Barbara Korsch and Caroline Harding have drawn on 50 years of experience in medicine in the USA to provide not only a useful guide to the doctor‐patient relationship, but also insight into the reasons why this particular relationship is so problematical. If, as many believe, better and more efficiently provided healthcare is likely to result from better dialogues in consulting rooms, with patients shouldering more responsibility in the health or management of their condition, then both parties have need to learn to appreciate what it is that shapes the attitudes and resultant language of consultation, so that they may both improve. This book will help them do just this.
The text elicited a variety of responses, in which I was forced to examine the doctor‐patient relationship in various settings, in a different culture, but armed with a deeper understanding of the training and influences that shape the way doctors are likely to behave. Illustrations of fundamental non‐communication that can occur were perhaps more vivid being couched in an American culture setting and in a different type of health provision setting. Many were profoundly depressing, not only by virtue of the complete failure in communication by both parties, but also because of the basic lack of politeness, common courtesy or sensitivity. Was I being too British, or is the current less respectful attitude for other people’s feelings, and the prevailing need to claim ‘rights’ a fundamental root cause of some of these difficulties? Decline in respect for hierarchical institutions with resultant strengthening of belief in autonomy requires a greater awareness of individual and societal responsibility, as the authors so cogently advocate and illustrate. Also disturbing and depressing were the portrayals of a sad state of morality in cases of patients asking doctors to fulfil unethical or illegal requests.
The pace and interest of the book varied with the most interesting chapters being half way through the book, and the opening chapter ‘Point Counterpoint’comparing how the same situation looks from each side of the equation, rather tedious. Yet an alteration of order would not be apt: all the parts are necessary if the authors’ aim of both educating and guiding is to be achieved.
The two most thought provoking central chapters – to my mind – were: Where is the truth? Secrets and Lies in the Doctor‐Patient Relationship and Does your Doctor Seem Unfeeling? The subheadings were also in the form of questions – indeed, each chapter was awash with questions, leaving the reader to realise that, in many cases, there was no clear answer! As the authors state:
When you’re dealing with human beings and tricky issues, nothing is absolute… Patients need to be aware that medical science is not always perfect. They need to know that their physicians will attempt to inform them as well as they can, but that an honest physician cannot pretend to know the absolute and final truth (p. 124).
Ample confirmatory illustrations are provided.
These underlying beliefs substantiate the authors’ arguments and encouragement for patients to be proactive in educating themselves about their own condition; to engage in an involved dialogue with their physician; to be more informed about their own health in order to be an effective advocate for themselves.
The chapters providing practical guidance for patients to get the most out of their time with their doctors demonstrate that different tactics are needed in different settings: the ‘ball game’ is quite different in A & E, where the doctor may never have seen you before and has no notes, to that of a visit to the family practitioner. Doctors with different functions need different patient responses: in A & E, for example, a cryptic summary of a patient’s health status, particularly if complex (e.g. diabetic, heart condition, etc.) is a sensible responsibility for the patient to shoulder! The subtle alteration of the status and power of a patient according to the circumstances is well drawn, by describing the ultimate transition of person to patient, from the independence of the dressed patient in the GP surgery, to the total dependence of hospitalization with its loss of dignity and individuality in the overpowering hospital setting, where practice of responsible action can be incredibly difficult. The book even provides guidance for hospital visitors!
As a layperson thoroughly aware of my own personal limitations which would prevent me from having the courage to have trained as a doctor, I was fascinated by the picture painted of the struggle that medical students engage in to cope alone with their emotions. Where training often ignores their need to cope with the initial response to patients, illness and suffering, where, indeed, they are trained not to feel, crippling their own personal development. This, in order to ‘professionalize’ them in a ‘conspiracy of silence’ culture of training. I particularly liked the illustration of an interview with a medical student who discusses how, in the beginning of his training, he tried to ‘feel as much as [he] could feel’, only to find that this did not work, which led to him having to learn how to ‘set his own empathostat’. Perhaps ‘setting our empathostat’ would be a good place for us all to start as we seek to improve the doctor‐patient relationship?
Hazel Thornton Chair of the Consumers Advisory Group for Clinical Trials (CAG‐CT), Colchester.
Footnotes
The CAG‐CT is a joint profession‐patient collaborative working group committed to sharing responsibility for improving research methodologies and advancing public education about research concepts.