The Six Laws of Patient-Physician Communication
Last Revised May 15, 1997.
The six laws of patient-physician communication |
In Part I
Questions patients ask their doctors |
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The six laws of patient-physician communication
The following six "laws" about communication between physicians and
patients have been put forward
for guidance only. These laws apply to physicians and patients, to
family, to friends, and to anyone
else involved. We have interpreted these laws in the context of discussions
about prostate cancer, but
in fact they apply in a host of other settings. Like all the best laws,
they are less than perfect. Your
attorney will not be impressed!
The first law of patient-physician communication: If your
expectations are reasonable, it is
reasonable to expect them to be met.
This is not the first place someone has suggested that patients sometimes
expect the impossible from
their physicians and physicians sometimes expect the impossible from
themselves. However, it is a
critically important aspect of the relationship between an individual
physician and an individual
patient. As the patient, it is vital to consider what it is that you
expect from a physician. For the
physician, it may be equally vital to consider what you expect from
yourself -- because that will
influence what you can offer to the patient.
Every conversation between a physician and a patient will be affected by
those expectations are normal and reasonable. For example, if your
physician suggests that you have a
PSA test, it is normal and reasonable to expect the physician to explain
what a PSA test is and why he
thinks you should have such a test. However, expectations can also be
abnormal and unreasonable.
Not all physicians believe that PSA tests are appropriate for all males
over 50 years of age -- despite
the recommendations of the American Cancer Society and the American
Urological Association. It
may be abnormal and unreasonable to expect a physician who does
not think you need a PSA
test to give you one. You, of course, have the perfect right to seek
another physician who has a point
of view more in concert with your own.
Something to ask yourself: Are your expectations reasonable?
The second law of physician-patient communication: Mortal men
and women are not
divine beings. They should not be asked to work miracles, nor should
they ask other mortal men or
women to work such miracles for them.
Prostate cancer is not a "nice" disease. It is predicted that it will
kill about 41,800 Americans in 1997.
However, every single one of those 41,800 men will -- at least once --
have or have had the hope that
he can be cured of his disease. It is normal, and proper, and human to
have and to hold such hope.
Without such hope we would be less than we are.
Just as patients hold such hopes, so do physicians and other health
professionals. The people who
spend their lives looking for better and better ways to treat prostate
cancer have all -- at least once --
hoped that the research they were doing was the next step toward a new
way of curing this disease.
The clinicians who treat prostate cancer every day have all had patients
whom they hoped --
reasonably or unreasonably -- to be able to cure.
Finally, of course, family and friends have hopes: hopes that their
father or brother, husband or son,
friend or lover, will be able to beat their cancer and return to a normal
Deep down within us we all know the difference between hope and prayer.
Hope is born of the
human belief that, when we make a supreme individual effort or we work
together with others in a
special way, we can achieve things we may be unable to achieve under
normal circumstances. Prayer,
on the other hand, is born of the belief that some things are religious or
mystical in their nature; many
people support the view that through prayer, sometimes, the seemingly
impossible can be made
possible by the intervention of a divine being or principle.
Something to ask yourself: Are you asking for a miracle?
The third law of physician-patient communication: Share your
fears with others. If you
hold them to yourself, they will consume you.
We all have fears, whether we are prepared to admit them or not. In
Western society today, fear of
cancer is widespread. It has become a part of the cultural landscape
just a fear of the plague must
have been a part of the cultural landscape of the European Middle Ages
and fear of slavery must at
one time have been a normal consideration for every free African-American.
It is interesting that we so often use the phrase "fight cancer." We
expect it of the patient. We expect
it of the doctors. Fear can induce a whole range of biological responses
which offer us potential
survival benefits in different situations -- specifically including a
fight. It has even been suggested
that fear can stimulate the immune system and thus assist the sick to
get well. Perhaps that is also
Patients and family members often have fears. Few of us actually want to
be sick. Surely none of us
would actively seek to have a disease like prostate cancer. All too often,
however, we get our fears
mixed up. Our fear of sickness becomes the fear of the unknown. Or our
fear of the unknown
becomes the fear of loss.
Physicians also have fears. For surgeons there is always the fear of
operative failure. For all
physicians in general there is the constant fear that they may have missed
some clinical sign or
symptom in a patient which would have led them to make a more informed
decision. In American
society today -- rightly or wrongly -- many physicians are also fearful
of a legal system which appears
to them to be able to punish them for carrying out what they believed to
be good medical practice.
Something to ask yourself:With whom can you discuss
The fourth law of physician-patient communication: Tell the
truth in so far as you feel
able. The truth never hurt anyone as much as a lie.
For many people, physicians, like lawyers and bankers, are figures of
authority to whom they should
simply say, "Yes," when they are told what to do. Other people have a
natural tendency to question
everything and to act only on their own beliefs and prejudices after
seeking and evaluating whatever
information they feel they need to come to what they consider reasonable
In the face of a disease like prostate cancer -- although this rationale
applies to almost any long-term,
life-threatening, and debilitating disease -- there is a need for mutual
trust between patient and
physician if the best outcome is to be achieved. The patient needs to
trust that the physician will
listen and will give that patient the same advice he would give his own
father if his father had the
same symptoms of prostate cancer. The physician needs to trust that,
when the patient says he will act
upon the advice of the physician, he will indeed take that action, and not
simply go and get another
opinion just because he did not like the one he was given. If you want
to get a second opinion, that's
fine; but you should be honest with the physician about it.
