Talking to the doctor; listening to the patient Part I

The Open Mind
Host: Richard D. Heffner
Guest: Dr. Mack Lipkin, Jr.
Title: Talking to the Doctor; Listening to the Patient
VTR: 12/03/02

I’m Richard Heffner, your host and thanks to the helping relationship the Commonwealth Fund has generously established with The Open Mind I’m able now more often than otherwise might be the case to look rather closely at some of the basic health care issues that concern me and so many of my viewers these days.

Now one of these issues has to do with doctor/patient communication. With your and my ability and willingness as patients to tell our medical providers what they must know to care for us well enough and with our physician’s ability and willingness to listen, hear and then act effectively.

That’s precisely what must begin with the medical interview which we are told with Internists in the United States averages 15 minutes per visit. With family practitioners 12 minutes; pediatricians 8 minutes and with physicians over all just 6 minutes. Besides, as today’s guest has written, the amount to be accomplished in this brief time with its commensurate bureaucratic burden has mushroomed. More illnesses to rule out. More diagnostic and treatment options to explain, more insurance complexities to sort through. Thus doctors and patients feel hassled, rushed and dissatisfied.

So much so that 40% of doctors would no longer recommend a career in medicine to their children. And 35% of doctors suffer symptoms of burnout, much of which is related to unsatisfying daily encounters with their patients.

But what has to be done has to be done and it is estimated that the average physician will conduct approximately 120,000 to 160,000 interviews with patients in the course of a 40-year career.

Now my guest today, Dr. Mack Lipkin, Jr., Professor of Medicine and Director of the Division of Primary Care Internal Medicine at New York University’s distinguished School of Medicine and a leading international researcher in doctor/patient communication writes about the medical interview between doctor and patient that it represents the core clinical skill.

All of which leads me to ask Dr. Lipkin just why, as he has said, students enter medical school with a high level of interest in dealing with people, with honing their people skills, but historically those skills are worse after four years, and I presume you mean four years of medical school.

Lipkin: I do. There’s a negative impact in medical school.

Heffner: How come?

Lipkin: We’re not exactly sure why. We are sure that it happens, from very good studies. We think that the reason is that … particularly in the first two years of medical school students really are being taught by scientists, not by clinicians; they’re encouraged to feel and they sort of imbibe an ideology that science is what matters in medicine. And the amount of teaching about working with patients and about clinical skills, particularly communications skills, historically has been relatively tiny compared to the rest of the curriculum. That’s also changing.

Heffner: Does it go downhill afterwards, after the degree is granted?

Lipkin: Well, it actually goes downhill again after the second year … when they start on the wards, because they’re being taught by overworked, sometimes exhausted, regularly hassled Interns and Residents for the most part. Those are who their models are. They may be wonderful people, but it’s hard for them to have the time to sit and talk to patients the way they should.

Actually once they graduate and become Interns and Residents, their skills gradually get better, but they never get back to baseline.

Heffner: Never get back to where they were when they began medical training?

Lipkin: Well, that’s what the studies have shown. I think that we’ve … we’re turning this around now, but historically that’s been the finding.

Heffner: Well I know you’re engaged in research to try to find out how to do so. And I know that in terms of your own teaching, this is what you press very, very hard on. How do you that? How do you say, “be as interested in people as you were four years ago, six years ago, eight years ago?”

Lipkin: Well, we don’t press. You know, that’s sort of like “eat your spinach.” We don’t do that. We really try to show the students that really understanding the patient as a person, understanding them in their life, their work, their family, their home, their community is essential to being a competent good doctor. That the data that they’ll get from that discussion with a patient about their complaints, their symptoms and also about who they are, are the most important data that they’ll use in clinical reasoning, in deciding what are the options that the patient might choose from, in deciding what treatments to recommend. And without good quality data and without understanding the values of the person, you really can’t help a person make the best choice for them. And we know that without good communication they won’t follow through.

Heffner: You say you can’t then help the patient make the best choice. But that concept itself of helping the patient make the choice, isn’t that something new and that doesn’t go with those years of scientific training?

Lipkin: Well, we don’t … I don’t believe that there’s a schism between science … scientific care and humanistic care. I think there are very strong data that show that they’re inseparable. But it is true that the preparation for the scientific part … organic chemistry and anatomy and those kinds of things really do take the life out of the human encounter that’s at the core of medicine and at the core of healing.

Heffner: Well, are you trying … it’s … as I read what you’ve written and what you teach and read around the subject, I know that I have to ask the question as to whether you are trying to return to an older tradition of doctor-patient relationship, or indeed that’s what you’re fighting now.

Lipkin: Well …

Heffner: I know “fighting” is going to be a word that you won’t accept.

Lipkin: [Laughter] Well, no. I think that we’re like any of the forces in society that deal in values and trying to sort of … in Rawles sense optimize choices. We do have to fight for our place at the table educationally, for research dollars, to overcome the attitudes you were alluding to that this is soft stuff, or it’s just a matter of talent … you can’t teach somebody to be carrier compassionate. Or that you can’t teach someone better behaviors or habits.

