Why our healthcare system forces the Patient to Know Best

The doctor-patient conversation is unlike any other communication process. With patients typically only remembering about 14% of what was discussed (Kessels, 2003) it could be argued that never is such an important and crucial conversation so completely and utterly understood by one party, and barely understood by the other.
Doctor-Patient Communication
Doctor-Patient Communication.

Within the scope of our family doctor visits – whom we see on average 5 times a year in Ireland, anywhere between on  3 and 10 times a year across Europe (European Commission, 2019), and just under 3 times per year in the US (National Center for Health Statistics, 2019)  – these doctor-patient encounters have certain nuances.

For instance, they do not follow a linear progression like in formal transfer of knowledge or educational settings (such as a school curriculum). No, we meet our doctors on a needs basis and rarely reflect on the previous visits and cannot forecast what the next chapter will entail.

The single biggest problem in communication is the illusion that it has taken place.

George Bernard Shaw

The staccato start-stop design of these infrequent encounters creates a dynamic that does not lend itself to a pedagogic approach of ensuring the transfer of knowledge to the patient over time. Instead, this model lends itself to systemic and socio-cultural barriers, causing the patient to not fully understand.

Equally, from the family doctor’s perspective, they too find it challenging. The structure of their day causes and compounds some of these communication challenges:

Across Europe, general practitioners (GPs) have list sizes (number of patients on their books) varying from 600 per general practitioner (GP) in Belgium, to 3500 in Turkey, and daily consultation rates varying from 10–50 a day (McCarthy, 2016). In the US, GPs (or family doctors) see on an average of 20.2 patients per day (Physicians Foundation, 2018) have mean per-physician list (or patient panel) size of 1751 patients, (Raffoul et al., 2016) and interestingly, on average, address approximately 3 problems per visit (Beasley et al., 2004).

In the case where the patient is being referred to a specialist, and may require surgery, he/she is having these crucial conversations with multiple doctors (who may not be consulting with one another); the veritable onus of responsibility of grasping the full picture of one’s health rests with the patient.

Where else would this scenario be true?

Where else is the novice expected to have the broad understanding of the seasoned professional? Think of the automotive engineer whom you trust and repeatedly return to in order to service your vehicle. This person has a team that will check the oil, the brakes, the engine, the steering, etc., and they will give you a reasonable diagnosis in a timely manner. This documentation will be shared with both parties and will be consulted upon the next and subsequent encounters.

Additional complexities arise in the case of a healthcare diagnosis involving multiple healthcare professionals – i.e when a patient visits several specialist consultants (i.e doctors in domain specific areas). For example a patient experiencing chest pain might have to liaise with a family doctor, cardiologist, coronary care nurse, radiologist, phlebotomist, respiratory consultant and more. From the patient’s perspective, each encounter is somewhat rushed in comparison to the family doctor experiences, with minimal rapport between doctor and patient possible.

Encounters with these specialists are indeed shorter – with European average consultations lasting a mere 10 minutes (Deveugele et al., 2002). IT could also be argued that these rushed encounters, that occur on a needs basis, are, by their very design, never intended for a rapport to be created.

The argument could also be made that it would be impossible for the patient to be educated extensively on the nuances of the specific illness by each of the domain specific areas of consultancy, or for the doctor to have the time, inclination, and/or tools to come up to speed on the ‘past lives’ of the patient with either family doctor or other specialist consultants.

Factoring in the two-tiered systems that exist in certain countries (like Ireland) where patients can avail of both public healthcare services (albeit with longer waiting lists) as well as private (if they have the necessary private health insurance), the tree diagram stemming from the lone patient to the vast array of healthcare specialists grows and grows.

From Lone Patient to Lone Doctor

Throughout this entire process, from family doctor to multiple hospital consultants, the patient, in many cases, assumes that there is an omniscient force taking stock of all of these complex verbal (for the most part) encounters. However, even with the most sophisticated software in the world, the patient (the lucky ones at least) realise that this task falls to them and their families – the task of becoming more learned about one’s own health than the vast array of (siloed) specialists.

Conclusion

Yes. The patient is forced, by the very nature of the communications systems (or lack thereof) that are in place, to assume this role as the overseer. The one who can keep track, piece together, decipher, and communicate these facts back to the lone doctors.

Beyond the (tongue in cheek) contrast with the automobile repair diagnosis, maybe there are no other examples where the nuances of doctor-patient communication challenges occur. Therefore, in order to better understand the nuances regarding the communication process between patients and their doctors, we must examine communication challenges in general – i.e communication barriers outside the clinical setting of the doctor-patient encounter.

References:

Beasley, J.W., Hankey, T.H., Erickson, R., Stange, K.C., Mundt, M., Elliott, M., Wiesen, P., Bobula, J., 2004. The Annals of Family Medicine 2, 405–410.

Deveugele, M., Derese, A., van den Brink-Muinen, A., Bensing, J., De Maeseneer, J., 2002. BMJ (Clinical research ed.) 325, 472.

European Commission, 2019. How often do you see a doctor? https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20191219-1

Kessels, R.P.C., 2003. J R Soc Med 96, 219–222.

McCarthy, M., 2016. Br J Gen Pract 66, 36.

National Center for Health Statistics, 2019. Products – Data Briefs – Number 331 – January 2019 https://www.cdc.gov/nchs/products/databriefs/db331.htm

Physicians Foundation, 2018. 84
https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf

Raffoul, M., Moore, M., Kamerow, D., Bazemore, A., 2016. J Am Board Fam Med 29, 496–499.

Mark Campbell, MSc. in Interactive Media

Mark Campbell, MSc. in Interactive Media

Mark Campbell is a researcher, lecturer and practitioner of multimedia design in healthcare. He is currently carrying out doctoral research into the communication that takes place between patients and their doctors and what role multimedia plays. His passion for user-centred design and healthcare education spans two decades. He is the founder of Anatomus and multi award-winning Pocket Anatomy.

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