Lets apply Roters and Halls insights to the case of Anne Dodge. Falchuk began their conversation with a general, open-ended question about when she first began to feel ill. The way a doctor asks a question, Roter said, structures the patients answers. Had Falchuk asked a specific, close- ended question What kind of abdominal pain do you have, is it sharp or dull? he would have implicitly revealed a preconception that Anne Dodge had irritable bowel syndrome. If you know where you are going, Roter said of doctors efforts to pin down a diagnosis, then close-ended questions are the most efficient. But if you are unsure of the diagnosis, then a close-ended question serves you ill, because it immediately, perhaps irrevocably, moves you along the wrong track. The great advantage of open-ended questioning is that it maximizes the opportunity for a doctor to hear new information.
What does it take to succeed with open-ended questions? Roter asked rhetorically. The doctor has to make the patient feel that he is really interested in hearing what they have to say. And when a patient tells his story, the patient gives cues and clues to what the doctor may not be thinking about.
The type of question a doctor asks is only half of a successful medical dialogue. The physician should respond to the patients emotions, Roter continued. Most patients are gripped by fear and anxiety; some also carry a sense of shame about their disease. But a doctor gives more than psychological relief by responding empathetically to a patient. The patient does not want to appear stupid or waste the doctors time, Roter said. Even if the doctor asks the right questions, the patient may not be forthcoming because of his emotional state. The goal of a physician is to get to the story, and to do so he has to understand the patients emotions.
Falchuk immediately discerned emotions in Anne that would inhibit her from telling her tale. He tried to put her at ease by responding sympathetically to her history. He did something else that Roter believes is essential in eliciting information: he turned her anxiety and reticence around and engaged her by indicating that he was listening actively, that he wanted to hear more. His simple interjections uh-huh, Im with you, go on implied to Anne Dodge that what she was saying was important to him.
Judy Hall, the social psychologist, has focused further on the emotional dimension of the dialogue between doctor and patient: whether the doctor appears to like the patient and whether the patient likes the doctor. She discovered that those feelings are hardly secret on either side of the table. In studies of primary care physicians and surgeons, patients knew remarkably accurately how the doctor actually felt about them. Much of this, of course, comes from nonverbal behavior: the physicians facial expressions, how he is seated, whether his gestures are warm and welcoming or formal and remote. The doctor is supposed to be emotionally neutral and evenhanded with everybody, Hall said, and we know thats not true.
Her research on rapport between doctors and patients bears on Anne Dodges case. Hall discovered that the sickest patients are the least liked by doctors, and that very sick people sense this disaffection. Overall, doctors tend to like healthier people more. Why is this? I am not a doctor- basher, Hall said. Some doctors are averse to the very ill, and the reasons for this are quite forgivable. Many doctors have deep feelings of failure when dealing with diseases that resist even the best therapy; in such cases they become frustrated, because all their hard work seems in vain. So they stop trying. In fact, few physicians welcome patients like Anne Dodge warmly. Consider: fifteen years of anorexia nervosa and bulimia, a disorder with a social stigma, a malady that is often extremely difficult to remedy. Consider also how much time and attention Anne had been given over those fifteen years by so many caregivers, without a glimmer of improvement. And by December 2004, she was only getting worse.
Copyright © 2007 by Jerome Groopman. Reprinted by permission of Houghton Mifflin Company.
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