There is very robust science behind the opposite of each of those statements. You can teach people to gather data efficiently and more accurately and more completely. You can teach them to create a human relationship with a person. You can teach them to be more compassionate. Most student doctors and even most jaded older doctors really want to be caring and good to their patients and to love their patients, perhaps … they might not use that word. And have their patients care about them. They just don’t know how.

And that’s really what we’re trying to change. We’re trying to show people at every level that there are ways that they can make the process be more effective professionally, more efficient and more satisfying to both people.

Heffner: Even in the face of so much more scientific knowledge that is required, even in the face of numbers of patients that has … well, you yourself write about this … about the burgeoning number …

Lipkin: Yeah.

Heffner: Even in the face of these hard, cold facts?

Lipkin: Well, you know, the per capita ratio of patients to doctors nationally has been improving …

Heffner: Improving?

Lipkin: Yeah. We don’t have fewer doctors per patient, we have more doctors per patient than we did ten years ago or twenty years ago.

Heffner: Then where did the time go? Or where does the time go?

Lipkin: Well, the studies also show … it’s … this is a really interesting issue … studies also show that the actual time spent between doctor and patient, if you have a seeing eye at the door when they cross it going in and when they cross it coming out … that time hasn’t changed in the last twenty years either. But the perception is that it’s changed. That’s because there’s more to do. I think. The doctors have more tests they feel they need to do and therefore to explain and to justify. The patients may have more concerns, patients are much more informed now than they were 20 or 30 years ago. You know they can go on the Internet and find a huge amount of information about whatever their problem might be. It may not be good quality, but it’s in their mind. And you can’t turn on the TV without seeing multiple ads for products that are being advertised directly to consumers and without seeing hour-long situation dramas and comedies about medical things. And magazine shows about medicine. It’s just really in the eye of the public constantly. So there’s more discussion that patients want.

Heffner: Now you’re saying that it is the desire of the patient to have more time spent that leads us as a people to think there is less time being spent, when in reality that’s not true.

Lipkin: Yeah. Well the things that go into the perception of time passage … you probably know better than I do, but …

Heffner: Because I’m a patient and you’re a doctor?

Lipkin: No, because you sit across from somebody every week and you have to get into that time what you want to get into it. It’s a similar thing. But that perception of time derives from how satisfying the time is, whether the person feels they’re being … as you said … heard and understood. Whether they feel frustrated versus empowered to participate. Those sorts of things are primarily on the patients’ side what contributes to the perception of time. On the doctors side it’s similar.

Heffner: Dr. Lipkin, let me ask you this question … empowerment. Is it such a positive thing that patients want to, and frequently do participate more now. Given the older medical model where there was an assumption that what patients really wanted, when you got down and scratched bottom was to have Herr Professor … Herr Professor Doctor … tell them what the situation is and what must be done about it. Has that really changed?

Lipkin: Well some things have changed. I’ll tell you my own feeling about empowerment and partnership. My feeling is that different patients have different preferences. And different doctors also have different proclivities. All things being equal, there’s pretty good data that when a patient is activated to take part in their own care … I’ll tell you about some wonderful experiments in a minute … about … that showed this … they do better medically.

One of the first studies of this sort of activation idea was by Kaplan and Greenfield and it was a very simple intervention. They randomized patients in the waiting rooms of clinics who had peptic ulcer disease, diabetes, hypertension and later, breast cancer. And in the control group the patients who were randomly assigned to that group were given a pamphlet which was about general health principals and prevention. The experimental group … a clerical level person, not a highly trained person … came up to the patients and said, “Your doctor has asked me to ask you to ask questions today. What sort of questions do you think you might ask?” And they would talk for ten minutes about that. The experimental group who were asked to ask questions had better control of their sugar, lower blood pressure, fewer bleeds and hospitalizations for peptic ulcer and in breast cancer patients eventually better quality of life. And actually statistically, but not clinically, significantly longer life. And since those were done in the late eighties there’s been a cascade of similar studies, trying to get at what it is about shifting the locus of care, in a sense, from a gray haired expert, or the no-haired expert … to a partnership where the patient feels, “Yes, I can do this. Yes, I can take care of myself. Yes, if I want to get better, I’m going to make it happen.”

We did a study where we analyzed 550 interviews in primary care return visits. And we found that … a lot of things … but we found that there were five different styles of communicating. One was that … was narrowly bio-medical, was about symptoms … “did you take your pills?” That kind of thing. “How’s your chest pain today? How many steps can you walk up?” And, “Let’s change your dose.”

Second was more broadly bio-medical. Third talked mostly about the person. Fourth was balance between medicine and the person. And fifth was what we called “consumerist” in which the patient primarily took charge, they asked questions, the doctor primarily responded. Believe it or not the doctors were most satisfied by that last group.

Heffner: Why do you think that’s the case?

Lipkin: Well, for one thing, they didn’t have to work as hard. They …

Heffner: Okay.

Lipkin: For another … it’s, it’s sort of the difference between the feeling of driving down the highway in a well-functioning car and digging your Land Rover out of the mud. You know, it’s just more satisfying if you feel that you’re going to really get there.

