An Ethnographic Study on Physician Communication Practices-- Bobbak Tadayon

Physicians are constantly involved in various forms of communication integral to medicine. In these various forms of interpersonal communication practices, doctors have to exhibit a sense of professionalism in both their discourse and actions to create a ubiquitous sense of knowledge to their patients, in order for their patients to entrust them with their care. This sense of professionalism can be seen in various forms of communication used by doctors in the constantly changing health care environment that physicians are required to adapt to in order to conform to their patient’s needs. In this ethnographic study I will be examining how physicians communicate with their patients who all have varying medical conditions and backgrounds. I will focus on how professionalism is portrayed and embedded into their interpersonal communication practices.

The bulk of the primary research in this study was acquired during a 6-hour observation/shadow of Dr. Foruhari on May 23^rd 2011. During this time period I was allowed to observe all the various forms of communication he partakes in on a day-to-day basis in his Medical Urgent Care Practice. An explanation of what Dr. Foruhari’s practice is and his medical specialties can be seen in the following video interview:

Physicians often adapt their communication style depending on the age of the patient. For example, for patients who are your standard adult (18+ years old) the way the doctor communicates to them is much different than with relation to a 5-year old child. However, regardless of the patient’s age the general communication with patient takes on 3 different stages throughout the patient doctor interaction. The first stage is what I consider the “introduction and Q&A stage”. The first thing Dr. Foruhari does before entering the patients examination room is to read the patients’ medical chart which his nurse had previously filled out which includes the patient’s chief complaints, a brief medical history, as well as their demographic background information (age, gender, etc.). An example of this exact chart can be seen in Figure 1 at the end of this assignment, (note: that I have cut out the personal information in the document). In this chart you have all the relevant information to the patients’ health background in one place. In the upper left hand corner you have the date and time the patient was admitted, allowing you to take note at how long they have been waiting. In addition, you can see their CC or chief complaint, which is the primary reason they are there. All other sections of the chart are for doctor to fill out during the Q&A process and examination stage, to accurately record the patient’s medical history.

Once analyzing the patient’s chart, if he realizes the patient is an adult he will enter the room and immediately go to the patient and shake their hand and introduce himself. In addition, it is important to note non-verbal cues the patient may be exhibiting at this time. Often times in a practice such as an urgent care where there are no actual appointments scheduled, patients may find themselves waiting for an extended period of time to see the physician, therefore it is essential to take this into account when communicating with the patient and account for their impatience and apologize for their extended wait to alleviate their tension (Teutsch 1117). After this introduction he will ask a series of questions further detailing the patient’s chief complaints on what is wrong. One of the key factors in this question and answer process is the body language Dr. Foruhari exhibits. He is constantly giving the patient eye contact when he asks his questions and during the patient’s answer. It is only after they have finished responding that he will write down details further explaining their medical conditions. This allows the patient to feel that they have doctor’s undivided attention, instead of the doctor typing on a computer while they answer, or writing behind a clipboard, they instead have direct eye contact with the doctor (Teutsch 1117).

After this Q&A process, comes the second stage which I define as the “physical examination,” where the doctor preforms various tests to allow him to help formulate his diagnosis. When the patient is an adult this process is very straight forward, the doctors does a head to toe examination preforming various tests relevant to the patient’s chief complaints. The doctor may ask the patient to perform various tasks to allow the tests to be more effective, for example asking the patient to breathe deeply, or to cough. In addition there are a few techniques doctors incorporate to make these techniques more professional. For example, when dealing with a female patient, Dr. Foruhari tries to avoid contact with their skin whenever possible out of a professional respect, he will for instance when using a stethoscope he lifts his fingers away from the patients allowing only the device to touch their skin. Also any procedure that may make the female patient uncomfortable (ex: breast exam) the doctor asks the patient if they would like to have a female nurse in the room to decrease the tension (Teutsch 1132). These small subtle techniques help create a sense of professionalism and respect in the patient doctor relationship.

