Dr. Dennis Rosen.
‘It is the providence of knowledge to speak,” said 19th-century American physician Oliver Wendell Holmes Sr., “and it the privilege of wisdom to listen.” However, a recent published study of US medical students specializing in internal medicine found that they spent as little as 12 percent of their time examining patients and even less talking to them – compared to 40% in front of their computer screens.
With such a seeming disconnect between doctors pressed by patient quotas and sick people worried about their lives and health, an English-language book advocating better doctor-patient communications, to be published by Columbia University Press, is quite timely. Titled Vital Conversations: Improving Communication Between Doctors and Patients, the 240-page volume was written by a Canadian- born Israeli who currently lives in Massachusetts.
An assistant professor of pediatrics at Harvard Medical School and a pediatric lung and sleep specialist at Children’s Hospital Boston, Dr. Dennis Rosen made aliya with his family to Jerusalem in 1982. There, he attended Rene Cassin High School, served in the Israel Defense Forces’ Nahal Brigade, graduated from the Hebrew University Faculty of Medicine and completed his pediatrics residency at Rehovot’s Kaplan Medical Center. Moving to Boston for his fellowship, he remained for his career.
FULL OF personal anecdotes, selected research in biomedicine, sociology and anthropology and lots of footnotes (but reader friendly), Rosen’s book should be read by physicians and students of medicine and nursing, as well as laymen interested in our medical system.
Israeli medicine – still the majority of it public and much more efficient than America’s private system – would also benefit from improved communication between doctor and patient.
Rosen maintains that such improved two-way communication actually reduces the cost and raises the level of medical care, improves patient compliance and minimizes medical complications and hospital readmissions.
He begins with his first and only experience of being hospitalized, at 18 with dehydration a few days after developing a relapse of mononucleosis. Taken to a hospital in Haifa after developing painful, bleeding ulcers in his mouth, he was unable to drink or eat anything. Nearly a dozen different people stuck their gloved fingers into his mouth, but none ever explained what his problem was. “Doctor,” he called after a senior-looking doctor, Rosen’s numbed-up tongue and lips making the words difficult to articulate. “What’s wrong with me?” “Gingivitis,” the physician said while going out the door.
The teen had never hear d of the inflamedgum condition before and thought he was dying.
“I certainly didn’t like the way [the word] sounded. All of a sudden, I was very frightened and felt small and inexplicably ashamed, unworthy even. Instead of asking what gingivitis was and why I had gotten it, I asked about its treatment.”
“Keep on rinsing your mouth with salt water and use the lidocaine gel for pain,” the doctor said in a hurry.
“How long will it take until I’m better?” Rosen asked in desperation.
The doctor “shrugged his shoulders silently and turned away,” Rosen recalled in his book. During his week of hospitalization, no one bothered to tell him that it was a self-limiting periodontal infection that goes away.
GOOD DOCTOR-PATIENT communication, he continues, is good for medical professionals, the healthcare system and society as a whole. It “establishes the trust necessary for patients to open up to their physicians and to commit themselves to the healing process.” The onus of improving the communications, he says, lies with the doctor.
This may be clear to ill people, but not always to the physician, Rosen notes.
A large US survey of patients found that a quarter complained their doctors did not encourage them to ask questions, while 30% complained that they weren’t given clear instructions regarding what symptoms to watch for or when to seek further care. Two-fifths said their doctors didn’t always discuss different treatment options or involve them in medical decision making, even though the practice of medicine has long ceased to be paternalistic.
Many low-income US patients avoid getting prescribed medication because they can’t afford copayments, and their doctors don’t bother telling them the cheaper generic version is just as good. Instead, the patient will go without. A recent review of over 700,000 patients being treated for any of seven chronic diseases found that non-adherence ranged from 32% to 63%, often because of copayments. This occurs in Israel as well, but it is less common, as copayments are cheaper.
Rosen writes that because some doctors do not explain exactly how to take medication, the drugs are less effective. In any case, doctors rarely ask about non-adherence. Another study, this by the US Veterans Administration, found that a fifth of those in smoking cessation courses claimed to kick the habit but lied, and their doctors didn’t check to find out if they were still smoking.
Patients whose doctors do not persuade patients effectively or at all about the need for preventative tests such as cancer screening or vaccination are less likely to undergo them and thus more likely to get sick.
