Introduction

Consideration of the relationship between doctor and patient is essential in all fields of medical specialization, even in those where there is no direct patient contact.

Patients construe a bad consultation as one in which there is inaccurate medical assessment. For patients to construe a doctor contact as ‘good’, however, there must additionally be good communication. Doctors need to include communication in their training to ensure clarity, precision, completeness and lack of ambiguity in their interactions with patients. Good communication improves patient satisfaction, memory for information provided, adherence to treatment plan and patient outcome.

This chapter considers the general issue of doctor–patient communication for medicine in general and specifically for psychiatry. Various theoretical aspects of the workings of the mind are described that provide a basis for understanding patient and doctor functioning (‘dynamic psychopathology’). Chapter 5 describes the content of the psychiatric interview and assessment.

First contact

Even before meeting, the patient and the doctor will have expectations of each other, based on culture (including media portrayal), prior experience and the accounts of others. These will determine the initial presentation, which will be modified by the degree to which the contact fulfils these expectations. This applies to all levels of interaction, from posture and degree of body and limb movement, through accent and vocabulary used, to mood and level of familiarity; and of course the content of the information presented. This applies as much to the patient as it does to the doctor. There are always going to be differences between the doctor and patient: sometimes there is an enormous cultural divide, sometimes communication is limited by impairments in one or other participant. These factors do not lessen the need for accuracy, efficiency and supportiveness.

As is often emphasized, doctors should be treating patients, not diseases. This may be lost in the fascination of MRI scan results or EEG traces, but if forgotten entirely will increase the likelihood of doing harm, or at least lessen the potential to be of benefit.

A distinction has been made between disease, the pathological abnormality occurring as a result of some specific noxious insult, and illness, the subjective interpretation of problems that are perceived as related to health. These are related to each other but can occur independently. Illness without disease can, for example, be malingering, hypochondriasis or somatization (the distinctions are covered in Chapter 11). In other ‘non-psychiatric’ disorders there may be a strong psychological contribution with varying levels of pathological or physiological change (e.g. tension headache, irritable bowel syndrome). A similar distinction has been made between:

The first doctor–patient contact may not be this simple. The patient’s initiation of contact may, for example, be to gain support for a housing application, to plead mitigation in criminal proceedings, or to put pressure on an ex-partner in divorce. The doctor may be gaining experience, being trained, carrying out research or working out their time until retirement. The only assumption the doctor can make about the patient is that a ‘message’ is being transmitted, which is a combination of informative (giving information), promotive (intended to make the doctor do something) and evocative (intended to make the doctor feel something). The doctor must be careful to pay attention to ‘illness’ information as well as ‘disease’ information in order to have a clearer idea of the patient’s perspective.

In most circumstances the doctor sets the rules of interaction, including the venue. This being the case, the doctor has a duty to pay explicit attention to the rules so the contact has an optimum outcome.

Setting

The facilities available to the psychiatrist will vary in their level of formality and comfort. The aim should be to provide comfort and informality at a level that encourages but does not deter the disclosure of important information or emotion. For example, a patient may, paradoxically, feel more able to disclose intimate details in a formal consulting room, where there is adequate provision of freedom from interruption and being overheard, than at home, where this is not so certain. Thus a balance must be struck between ‘homeliness’ and clinical atmosphere. The increase in the practice of community psychiatry in Western countries means that it is more than likely that the consultation will occur outside the office setting.

The layout of all settings should try to ensure that patient and doctor are at a similar height, that there is no barrier to communication (e.g. a desk) and that eye contact is possible but not forced. Placing similar chairs at an angle of 90° to each other usually achieves this, possibly with a low table to one side. If the doctor requires a writing surface, the doctor sitting to one side of the desk (Figure 4.1) can achieve a similar effect. Lighting should be adequate but not too bright, and should not shine in the patient’s eyes.

Figure 4.1 • The clinical setting.

