After more than two decades practicing medicine and chronicling the relationship between physicians and patients, Dr. Danielle Ofri has a unique understanding of the doctor-patient relationship. She’s written numerous books about the experience of practicing medicine, how physicians’ emotions impact their work, and about her own experience of transitioning from physician to patient. In addition to practicing medicine at the nation’s oldest public hospital, New York’s Bellevue Hospital, she is the co-founder and editor-in-chief of the Bellevue Literary Review and teaches medicine at New York University.
In her newest book, What Patients Say, What Doctors Hear, Dr. Ofri investigates the ways patients and physicians speak to and hear one another, and how this impacts physicians’ ability to perform medicine, as well as patients’ ability to receive and adhere to treatment plans.
Ofri spoke with Folks about her latest work, in which she explains why physicians can struggle to spend quality time with their patients, and how to improving the physician-patient relationship can lead to better treatment and medication adherence.
What was the impetus for writing this book?
This book began thanks to my last book, What Doctors Feel: How Emotions Affect the Practice of Medicine, after which I wanted to write about doctors and friendships. During my research, I found an interesting blog belonging to a doctor who wrote about befriending patients, including a patient who had been very difficult, and they had a lot of clashes in treatment.
I started reading all sorts of doctor blogs and looking at comments from patients when it really hit me. It was like they told two different stories! Both sides had their shortcomings and often admitted them, but they still saw things so differently. It was like doctors and patients were filming a scene in a movie with two different cameras, almost like making a completely different movie all together. That got cut from my last book—the story of how they see things very differently—and I wanted to pursue that fully.
It was like doctors and patients were filming a scene in a movie with two different cameras.
I know it’s a lot to sum up so briefly, but why do you think patients and physicians have such different experiences during an office visit?
For a patient, illness is the crisis of his life. For a doctor, it is one case on daily rounds. I might see 10 patients in a morning, so each patient is not the crisis of my life. The priority level is different, and the anxiety level is different in terms of where it ranks in my personal hierarchy. A patient may also want to tell the story of his whole life, whereas the doctor is focused on the useful aspects of the narrative in order to find a diagnosis and treatment.
I wouldn’t call them errors, but doctors do come at it with a different focus, so they can be perceived differently. For example, a doctor may say, “Here’s your treatment,” and a patient may hear “cure.” Those are two very different things.
How have you witnessed miscommunication between physicians and patients evolve over the course of practicing medicine?
One thing I’ve noticed in general, and over the course of my research for this book, is that a patient will say something like, “I have this pain over here,” and immediately, the doctor jumps in, asking when did it start. On average, we physicians interrupt within 10 seconds. We want to track down the problem quickly, but in the process, we may take a patient down particular avenue when patient has something important to add, such as, ‘This pain makes me afraid of a heart attack” or some family history we need to know.
I try to make other doctors aware of that, and I try to urge doctors to not say a thing, to totally shut up and put the computer down for one full minute. One minute is actually quite a bit of time when someone is looking at you and not typing. It’s very full listening. After the first minute, of course, a physician can ask, “Would you mind if I take notes?”
For a patient, illness is the crisis of his life. For a doctor, it is one case on daily rounds.
On the patient side, I like to have them think about the point of a visit. If you don’t have an approach, everything will be superficial. If you try and do many things, nothing will be in-depth. I suggest selecting one or two priorities to begin, and to think about telling your story, honing your narrative a bit.
That said, patients should always feel free to ask their doctor to repeat something, whether it’s a description of their treatment or simply part of the intake or exam. If the doctor still isn’t listening, it’s time to get a new doctor.
There’s an interesting chapter about patient non-compliance, and the statistics—that between 50-75 percent of patients may not adhere to recommended treatment plans—seemed surprisingly high. Why is that, and what can both parties do to meet halfway so that patients can be more fully invested in and empowered to control their own wellbeing?
When it comes to medication adherence, if patients aren’t taking their meds, physicians may be well advised to normalize that taking medication is difficult. A patient may say, “It makes me nauseous,” and that is important for figuring out and addressing why there’s no adherence. Again, it goes back to listening, as well as asking the right questions.
Sometimes you have to ask a question in different ways or go off-script. “What’s the hardest thing about having diabetes?” is an important question, and a physician might learn a lot from the answer—and also get a different answer than one might get from asking a standard question. That question is probably not on a medical chart, though.
Another thing to consider is a patient’s background: where they live, what they do, are they a recent immigrant, are they homeless, are they caring for elderly parents, and so on. Asking these types of questions and understanding this personal information establishes a lot of respect. It demonstrates that the physician is interested and cares about them, even if there’s nothing a physician can do to help address any of these life circumstances. It is nevertheless a helpful method that pays off later in the relationship.
What’s the balance for physicians between labeling a patient (i.e. “difficult”) versus keeping track of symptoms, life circumstances, and effectively conveying that personal information to other physicians who may also work with that specific patient and need some frame of reference?
There are different kinds of labels to help keep track of patients and get the right referral. Sometimes it’s not that the person is a difficult patient; it’s that their circumstance is difficult, whether it’s something socioeconomic or medical, and that difference can impact how a patient needs to receive care.
If my patient’s issue is poverty, I can’t do much about that. So whatever problems a patient mentions, I record them all. I recognize I can’t solve them, but it’s worth acknowledging, especially how frustrating must it be to get the right medicine while also looking for job or being a single parent.
There have been studies on medication adherence, and how during an office visit, touching on non-medical issues improves adherence. It’s important for physicians to ask: how’s your work, how’s your family? Just by asking, you can immediately improve how someone will behave. It’s sort of the same principle as dealing with the cable company. If someone says, “I’m sorry you waited a long time; that must be frustrating,” your interaction changes.
It’s important for physicians to ask: how’s your work, how’s your family? Just by asking, you can immediately improve how someone will behave.
This type of understanding and communication lowers biological stress levels, and lowers anxiety and adrenaline. It helps the interaction, even if you can’t solve the underlying problem.
I have patient who struggles financially who has diabetes, and I know when her government assistance check comes, she buys better food. Her condition is better managed based on certain times of the month. I know this by now because we can talk about it. I can’t change her benefits, but I can recognize what my patient is doing well. I also can’t solve the problem of getting her a job, which would help her health, but by being sympathetic ear, that is helpful. We as physicians can’t solve all those problems, but we can help change the concept of what is helpful. Many of my patients get disrespected when they are asked about their life, and I believe the doctor’s office is where they can be treated really well.
How else has practicing medicine changed, in your experience, in recent years?
The practice environment has changed a lot, putting a lot of additional administrative pressure on doctors. It’s not that we don’t want to sit and talk. It’s mostly that we’re forced to do annoying tasks to close out electronic medical records (EMRs). The template can make certain fields mandatory—that you must check certain boxes—and physicians end up forced to do mindless work they could be spending with their patients.
The other day I had three new patients on the schedule, and because I wasn’t super busy, I could spend an hour with each one! I was grateful I could get to all of their issues, and it felt so gratifying because they benefited from the time I was able to spend with them. This is the medicine I wanted to do! We only have so many hours. But if I had an hour to talk with patients, I’d do great medicine.