Home Diagnosing The Physician-Patient Dialogue
Miles Council for Physician-Patient Communication
A selection from the Lupus Foundation of America Newsletter Article Library

One technique to enhance communication skills is to review a typical physician-patient dialogue to determine where improvement could be made. The following case and commentary were provided by Comment reader, Frederic W. Platt, M.D. Dr. Platt’s cases in conversation failure are about to be publisher in Conversation Failure: Case Studies in Doctor-Patient Communication by Frederic W. Platt, M.D.

Just A Cold

Patient: Thanks for seeing me on such short notice, Doc. I wouldn’t have come in I wasn’t nearly dead.

Doctor: Oh? Are you feeling bad? How?

Patient: I’ve been sick all week, and I have to fly to Portland this weekend.

Doctor: What sort of symptoms?

Patient: Mostly a sinus infection. I can’t breathe and I’ve got this yellow stuff I keep blowing out my nose.

Doctor: You can’t breathe?

Patient: Nah. My sinuses are so stuffed up, I can hardly breathe on one side if my nose.

Doctor: How is it with your mouth open?

Patient: Well, that’s fine. But I can’t go around like some kind of fish you know.

Doctor: OK, then. Stuffy head, nasal drainage, what else?

Patient: I see. Any other symptoms? Cough? Fever? Anything else?

Doctor: Well, let’s take a look at you. Hop up on the examination table.

(Examination)

Doctor: Well, the exam is entirely normal. All you’ve got is a cold. Take one of the over-the-counter decongestants, such as ABC or XYZ. Maybe a couple of aspirins. We’ll see you for your physical in six months.

Patient: You mean you aren’t going to give me something? I got to go out of town in three days, and I can’t be sick.

Doctor: Sometimes we use an antibiotic; but you aren’t sick enough to make it worthwhile.

Patient: What is this? I’m not sick enough? What’s going on? Is this because I’m enrolled in Care-a Care? They tell you they save a few bucks by not prescribing penicillin?

Doctor: That doesn’t have anything to do with it. I treat you just like patients who pay right up front.

Patient: Hey! I pay plenty for this insurance, Doc, and I don’t see how I’m getting my money’s worth.

Discussion

There is a lot to consider here. But one of the major problems arises from the “negative” approach to diagnosis, prognosis and therapy. The doctor in this example did not provide enough explanation for this patient. Patients are almost always eager to know what has happened to them, what will happen if they do nothing further therapeutically and what the doctor is advising. Even a patent with a minor illness may need in-depth explanations. Physicians can enhance the patient encounter by not confusing the patient’s need for education and explanation.

What might the physician have done differently? He or she might have said something like this:

Doctor: Well, based on the exam and the symptoms you explained, I think you have a viral infection of your upper respiratory tract. It involves the nose and the lining of the respiratory system, probably the sinuses too, as you suggested. We can call that a “cold,” if we wish, but even a common cold can be quite bothersome and make life really miserable for you.

Patient: Yeah, it does.

Doctor: The trouble is that there is no useful therapy beyond symptom relief. We usually suggest some decongestant, such as ABC or XYZ brands. They are available over the counter and are really as useful as anything we can prescribe. Then, high intensity humidity-steam-helps in decongestion. If you fly into Portland and are stuffed up on landing, or if your ears are painful, you might try some intense steaming. The trouble is that there is no effective treatment or cure for these infections. We just have to wait it out.

Patient: You mean you aren’t going to give me an antibiotic?

Doctor: I’m glad you asked that. It would probably be a mistake to treat you with an antibiotic. They have no effect at all on viruses and this is almost certainly a viral cold. Then the antibiotics can often do damage, for example they can cause persistent diarrhea, certainly something you would rather not have during your trip. So I think an antibiotic wouldn’t be a good choice.

Patient: You mean I gotta just wait it out?

Doctor: I’m afraid so. Now I do want you to keep an eye out for complications. Even a viral illness can develop into something worse. For example, if you start coughing up a lot of dark green stuff or get fevers over 101 or chest pain or shortness of breath, I’d like you to come back in to see me.

Patient: You bet I would. If I start running high fevers, you’ll be the first to know. OK, Doc. Let’s see. You want me to take ABC contestant and use steam and come back if I’m worse of just not better in a couple of weeks, right?

Doctor: Right.

A few important points:

1. The doctor used the same terminology-”sinus infection”-that the patient did in this “explanatory model” for his illness. At the least, physicians should let the patient know that his of her diagnosis was considered in the physician’s evaluation.

2. The doctor and the patient repeat each other’s phrases at the end of the interaction. “Just wait it out,” and “Right” demonstrate that they are listening and understanding each other.

3. The reason to withhold antibiotics is made clear and it emphasized as being in the patient’s best interests. Again, this reinforces the doctor-patient partnership.