Some physicians tend to be less than forthcoming with all of their
patients. Perhaps that is just their
nature, or perhaps it has to do with their training. If you believe
that your physician is not telling you
everything that you want to know, you should explain that to him or her.
It is easy to do very
politely. All you have to say is, "Doctor, I don't want to seem difficult,
but I get the feeling that there
are some things that you aren't telling me. Is there anything else that
I need to know?"
In the end, the way you and your physician relate to one another will
probably have more impact on
your treatment than any other individual technical skill. If you relate
well to your physician, you will
be able to say to him or her, "So if you discovered that your father had
these symptoms tomorrow,
what would you recommend that he did?"
There is nothing wrong with letting the physician tell you what to do ...
and there is nothing wrong
with asking a thousand questions and then making up your own mind. The
crucial factor is whether
you and your physician both understand and accept the situation as it is.
What tends not to be a good
idea is if management of disease is dictated either by the physician to
the patient or by the patient to
the physician with little or no regard for the expertise of the physician
on the one hand or the opinion
and personal input of the patient on the other.
Something to ask yourself:Do you want the physician to take charge,
or do you want to take
charge with your physician's guidance?
The fifth law of physician-patient communication: If you are the
patient, always ask the
doctor what he would do in your circumstance. If you are the doctor,
always ask the patient what he
would like to be able to accomplish if treatment fails?
We are all biased by our experiences, our education, and our cultural
attitudes. Sometimes, those
biases are valuable. Other times they can become nooses around our
necks. In the face of a diagnosis
of prostate cancer, you may want to be very aware of the possible biases
of your doctors if you are a
patient and your patients if you are a doctor. Every little bias counts.
Let's see if we can spot some.
How about these?
When you talk to your doctor about your prostate cancer, you
need to remember what
he or she is. Medical school and clinical training teach a physician
first and foremost how to practice
medicine. If your doctor is a specialist, such as a urologist or a
radiation oncologist, he or she has
been taught even more specifically how to practice those specialties.
It is not reasonable to believe
that in many cases a radiation oncologist would recommend to a patient
that the patient have surgery
when he or she believes that radiotherapy works just as well or maybe
better. Conversely, it is hardly
likely that radiation therapy will be the first form of treatment
recommended by a surgeon if you have
localized prostate cancer. This is your prostate cancer, and you
should always remember that.
Whatever the doctors suggest or recommend, in the end the decisions are
yours and you are the one
who will have to live with those decisions.
- "He's the doctor. Just do what he tells you."
- "If I can't have sex I won't be a man."
- "Smoking cigarettes never hurt anyone."
- "Eating meat gives you cancer."
- "I didn't pay Social Security for 40 years to be told you can't cure me!"
- "Look I know this is difficult for you, but we need to schedule surgery quickly."
Something to ask yourself:Are my prejudices stopping me from making
The sixth law of physician-patient communication: You will never
truly trust a person with
whom you feel uncomfortable, and it is hard to be honest with someone you
We are a less formal society than we were 40 or 50 years ago. People are
less inclined to be patient
with each other. And we all tend to take each other for granted too much
of the time.
The practice of good manners helps us to feel comfortable with people we
do not know well. Good
manners are simply a set of tools which have been designed to help us
through unfamiliar situations
with the minimum of discomfort for all concerned.
The application of good manners by both parties can profoundly affect the
relationship between patient
and physician. We have all heard the stories about the good physicians
who listened carefully to their
patients. Equally, we have all heard stories of patients who were rude
to their doctors because it just
was not possible for them to be seen immediately. If you make an
appointment to see a physician at a
specific time, you should reasonably expect to be seen. Similarly, if
the physician makes an
appointment to see you at a specific time, he should reasonably expect
you to turn up!
If your physician wants your respect, he or she will be on time if he or
she can manage, will
apologize if he or she has been delayed, will be clean, tidy, and ready to
deal with you, will listen to
what you have to say, will ask you questions politely, and will check with
you carefully to be sure
you understand what he or she is saying. Conversely, if you want the
physician's respect as a patient,
you also will be on time if at all possible, you will be ready to comply
with the physician's need to
ask you questions and give you any necessary physical or other examinations,
you will listen with care
to what the physician has to tell you, you will ask questions politely,
and you will clearly indicate to
the physician those issues which you do and you don't understand.
We have already talked about being on time. It is just as
important for patients as it is for
physicians. However, there is one other matter which we need to handle
and which can also affect the
ways in which physicians and their patients interact. It has to do with
the amount of time
which an individual patient needs from his physician.
A good physician wants to give patients as much of his or her time as
possible. However, no
physician can give all of his time to a single patient. When you need
to be able to gain information
from your physician, try to make sure that you are not holding him or her
up if there are other patients
waiting. If the doctor is delayed, and you are the next patient in line,
think how you would feel. You
can always ask the doctor if you can make another appointment to come back
and talk some more. Or
you can offer to wait until the doctor has seen the other patients who are
The point, of course, is that we live in a world in which there are
multiple demands on all of our time.
It is difficult to fit all the things we would like to manage into our
lives. The least we can do is
remember this, and try to consider others when we plan our days. The way
we use time affects the
way we talk to each other: in this case it affects communication between
doctor and patient.