April 17, 2006

Doctors return to their senses

The New York Times reports that third-year students at the Mount Sinai School of Medicine are required to take a course in art appreciation (here). Other med schools also have been offering such courses in the effort to help train future doctors improve their sense of visual observation. This seems particularly important in an age of managed medical care that makes it difficult for doctors to notice much about the twenty patients they can give only about 15 minutes to each day. So training in using their five senses, from art or anything else, is a promising development. Patients are complex human beings — a lot more than bodies — and it's important to see the details of their physical problems as well as the details of their social, pschological and cultural context, the same way one sees a painting or sculpture. But seeing is not the only sense to be enhanced in medical students. What about some more training in hearing and speaking?

I once heard a physician say that 95% of success in a medical diagnosis comes from getting accurate information during the medical interview. Information comes from seeing, of course, but also from hearing what the other person has to say. And hearing is related to talking — asking the right questions based on what is heard. Way back in 1971, Dr. C. P. Kimball advocated this in his article in Annals of Internal Medicine (74:137):

The physician speaks a strange and often unintelligible dialect. He calls everday common objects by absurd and antiquated terms. He speaks of mitral commissurotomies, pituitary insufficiency, and reality feedback. This world is peopled with cirrhotics, greensticks, and hebephrenics. The professional dialect creates a communication gap between physician and patient that is generally acknowledged by neither. Increased specialization refines the physician's particular dialect, and he becomes much like the computer, tolerating only the imprint of words that fit into the programmed languages.

In the past thirty or so years others, mostly linguists, have echoed and amplified Kimball's statements but since there is little room for more courses in the already overcrowed curricula of medical schools, only small progress has been made to train doctors in how to communicate effectively with their patients. And managed care has reduced whatever opportunities even the best physicians might have. In fact, some doctors are dropping out completely. I've lost two of my own doctors in the past five years. One left the profession entirely and the other accepted a more normal 9 to 5 life at a hospital. One problem is the fixed-choice medical interview form, which has to be zipped through as quickly as possible.

Another communication barrier stems from the difference between middle class doctors and working class patients, who often have their own very different words for things, such as "sugar" for "diabetes." In a study I conducted years ago a doctor asked a patient if she ever had an abortion. She replied, "No," even though her chart indicated two of them. I spoke with her privately after her interview and she explained that to her an "abortion" meant deliberately getting rid of the fetus. In her case, she miscarried naturally (‘The Medical Interview: Problems in Communication’, Primary Care, September, 1976).

So here's another voice in the wilderness calling for the medical profession to expand its thinking beyond seeing details to hearing them and learning to talk to patients in ways they can understand. And allowing some time for them to talk would help too.

Posted by Roger Shuy at April 17, 2006 12:27 PM