Poor communication with patients has been shown even to increase “burn out” among doctors and raise the risk of malpractice suits. Many physicians are also very reluctant to speak to patients and their families about end-of-life care.
The need before discharge to explain carefully to patients and their families what to expect, how to take medications and what signs of problems to look for.
Communications would also benefit from better surroundings when patients and doctors meet. The typical “hospital smell” of chemicals, sanitizers and bodily fluids can cause dread, unease and stress, Rose notes.
Improved lighting, noise control and even essential oils for scents can reduce anxiety during these encounters.
In an outpatient clinic waiting room, presenting patients with relevant videos to explain conditions and answering questionnaires that would save time in the encounter with the doctor would be welcome.
Recommendations to patients include taking notes, bringing someone along with you, speaking up to the doctor if something is not clear and preparing a list of questions in advance.
Doctors, he advises, should shake hands with their patients; smile; maintain eye contact instead of constantly looking at the computer screen; face the patient squarely, leaning forward or in a relaxed body position; avoid technical jargon; ask open-ended questions; and follow up patient’s comments or questions.
ROSEN DOES not present himself as a know-it-all doctor, and he also discusses his failures to communicate properly. He recalls the case at Kaplan of a three-week-old daughter of an Ethiopian immigrant couple who brought her to the pediatric ward severely ill. It took some time for him to discover that the infant had had her uvula (the dangling piece of flesh at the back of the throat) removed at the hands of a traditional healer, which almost killed her.
He urges that physicians familiarize themselves with cultural, ethnic and religious influences so they can learn how to deal better with their patients.
The author also differentiates among disease, illness and sickness. They are not variations on the same theme. “Disease” is a malfunctioning of biological and/or psychological processes, while “illness” refers to the psychosocial meaning and experience of perceived disease and includes personal and social responses to disease, he notes. “Illness is a human event” and larger and more complicated than disease.
“Sickness” relates to how society defines the unhealthy and assigns them roles within it, even when the patient doesn’t regard himself/herself as being unhealthy. “Societal attitudes toward disease weigh heavily upon how patients interpret their symptoms and construct the narratives of their illnesses. They also directly influence the way patients are treated by their physicians and by larger society.”
Communications-skills training, including how to break bad news, has begun in both American and Israeli medical schools after having been neglected for too long.
Examples for these subjective terms include ultra-Orthodox parents of a child with epilepsy who refused to describe seizures because they worried that when others learned of the diagnosis, the child and even his siblings would have problems finding a marriage partner.
When going on a medical mission to Haiti, the author encountered a new mother in a Port-au-Prince facility for earthquake survivors who refused to nurse her premature baby. As formula based on unsanitary water supplies could have killed the baby, but Rosen couldn’t get through to her the importance of breastfeeding him. It seemed a “frivolous and reckless endangerment of her son’s life.” But after a lot of digging, the medical team learned that the woman had a previous child who died in infancy and had been told by a voodoo priest that it was because her milk was “bad.” If she breastfed subsequent babies, the priest said, they too would die. Haitian women abused by their husbands are frequently accused of having “spoiled milk.”
Finally, they persuaded the woman’s mother that her daughter’s milk was not tainted. The grandmother “gave her blessing for the mother to express a small quality of milk into a bottle for her baby. Once the mother saw that no harm befell him, she began to nurse him fully, and within a few days we were able to send him home safely, thriving and gaining weight,” Rosen recalled.
He still carries with him the lesson of one case during his pediatric residency at Kaplan. Rosen was in charge of Tomer, a three-month-old boy with seizures due to an incurable disease. He did his best medically for the infant, but he had failed to communicate with the parents regarding what to do when his end was near. Rosen was unable to move as the child’s heart rate slowed.
Sigal, a somewhat more experienced doctor, took over. She walked to the crib, stroked the baby’s face softly, put her arms around both parents and drew them toward her.
“It’s time,” she whispered softly. Then Sigal suggested they say their final goodbyes. “Several minutes later, the door opened, and the parents stepped into the hallway. They were tearful and clearly distraught, but they also had a certain inner peace that I’d not seen since we’d first met,” Rosen confessed.
“I became aware, suddenly, of just how poorly I actually had connected with Tomer’s parents and how little I had allowed myself really to understand what it was that they had been feeling and struggling with.”
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