryness or dampness of the skin. From a patient's standpoint, however, the handshake makes an important statement that reaches back to the Middle Ages, when it originated as a way for strangers to demonstrate they were not armed. A handshake presents you as nonthreatening, friendly and well-intentioned, even when it involves a man offering his hand to a woman - unless it involves a woman brought up on philosopher and etiquette advisor Emily Post, which still can happen. Handshakes imply mutual respect.

Local customs differ concerning other kinds of touching. Putting your hand on a patient's shoulder or arm can be reassuring, but it can also be felt as patronizing, so think about what it may mean when you do it. After all, a pat on the head is only suitable for children. Avoid placing your arm around a patient's waist or giving a hug unless you are positive it is acceptable in your community and with that particular individual. A lot depends on how you and the patient are related in terms of gender, ethnicity and age. Remember, while touch can have significant therapeutic benefits, too much touching can cause a decrease in satisfaction by the patient. There may be difficulty in distinguishing nonsexual from sexual touching, and misinterpretations by the patient may occur because of differences in experiences and values between the patient and the physician.^5,7

Given current legal and ethical concerns about harassment, it is generally wise to keep social touching to a minimum.^1,13,17 Clinical touching, during procedures, palpation and manipulation, is of course a different matter. Keith Ferdinand, reflecting on how his disadvantaged African-American patients feel at the Heartbeats Life Center in New Orleans, writes, "I cannot tell you how many times I have examined a new patient and have been told, 'This is the first time a doctor's touched me.'" That these patients have not previously been touched suggests that their medical care has been inadequate, but it also speaks to the emotional tone of their clinical experiences. Is it any wonder, Ferdinand asks, that these patients feel distanced from their physicians?⁶

• Attire. "Dress for success" is an old motto from the advertising world that encourages the idea that you should purchase expensive, stylish clothes. The goal was to succeed in business and in high society. In fact, we all usually dress for success in a broader sense. How we dress, arrange our hair, and wear what archeologists refer to as "portable art" is a way in which we create visible identities. Traditionally, doctors wore predictable clothing that included a conservative dress or shirt, a tie and slacks under a white coat. The portable art included a stethoscope (its symbolism understood internationally), and just to be absolutely clear, across the coat pocket was embroidered the doctor's name, followed by "DC," "MD," or an equivalent. This conveyed a powerful symbolic message, saying, in effect, that in the medical setting, the doctor was at the top of the hierarchy.

But times are changing. The multiple roles we play in our lives away from work have begun to intrude into the workplace. Casual wear that symbolizes something about being unpretentious now shows up in doctors' offices and on hospital wards, at least on weekend and evening shifts. Pediatricians appear to have started the trend, noting that children find doctors and nurses less threatening if they dress in clothes that resemble those their parents wear around the house. With adult patients, the symbolism is more complex. Patients can respond with good feelings to the idea that your casual attire means you see yourself as approachable, but it can also suggest that you are not living up to the traditional standards of highly trained professionals.

For many health care professionals, organizational dress codes make a shift to casual attire nonapplicable. For the rest, local customs and personal predilection can influence how we use our bodies as walking advertisements.

Personally, I have no pat answers to offer. Many patients are fed up with current status discrepancies, while others like things just the way they are. We need market research on this, and it should extend beyond dress as such to include green hair, pierced body parts, beards and tattoos.

References

1. AMA Council on Ethical and Judicial Affairs. Sexual misconduct in the practice of medicine. Journal of the American Medical Association 1991; 266:2741-2745.
2. Birdwhistell, Ray L. Kinesics and Context: Essays on Body Motion Communication. University of Pennsylvania Press, Philadelphia, 1970.
3. Editorial. Residency training in America: Focus on internal medicine. Hospital Physician 1997;33(10):17-23.
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6. Ferdinand KC. Cultural Competence. Internal Medicine News 1997;30 (20):12.
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13. Jensen PS. The doctor-patient relationship: Headed for impasse or improvement? Annals of Internal Medicine 1981;95:769-771.
14. Katon W, Arthur Kleinman. Doctor-patient negotiation and other social science strategies in patient care. In The Relevance of Social Science for Medicine, L. Eisenberg, A. Kleinman, Eds., D. Reidel, Boston, 1981.
15. Kleinman A, Eisenberg L, Good B. Culture, illness, and care. Annals of Internal Medicine 1978;88:251-258.
16. Korsch BM, Negrete V. Doctor-patient communication. Scientific American 1972;227:66-74.
17. Larsen KM, Smith CK. Assessment of nonverbal communication in the patient-physician interview. Journal of Family Practice 1981;12:481-488.
18. Schechner, Richard. Between Theater and Anthropology. University of Pennsylvania Press, Philadelphia, 1985.
19. Tenery RM. Commentary: Doctors are forming partnerships with their patients. American Medical News 1998; 41(5):21.
20. Thornquist E. Three voices in a Norwegian living room: An encounter from physiotherapy practice. Medical Anthropology Quarterly 1997;11(3):324-351.

Robert Anderson,DC,MD,PhD
Professor of Anthropology
Mills College
Oakland, California