Introduction

As one part of the epilogue to a collection of studies labelled Doctor-Patient Interaction (ed. von Raffler-Engel 1989), D. H. Sevin interviewed B. U. Sevin, a renowned gynaecologist oncologist, on doctor-patient interactions. Approximately twenty years later I was asked (being an oncologist as well) if I could respond to the identical set of questions. The aim of the request was twofold: (1) to find out a Czech perspective on exactly the same topic and, more importantly, (2) to see what changes in judging the importance of doctor-patient communication might have taken place within the two decades.

Interview

Do you feel that having a good rapport with the patient might be helpful during and after the operation? I do, absolutely. Moreover, I have personal experience which confirms this. Appropriate communication (although it is, in my view, almost impossible to provide a strict definition of this) enables us to calm the patient down as well as to establish a partnership and collaboration with the patient, which is the starting point of any successful treatment. As regards the operation itself, it is important to make sure that the patient knows about all the risks and potential complications of the medical intervention, but, at the same time, it is necessary to assure her that we (doctors, nurses) do as much as we can to handle such undesirable events.

How do you actually accomplish this? How do you try to instill this will in the patient’s active participation? How do you actually convert the patient? First of all, it is essential to inform the patient about what types of treatment and/or therapy are available and why. If it is possible, it might be useful to let the patient choose herself what cure she prefers and what, by contrast, she rejects. In other words, it is essential to keep asking about the patient’s own ideas regarding her diagnosis, treatment and future prospects. I need to know what the patient wants, whether she expects complete recovery, slowing down the progress of her illness, or just pain relief. If our opinions differ, I always try to draw the patient’s attention to relevant details to show her what is, from the perspective of her diagnosis, feasible.

Do you do most of the talking? What is the role of listening? It depends on the kind of patient. There are patients who wish to talk about their troubles with health, and there are also patients who are silent. As regards the former group, I always try to listen to them attentively, and give them enough time so they are able to express all they would like. With the latter group I attempt to be as clear as possible. Of course, listening on the part of the doctor is important, but often there are situations when the patients prefer doctors to be informants rather than listeners. As far as my experience goes, most patients start talking during our second meeting.

In a situation where you want to talk to your patient but you do not have that much time to establish this relationship, how do you proceed? If there is not enough time for a longer interview, I simply tell the patient that we really have to see each other again. Oncology is a branch of medicine where doctor-patient communication plays a crucial role and it cannot be avoided or omitted. So far all the patients have been willing to make another appointment.

Do you have any methods of sending out nonverbal messages? What about touching? Physical contact? Nonverbal messages form an inseparable part of doctor-patient interaction. Mimics, gestures, haptics, eye contact, body spacing and posture – all that should be taken into consideration. I make use of all these types, some of them intentionally, other types subconsciously. I employ touching when the patient is disturbed. Also during my daily ward rounds I hold patients’ hands when talking to them. During medical examination I often use one hand for examining the patient, the second hand to touch the shoulder or the hand of the patient in order to soothe the patient. Logically enough, it is not viable each time because frequently the medical check-up requires both hands.

You refer to relatives and probably realize how very important the influence of relatives on your patients must be. How do you try to assure that your communication will later help them to talk to your patient, which might also help her to build up a positive attitude and assurance that things will get better? First of all, it is inevitable to respect the patient’s will, i.e. whether she allows us to inform her relatives or not. Sometimes patients do not want their relatives to be informed, and in such cases it is quite difficult to cooperate with them. What we usually do is that we gently refuse to share any information with them, and we refer them to the patient herself. If we do get permission to inform the relatives, then I make an effort to give them exactly the same explanation as I have given to the patient. Sometimes the relatives want to know how they may contribute to the treatment, and I always stress the importance of their support, the relevance of the contact with partners, family members, friends, colleagues from work, etc. What may, on the other hand, also happen is that the relatives refuse to participate in the progress of the treatment. Nonetheless, this might be solved just by telling the relatives that the disease or the illness the patient suffers from is not dangerous for them and that they do not have to be afraid of getting infected. Usually they rediscover their lost resolve.

One of the main objectives in communicating with the patient is to establish some sort of human relationship. What is the main purpose of this? Is it primarily to reassure your patient that things will go well? Establishing a relationship with the patient is very important in order to develop trust between the doctor and the patient. Nevertheless, personally, I never lie to the patient. She should know that I will do my best to improve her health, to save her life or at least to improve the quality of her life. At the same time, the patient should be aware of the fact that medicine can never guarantee that things will go well.

There are situations where the patient may ask questions about her health which you would rather not answer at a particular time and, if so, what do you do? It depends on the question. If the patient asks how soon she is going to die, I always try to give the most accurate answer. For example, “Your health condition is serious, even you feel that it is worse than a month ago. I cannot promise you full recovery, but for how long you will live, it is only up to you. We can help you with pain, vomiting, diarrhoea, constipation, etc. If you fight, you might have a chance to prolong your life. If you give up, you might die very soon.” Frequently I add a story about one of my patients who was diagnosed with acute leukaemia. Although she could not be treated medically because of her age, she did not live just that one month more as she was predicted, but a full year, just because she had enough mental strength to fight the disease.

Does the seriousness of the patient’s condition affect your behavior? Of course. It really matters if a person comes with a cold, or if somebody has suffered a heart attack, a stroke or cancer. Yet still it does not affect my understanding of any suffering. Sometimes it is sufficient to lend an ear, sometimes to give advice. Other times it is necessary to assure patients that we are here for them – not all the time, but in specific hours – and if they wish, they may come and ask and talk…

With different social groups of patients, do you use different conversational styles? Yes, I do. Otherwise it would not be possible to come to an agreement between me and them. Sometimes it is better to make things simpler, sometimes to go into details. However, I always tell patients that in medicine nothing goes hundred percent. What I also find useful is to compare human organs or medical systems to other, more approachable things, e.g. cars, household, nature, animals, plants.

I suppose the answer to the questions whether you are the best physician around is a resounding yes. It is not so important for the patient to know that I am the best specialist around. It is important that she knows that I have the best specialists at hand and that I know when to ask for help and that I do so, i.e. that I do ask when the treatment is complicated, when something is not clear to me. This way I show the patient how much I care about her – so much that I admit that I do not know something, and I go to ask just because of her.

Does your nonverbal behavior differ with different ethnic groups? I do not think so, definitely not intentionally. But to be honest, it is hard to assess as I do not have a lot of experience with these differences.

If during your conversation a conflict arises, how do you solve it? Do you utilize humour, for instance? I utilize humour as part of everyday communication with my patients, i.e. during ward rounds, during reception and release of the patients. As regards the way I solve conflicts, it depends on the particular type of the conflict, on what level it has arisen, whether the conflict has started as miscommunication between the patient and the doctor, or whether it is about faulty procedure on the part of the doctor. Personally, I solve conflicts in a calm manner, I do not blame, I always try to find possible reasons why the particular person behaved the way she behaved.

I know you frequently have patients where the risk factors of the eminent operation are especially high. How do you cope with the conflict of the need for telling the patient about this high risk factor and, on the other side, the resulting effect of possible discouragement and hopelessness? You never know all the risks. Most often I draw the patient’s attention to the most frequent complications and side effects, and I immediately continue with supplementary information on how we are able to cope with the problem. If the patient gets frightened and wants to back away from her therapy, I introduce an example with Paralen, where a certain amount of the drug will suffice to cause the death of any person. This example usually persuades the patient to cooperate again; she knows Paralen, has used it many times during her life and nothing disastrous has ever happened. Her hope is restored.

I presume that these conversations, these attempts to communicate and to establish a human relationship with your patient, sometimes take a considerable amount of time. How do you handle this? How do you try to disentangle yourself unobtrusively, if the patient talks too much about subject matters that are not germane to the issue? Just how do you get away, if you need to, if the patient wants to continue the talk? Well, that is a tricky situation. It took me quite a long time to learn how to cope with such cases. But again, this is a matter of how you communicate with your patient. What I commonly do is as follows: I interrupt the patient; then I apologize for interrupting her; then I tell her that we have only a limited amount of time to sort things out; after that I try to persuade her to give me clear information about relevant issues; I convince the patient that we may talk about less relevant, private issues (e.g. family and job problems) later on.

I understand that a hospital is a teaching institution as well. And so we might be interested in how you handle the presence of interns and residents in these conversations? Are they present, while you converse with your patients? To what extent are they involved? The presence of medical students takes two forms: either as part of their seminar work or within the bounds of their practical placement. During the seminar work students are under the supervision of their teachers and, because there is no time and there are always so many students (around 16–30) in the seminar, they do not participate in my rounds and interviews with patients. It differs when they are on their placement. During that time students attend my ward rounds and take part in medical interviews. Later on they carry out their own rounds, under my supervision, of course, and learn to treat some less demanding cases. All of that requires a significant amount of verbal interaction with their patients.

In that context, are students of medicine taught the importance and techniques of communication with the patient? And if so, how are they involved? As far as I know, school does not develop their communication skills much. During the students’ placement the situation is a little bit better. However, to a large extent it depends on the supervising doctor and institution. Somewhere they may be given proper training in communication, elsewhere they even learn wrong communicative strategies. As regards the future, I have heard that some medical faculties in the Czech Republic are preparing courses with the aim of teaching medical students how to manage their time, how to communicate with patients, colleagues and nurses, how to relax, how to specify priorities, etc. The courses will be instructed in an interactive way, imitating real-life situations and testing individual communicative skills.

Are your nurses aware of what you are doing, of what you are trying to accomplish? To what extent are they cooperative? Doctor and nurse make a team. If one of the two components does not function, the team does not work properly either. That’s why it is so important to learn to communicate not only with patients, but with nurses as well. While interacting with a nurse, it is important to express how much you respect and appreciate their work.

To summarize, I would like to ask you if you feel that in your profession at large there is enough awareness among teachers, professors, concerning the importance of communications between physician and patient. Is it emphasized sufficiently in the medical schools? No, it is not.

As a final question, I would like to come back to what we touched upon at the beginning of this interview. Can you really notice the medical benefits of what we sociolinguists call therapeutic conversation? Yes, I can. Diseases are psychosomatic, i.e. mind influences body and vice versa. The better the communication with the patient, the better the relationship with the patient, the better the psychological resources of the patient, the better the chance of the patient recovering.

Conclusion

One interviewer, one set of questions, two interviewees, two sets of answers: not too much statistically relevant data, some of you may object. Nevertheless, if you compare the replies by D. H. Sevin with those provided by me, you will at least realize that they are more or less the same; irrespective of the nationality or the time in which they were acquired. Both of us strongly agree that “the success of any form of treatment will very much depend on the patient’s participation and the quality of communication and trust between the patient and her physician” (Sevin & Sevin 1989: 258). This supports the idea presented and elaborated, among others, by Černý in his series of articles (2007, 2008a, 2008b, 2008c, 2008d, 2009) on the topic concerned.