(The antithesis of this emphasizes the power differential: one professor of psychiatry, a big man, sat in a large ‘airline’-type chair behind a large empty desk, in front of the window; his hapless trainee was perched on a low small chair facing the desk.)

Behaviour

The sequence of ‘smile, touch, question’ (where touch is a handshake or gentle direction to the consulting room) is fine for general medical consultations, but may be less straightforward in psychiatric assessment. The paranoid patient may interpret a smile as mocking. A touch may produce a flashback or unpleasant memories for the patient with post-traumatic stress syndrome following assault. Thus, a neutral but welcoming stance is advised.

Note-taking during the interview is a matter of personal preference. It is argued that taking notes reduces the potential for observation and the amount of attention given to the patient. On the other hand, many patients regard it as indicative of the doctor taking what they say seriously. Judicious note-taking can greatly aid formulation and is particularly useful where there are mental state abnormalities to record verbatim, for example the speech in thought disorder or delirium.

Looking interested also facilitates disclosure. It is important for the doctor to examine personal attitudes at the outset of the interview, as a jaded or bored state of mind will be picked up by the patient and will interfere with the quantity and quality of the information derived by the doctor. (Non-verbal communication is continuous and on the edge of consciousness. Where there is an inconsistency between verbal and non-verbal communication the latter takes precedence.) Leaning forward, nodding and slightly inclining the head tend to encourage further disclosure. Looking at the patient also gives the impression of listening. In normal circumstances, while patients are talking, they will not maintain eye contact all the time but will keep checking that the listener is paying attention, and may fix their gaze at important junctures (Figure 4.2). If the doctor is looking at the notes while the patient is talking, the quality of the communication deteriorates significantly.

Figure 4.2 • Non-verbal communication.

Questioning should progress from open (‘Can you tell me of your concerns?’ … ‘Tell me more about that’ …) to more specific closed questions (‘When did your father die?’). Different types of question will tend to produce different responses (Figure 4.3).

Figure 4.3 • Type of question (in order of decreasing openness and increasing chance of limited response).

Studies have shown that doctors tend to interrupt opening statements from their patients, and as a result do not hear the full reasons for attendance. This may explain the phenomenon of ‘important topics’ being introduced later in the consultation (perhaps when there is insufficient time to explore them).

Attentive listening is an active process that improves the efficiency of doctor–patient communication. There are four core skill areas:

• Wait time. Allowing longer for responses before interruption increases the amount and quality of information volunteered.

• Facilitative response. A short, non-verbal cue that encourages continued response from the patient is more effective at the beginning of a meeting. Later in the interview echoing, paraphrasing and interpretation are more useful.

• Non-verbal skills. The most important of these is eye contact.

• Picking up patient cues. These are verbal and non-verbal hints of other information that are seen more at the beginning of the interview, and need appropriate acknowledgement.

Carl Rogers identified three therapist characteristics most associated with successful therapy outcome:

• empathy

• non-possessive warmth

• unconditional positive regard (this is not the same as liking or always agreeing with the patient).

These further emphasize the need for an attitude of truthfulness and honesty, remembering that truthfulness is not the same as bluntness.

All the doctor’s senses will be necessary for an accurate and effective diagnosis and treatment:

• hearing to hear the symptoms, breath sounds, heart sounds, etc.

• sight to see the signs, read the non-verbal signals, etc.

• smell to detect diabetic ketoacidosis on the breath, fetor, etc.

• touch to palpate the abdomen

• taste to taste the cups of tea offered on home visits (has salt replaced the sugar?).

A further vital sixth sense has been proposed: the emotional response evoked in the doctor by the attitude and bearing of the patient. Most experienced psychiatrists will report rather quizzically the ‘feeling’ that a patient is psychotic or that a condition is organic, which amounts to more than a confluence of the signs and symptoms. Trainees would do well to cultivate such ‘feelings’. Perhaps more straightforwardly, the emotions of anger, depression, anxiety, admiration and sexual arousal may arise in the context of the doctor–patient relationship and influence actions, particularly the decision to refer on. These themes will be developed further below.