Communication is the key to success when it comes to the patient-physician relationship. Compared to the past however, this relationship has changed somewhat: although physicians are still the experts, thanks to the internet and popular science, patients now also know more about health and diseases. An "informed patient" is not a problem for physicians, but rather a source of better understanding.
In this interview with MEDICA.de, Dr. Heiner Heister talks about the informed patient in the doctor's office, how physicians can support a discourse and what ultimately stands in the way of comprehensive communication with the patient.
Dr. Heister, we are talking about "the informed patient" – does such a patient actually exist in your opinion?
Heiner Heister: From a practitioner's point of view, the degree of knowledge is of course always relative when he deals with a layperson in his field of expertise. Even highly sophisticated, discerning people become helpless and destitute to some extent when they are sick. A qualified physician needs to be able to handle this appropriately and always consider this in his behavior.
When would patients actually be sufficiently informed about their condition?
Heister: When the physician to the best of his knowledge has explained what the health situation is, what consequences may result and what measures can be taken. The physician should also be sure that the patient has really understood all of this.
What do you think about a patient, who comes to a consultation with prior knowledge – and has looked into symptoms for instance and researched on the internet?
Heister: This is essentially welcomed. This patient is interested and has perhaps already developed preconceptions about his health situation. As a physician, I then try to take the patient’s perspective and discreetly insert my expert point of view. Ideally, a discourse develops from this.
How do you respond to false perceptions of patients?
Heister: You need to find out how the patient arrived at this point of view and what proof he has to support this. If I know this basic information as a physician, I can also refute and realign such notions. Not every patient has an academic education of course, but you can also explain complex medical context in simpler words. Physicians need to practice this.
Knowledge keeps getting easier to obtain on the internet for instance. Can physicians still see themselves as so-called "demigods in white" and treat patients as they see fit?
Heister: No. This has always been a distorted picture of reality and more than ever today. I am a general practitioner, psychosomatic medical specialist and psychotherapist myself and I already heard justified criticism during my university studies. This was in the 70s during the educational and psychiatric reforms. However, I am sure that the staff, the physicians and my superiors in the past would not have treated any patients as they saw fit. These days, the patient's right to self-determination is extremely important in the legal system to where physicians are no longer able to make lone decisions pertaining to treatment. Of course, back then and today, there are always improvement opportunities; I will not argue that point.
What could be improved?
Heister: Training for example. During the so-called educational reform, medical psychology and medical sociology were being introduced into preclinical training. This was certainly an important step. These days, physician communication skills are an examination subject during the second and third sections. This is just as important.
Unfortunately, not much of this can be implemented in everyday practice in hospitals and doctor's offices however. Given all kinds of personnel reductions and rationalization measures, aspects of the patient-physician relationship and communication are more subordinated. Increased workloads leave little time for more intense conversations.
Preventable disease outbreaks such as the current measles outbreak keep occurring. As a physician, how can you handle a very skeptical patient, who refuses vaccines for instance?
Heister: Technically, you have to be very experienced and know the current state of research. And then you truly need to adopt the perspective of the concerned or affected person sitting across from you, even if that is perhaps hard to do. Those who refuse a sensible and time-tested measure are not automatically "ignorant", just because they do not know the science behind it. After all, these patients also have their arguments. It makes a lot of things easier when you pay attention and try to understand what the arguments and psychosocial background is. Patients subsequently feel accepted and taken seriously in an entirely different way.
In your opinion, are there enough informed and responsible patients?
Heister: No, I do not think so. Besides, those patients simply cannot exist. The development of medicine is so rapid to where even physicians have a hard time keeping up. Staying in touch with patients is a continuous process that is primarily handled by physicians in primary health care, general practitioners.
Ultimately, this is also an economic problem. No primary care physician receives adequate compensation to counsel a patient for an hour, so he completely understands his drugs with all mechanisms of action and adverse effects for example. In the meantime, things in the medical practice would be at a standstill and the physician loses money. There are still immense structural issues to be resolved.