After the doctor has ascertained enough information to make an accurate diagnosis he then presents it to the patient and then explains what the course of treatment is. This brings about the 3^rd and final stage of the doctor patient interaction, which I define as “diagnoses and treatment”. This stage of communication has multiple depths based on what the diagnosis actually is. If the diagnosis is a simple cold or infection, and all you need to do is take antibiotics for “x” amount of time for treatment, it is relatively straightforward and simple. However, if diagnosis is for example diabetes, then essentially the doctor must go into detail explaining how the patient needs to control the disease and the ramifications of what the disease can do to the patient if left unchecked. This of course can be extremely elaborate medically in terms of the complexity of the disease, therefore it is required that the doctor essentially explain the significance of this disease to the patient in laymen’s terms. One of the key things Dr. Foruhari focuses on is not to overwhelm the patient with information right away. Often times when a patient is told they are diabetic, all “the information enters one ear goes out the other,” therefore it is important to reiterate the key points of this disease without overwhelming the patient with information. An explanation of how Dr. Foruhari does this can be seen in the following video interview:

However, sometimes this third stage of communication requires a bit more detail and understanding from the doctor to the patient. This often occurs when the diagnosis is something unpleasant, something that is very serious and poses a significant health risk to the patient, a diagnosis such as cancer falls in line with these criteria. Often times when diagnosing something like cancer it requires a outpatient procedure, such as a MRI or biopsy, something that essentially cannot be accomplished in a simple visit to the doctor’s office. The doctor will then receive the results of the test, and then have the patient come back in for another appointment to reevaluate the situation. If the test does indicate cancer, Dr. Foruhari immediately sets the tone to the patient by saying, “I have some good news, and some bad news”. This immediately allows the patient to prepare for bad news, and once Dr. Foruhari tells bad news he then immediately follows it up with good news by saying, “there are however different treatments available such as surgery, chemotherapy”. Dr. Foruhari uses this good news to outweigh the bad news, and he is very optimistic and focuses on the positive things the treatment can do.

However, there are just some cases where there is no good news to give, and there only is “bad news”. Often times when a disease is terminal there is no easy way to communicate to the patient that this is your prognosis and there is nothing more we can do. The only thing the doctor can do is to explain to the patient that everything in their power has been done to help fight this illness, but even with their best efforts there is nothing more that can be done. This news is obviously very difficult for the patient to take in, and a study published in the British Medical Journal shows that patients who are faced with imminent death will often times be falsely optimistic on their prognosis even though the physician has made it very clear what the outcome will be. The study found that patients will often tell their family and friends that they are cancer free, or have been cured, when in fact they only have 2 years to live (Hak 1377). It is because of this that Dr. Foruhari likes to communicate to the patient that life is fragile, and that everyone will eventually die at some point, and once the patient realizes this fact of life, it is easier for him or her to accept the news. A more detailed explanation on the communication methods that Dr. Foruhari uses when dealing with severely ill patients and family members can be seen in the following video interview:

The patient doctor relationship is a very delicate in that the patient must have the uttermost confidence in their doctor that they are providing them with the best possible care they can provide. The patient is potentially putting their life into the hands of a stranger, and because of this the doctor must exhibit an unparalleled sense of professionalism in their discourse and actions with the patient. Many of the communication methods I have discussed in this paper are the correct way of doing things; there are some doctors however who do the exact opposite. For example, they can be very crude when telling someone they have cancer and show no real empathy to the patient, creating a very disrespectful atmosphere lowering their professionalism. When this occurs the patient begins to question the doctor’s medical judgment, which is the very thing you are trying to prevent, as if a patient begins to second-guess the physician’s diagnosis. This can in fact make the patient worse off. It is for this reason that is essential for physicians to remain professional in all aspects of their occupation to allow efficient care and treatment of their patients.

References and Figures:

Hak, Tony. Collusion in doctor-patient communication about imminent death: An ethnographic study. British Medical Journal; BMJ 321.7273 02 Dec 2000: 1376. 24 May 2011.

Teutsch, C. Patient-doctor communication. The Medical clinics of North America 87.5 01 Sep 2003: 1115-1145. Saunders. 24 May 2011.

Figure 1: