A Diagnosis: Doctors Fail to Communicate : UCI Professor Tapes Routine Office Visits, Says Lack of Information Frustrates Patients
You’ve just been to the doctor. You’ve been diagnosed, treated, prescribed medicine. Now you’re heading out the door after a 20-minute visit and your head is spinning. Not with fever but medical mumbo jumbo and questions about your condition.
And no wonder.
If your visit lasted a typical 20 minutes, your doctor spent only slightly more than a minute giving you useful medical information, according to a study by a UC Irvine professor.
Doctors spend most of their time examining patients and questioning them about their medical history; they actually explain very little about patients’ medical conditions, said Dr. Howard Waitzkin, a UCI professor of medicine and social sciences, who did the study.
“It’s clear that there’s a misperception between what a patient wants and what his doctor tells him,” Waitzkin said in his office at the North Orange County Community Clinic in Anaheim, where he is medical director.
“Doctors believe that only patients who ask a lot of questions want much information, but the study found that patients in general want as much information as they can get--delivered in a language they can understand. So doctors ought to provide information even when they’re not asked questions because their patients often feel uncomfortable questioning them.”
Ordinary Visits
Other studies have documented the doctor-patient communications gap. However, Waitzkin believes his analysis of more than 300 audiotapes of patient visits to doctors in Massachusetts and California is the first study of ordinary visits because they are recordings of doctors in private practice or outpatient clinics rather than in academic settings.
Versions of his study have appeared in recent issues of the Internist, the Journal of the American Medical Assn. and the Journal of Health and Social Behavior.
The study has received surprisingly little criticism, Waitzkin said. In fact, it has been the impetus for the American Medical Assn. and other medical organizations to prepare continuing education cassettes on how doctors can improve communications with patients, he said.
The study also has caused Waitzkin to change the way he talks to patients: “I’ve taken more of the initiative in providing patients with information and detailed explanations. Also, I now pay more attention to communications and less attention to things we are taught to be concerned about in our medical education--things like taking a complete history and completing every aspect of a physical examination.”
A major cause of friction between doctors and patients stems from physicians’ explanations being too brief and needlessly confusing, the study showed.
“When doctors talk to patients they rely too much on medical jargon,” Waitzkin said, adding that doctors’ poor communications skills can undercut patients’ compliance in taking medications or following other medical orders.
Economics plays a role in why patients receive little information. Wealthier doctors tended to see more than 20 patients daily and give fewer explanations. Giving information takes time, Waitzkin wrote in the study.
Various groups of patients also were treated differently, he said. Women received more time and explanations because they asked more questions. Nonetheless, they left their doctors’ offices frustrated because their doctors, usually men, interrupted so often.
Lower-income patients received less information. They tended to ask fewer questions because they were diffident and shy when dealing with doctors. Waitzkin said their doctors mistook their failure to ask questions as meaning they didn’t want much information.
Shares Many Criticisms
Dr. Michael T. Kennedy, president of the Orange County Medical Assn., said he agrees with many of Waitzkin’s criticisms.
“Doctors too often don’t think it’s important that they put much effort into talking to patients on a personal basis.” Kennedy said. “There’s no doubt that the demands of modern medicine require that doctors concentrate on providing accurate diagnoses and treatment.
“Still, doctors can do a much better job of making sure their patients understand what’s going on. They need to make their patients feel comfortable in talking with them by sitting down and listening to them, rather than looking rushed by standing and edging towards the door.”
Added Kennedy: “Doctors should use visual aides like pictures of the anatomy, booklets about certain medical conditions and fact sheets of questions and answers frequently asked by patients.”
Waitzkin believes that patients’ complaints that their doctors don’t listen to them are valid “because doctors are trained to ask questions to get a technically correct medical history, they tend not to let patients speak very much. And they interrupt their patients a lot.”
An example of a doctor’s poor communications skills can be seen in the visit of a 39-year-old fishing-net maker to his doctor’s suburban office to get a blood test for a marriage license, Waitzkin said. The tape recording of the visit reveals that at the beginning of the session, the doctor insists that the blood test is not the only thing on the agenda: “I’m more interested in your liver.”
The patient had been seeing the doctor for nine months for what the physician diagnosed as alcoholism “under control” and “excess cigarettes with asthmatic bronchitis.”
Waitzkin writes: “What begins as a straightforward request for technical information required by the state becomes a wide-ranging inquiry into the patient’s medical status, social relations and personal habits. Eventually, a variety of moral judgments issue forth, all under the rubric of medical advice.”
Critical of Approach
Waitzkin also is critical of the doctor’s style of conversation. “The doctor dominates the interaction through a long series of questions.”
The patient readily acknowledges he recently broke the vow of abstinence required by Alcoholics Anonymous. Waitzkin faults the doctor for spouting pieties about self-control without providing details about alcohol’s impact on the liver or smoking’s effect on the lungs:
Doctor: Yes I’d like to give you some sort of uh alcoholic base uh, that is, when things get bad, you know you can always come here.
Patient: Right, right.
Doctor: You know that. You know that (the alcoholism counselor will be furious), and you know that you can always depend on me, too. And then you also know that you’ll have the AA who are used to dealing with people like you. So that I think that it’s very important, not that you ever use it, but if you do (interruption)
Patient: I would go to him. I’ll tell you if I goofed again. I--
Doctor: But we need contingency plans, and this is for, uh, sit up on here (long pause) and come on down here a minute, and let’s poke a little and see. Let me listen to your heart first. . . . Deep breath. . . . You hear that? Boy, your lungs are loaded with uh wheezes. . . . Boy, you’re smoking up a storm.
Patient: I did last night something awful. ‘Cause everybody was on my back about. . . .
Doctor: Yeah, well, when people get on your back, you can’t go to booze or cigarettes. . . . You’ve got to think of something where you can hang out by yourself and control (your drinking).
It’s not that doctors are uncaring, Waitzkin said. They simply differ with patients on the kind of medical information needed.
In their survey questionnaires, patients indicated a lot of information would be helpful, he said in the study, “but doctors underestimated the patients’ desire for information (and) underrated the clinical usefulness of information giving.”
Doctors particularly don’t want to discuss patients’ personal lives, Waitzkin said. It doesn’t fit neatly into the format of taking a medical history, though he argues that patients are probably correct in feeling that emotional or social concerns affect their medical condition.
Patients seeking to bridge the communications gap with their doctors, Waitzkin said, should be more assertive in asking questions. “Patients have to be more vocal with their doctors even if it means writing down their questions in advance.”