Heffner: What about those people though, and there are such, and if I didn’t know it, I’d have to be made of … I would be made aware of it by reading this chapter of yours on the medical interview and related skills. And let me see … where, where I find your caveat here. Ah, yeah, “Patient education is essential for consumer oriented middle class American patients. However laborious or defensive justification of the regime may be counterproductive for those patients who have strong needs to see the physician as powerful, magical or omnipotent. For such patients education may not be necessary and may undermine their coping with their illness.”

So you’re not … as you said … as we began … you’re not pushing …

Lipkin: No.

Heffner: … you let it surface, as it shall.

Lipkin: Yeah. And I think that there’s a division among the scholars in this area about this issue.

Heffner: What do you mean?

Lipkin: Well, one of the most wonderful social scientists who does research in this area is Deborah Roter at Hopkins. She believes very strongly that partnership is better.

Heffner: No matter what.

Lipkin: Yeah. So does Sherry Kaplan who did that question asking study. But those of us who work at Bellevue, we know that if we’re dealing with a recent immigrant from say the Middle East, or China where culture is traditional and authoritarian in some respects, might be made very uncomfortable by our trying to engage that person in decision making, where they feel that we are the authority, we have much more experience and … we know, because we’ve asked … they begin to think “Well, why isn’t Dr. Lipkin telling me what’s the best treatment. Doesn’t he like me? Doesn’t he care about me?”

So you really need to understand the deep cultural set of a person and also their values.

Heffner: But let me ask you this question. Doesn’t Dr. Lipkin know better? Dr. Lipkin after all has devoted so many more years, so many years to the study of whatever it is is at hand in terms of illness. Dr. Lipkin is the doctor.

Lipkin: Well, there’s no question that I know more about a lot of illnesses than a lot of patients. However, I have to tell you … you know, we were very involved with the early days at the AIDS epidemic at Bellevue, which in those days initially was primarily in gay men.

After about three years we’d have men coming into our practices who knew what studies were being done the day before at the NIH. And they knew so much. If I find a patient with a chronic disease that I don’t know a whole lot about … you know I know a lot about diabetes … but, say a more unusual auto-immune disease, or something like that that I don’t see every day, that I might see five or six times a year … but that person’s lived with it for 20 years. Believe me they know an awful lot. We’re better off as partners.

And the other thing is that, you know, if you’re just looking at it in a kind of a crude outcome-oriented way, the outcome I want for the patient is that …for them to get better. I’m trying to suggest to them that they take one of several treatment options in a roughly equivalent, but all of which require some action on their part.

We know that even the simplest situation which was the first really good study of this kind, done a long time ago, take a parent whose child has strep throat. The child needs to take penicillin four times a day for ten days or they are at risk for valvular heart disease, or rheumatic fever … serious. Parents told that. Only 60% of those mothers complete that course of medicine. 40% do not.

And then you think about our AIDS patients who are taking ten, 12 and 14 medicines. You think about our patients over 65 with three or four medical conditions that require medication, in complex regimens some times. It’s hard to do. And the patient is the expert on themselves and what they will do. I may know what’s good for them, but they know what they’ll do.

And how we can work together to let them figure out how to do the best for themselves and also equally not to stigmatize them with a plan that was cooked up in a university hospital by a Professor of Medicine who had complete control, because they had a lot of technicians and nurses handing things to patients. But never once went down to the lower East Side where there are five people in a room and they don’t have heat and they don’t have hot water and the baby’s crying and somebody’s intoxicated, or been a victim of violence or chaotic social settings. Those hospital developed plans, which work under controlled circumstances, don’t necessarily work in the field.

Heffner: We have two minutes left for this program, though I hope you’re going to sit there and let us do a second program. Let me just ask, to what degree do medical school curricula reflect this more humanistic attitude you’re expressing.

Lipkin: Well, there’s been a migration in that direction since the late sixties. In 1978 only about 35% of schools had any reasonable teaching in this area. Now about 80% have some, although probably only half of that 80% have good quality teaching. It’s coming. The Leading Boards that American Association of Medical Colleges, etc., etc., the Board of Internal Medicine … are now requiring communications training. And what’s exciting to us is that we’ve just finished a four year experiment with our partners at Case Western Reserve Medical School in U/Mass showing that by instituting comprehensive curriculum you can really make a significant, experimentally done, tightly tested study … significant improvement in skills.

Heffner: Is there resistance to this?

Lipkin: There’s a great deal of resistance. For many reasons. Some people think it’s hogwash and soft. Some think you can’t train behaviors, which is obviously wrong. Some people just don’t want the curricula time to go in this direction, they want it to go in their direction.

Heffner: Which you can appreciate.

Lipkin: Of course, it’s the currency of education, is curricular time. So … I think we’ve raised the bar now, it’s going to change.

Heffner: Well, I want to talk with you about the other things that have to change and if you’ll stay there, we’ll do another program.

Lipkin: Great.

Heffner: Thanks Dr. Mack Lipkin, Jr. And thanks, too, to you in the audience. I hope you join us again next time, and if you would like a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.

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