Briefly: I acted as do many of my colleagues. In doing this, I have missed many opportunities, disappointed hopes and have cheated myself out of part of the fruits of my work. I am now aware that the right dialogue between doctor and patient can bring about almost anything, but that incorrect dialogue achieves almost nothing. This book is a personal attempt to demonstrate the correct way in which discussions between doctor and patient should be carried out.

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A doctor enters a ward without saying a word. A wasted man, about 70 years old, looks up at the doctor expectantly. The doctor exposes the arm of the patient, and applies a tourniquet, inserts a venous cannula, hangs up an infusion set and adjusts the rate of infusion. After checking that the apparatus is functioning correctly, he leaves, as he has come, not saying a word. This ghastly scene becomes even more nightmarish when the drama is taken further: before the doctor reaches the door, the patient sits up with great difficulty and says: "Excuse me asking, doctor, but please could you tell me what you have just done?" The doctor turns, and replies with an expressionless face: "You have got lung cancer, and I have started an infusion to treat your tumour."

Most of my readers will find this scene absurd. Who on earth would start a patient with cancer on an infusion of chemotherapy without telling him what disease he has, what the objective of the treatment is, what side-effects might arise and what the success rate is likely to be? And what sort of doctor would approach his patient in such an uncompromising manner, without a "how and why", to start treating a disease which will probably result in death?

Why is it that this vision takes on such a ghastly and apparently absurd dimension? The answer is easy. In the initial part of the drama, the whole scene is so oppressive and incomprehensible as not a single word passes between the patient and the doctor. This is a vision of absolutely speechless medicine. It represents the unease which is coming upon us with the suppression of speech by technology in modern medical practice, described by Paul Lüth in the following way: "Modern medical practice is dumb in areas where it is most successful, that is in cases of extreme sickness." The spoken word is an embellishment or by-product, and certainly not a genuine part of the therapy. Therapy is non-verbal. This produces the uneasiness of modern, successful medical practice.

But the second part of the vision also has a depressing effect; in fact for the same reason. Even here, there was no real doctor-patient discussion. What actually took place was a communicative procedure, which broke all rules of discussion between doctor and patient and, if the expression existed, could be best described as "non-discussion".

Of course one must ask if this vision is not completely absurd and probably unthinkable in day-to-day medical practice? However facts with a short selection of authentic examples probably give the best answer, even to the question as to whether a book about discussions between doctors and patients is really necessary.

Example 1 (or: Is the patient allowed to speak?):

H. Beckan and R. Frankel, American sociologists from Wayne State Medical School in Detroit, secretly videotaped 74 discussions in general practices. The results showed that the patient was interrupted by the doctor on average within 18 seconds of beginning to speak. Only one quarter of the patients managed to continue describing their Symptoms until they had finished.

Example 2 (or: Why are patients not satisfied with their doctors?):

N. Cousins from the University of Los Angeles, who lectures in "Humanity in Medicine", wondered what grounds patients had for changing their doctors. He questioned 1000 patients who had changed their doctor in the 5 years previously, or who intended to do this in the near future. He received 563 completed questionnaires. Typical reasons for changing doctors were: "I had the impression that my doctor did not want to listen to my symptoms; he seemed to want me to be examined by machines as soon as possible", "I have no idea what the doctor explained to me. I was too confused and worried to ask any questions." The art of being able to listen is more important for the doctor than that of talking. 

Example 3 (or: The ability to speak to relatives):

The advice that was given by a hospital doctor in 1985 to the wife of a patient with multiple sclerosis with regard to anticipated difficulties with potency was: "Your husband has multiple sclerosis; you should get a divorce!" (G.H. Seidler).

Example 4 (or: Are computers better conversation partners?):

St. Silicon's Hospital in Cleveland, Ohio, cannot be found on any map of the city. It is not a hospital building that one can visit, but instead a computer databank, from which patients can receive advice. It answers such questions as: "Are there various sorts of breast cancer?", "What is atria fibrillation?", "Does electric shock therapy help schizophrenics?" etc. Patients can type such questions into their home computer and get an answer back from a "specialist" ("Doc in the Box"). This programme, which is available for a small fee, has been developed by the Case Western Reserve Medical School in Cleveland. The patient has direct access into the information system where the questions are stored. Doctors go through the questions every day, formulate answers and mail these back electronically to the questioner.

Thomas Grudner, who developed the programme, insists that the computer should never replace visits to the doctor. In fact it offers personal tips and never real diagnoses. Nevertheless Grudner is aware that patients ask many questions that they would not ask a doctor, and that this service is teaching doctors how to manage patients better.

Example 5 (or: Is it difficult to create a reality common to both the doctor and patient?):

Anne-Marie Tausch, a professor in psychology who died of cancer, described (1983) the following transaction: a patient who complained that she was losing her hair as a result of chemotherapy, received the following reply from her doctor: "Is losing hair a loss of your ego? I don't believe that the ego resides in the hair".

Example 6 (or: One way of dealing with a cancer patient):

Anne-Marie Tausch describes in her book how she was informed that she had cancer: 

"I was told about the diagnosis of cancer in hospital. The doctor, during her usual ward round, briefly described the histological findings. She immediately started to talk about therapy. She stood at the foot of the bed, not next to me. Then the nurse, who was accompanying the doctor, stuck a thermometer into my mouth without saying a word. It was more important for her to measure my temperature according to the regulations. I was extremely aware that neither of them were the least bit aware of my pain".

This scene from daily clinical practice reveals nearly all of the mistakes and deadly sins that can arise in conversation between doctors and patients. A diagnosis which decides the fate of the patient, and may be a death sentence, is curtly given to an unprepared patient, with no obvious sympathy. The discussion is totally asymmetrical, as only the doctor speaks and the patient is hardly allowed to utter a word, although many urgent questions are raised as soon as the diagnosis of cancer is given. In addition (on a completely different level of reality), the ritual of normal nursing procedures continues regardless. Instead of experiencing human care, and understanding, the patient is required to have her temperature measured. By keeping her distance, the doctor is signalling by body language either her defensiveness or inability to get involved with her patient.

Of course some of these are extreme examples, and were not used in order to show common situations, but to reveal the basic disorders in communication between doctors and patients in a particularly strong light. The majority of difficulties in discussion between doctors and patients are not so dramatic; that is if considered at the superficial level. Throwing light on the background reveals that, from the patient's point of view, they are not at all of petty importance. These sorts of discussion actually take place every day.

Benjamin gives a particularly pertinent example in his book "The Helping Interview". 

"'Why have you not taken your tablets? Didn't I tell you how important it is that you take them?' Mrs Bell struggled not to cry. She knew that her doctor meant well; she also knew that he had a lot to do, and just how long it would take her, if she even tried to explain the reasons to him. She knew well enough why she had not taken the tablets. She did not know if it was right or wrong, but she didn't bother about that. She knew that it really didn't matter if she got better again. In fact she was much better cared for if she was ill. She knew something ... about the children and grandchildren and why they had stuck her in this home. And about this home ... she knew a lot about this. But the doctor wanted to know why she had not taken the tablets, and so she replied briefly: "I'll take them now, you'll see." The doctor was satisfied. He smiled, shook her hand and opened the door for her. He really didn't want to know why. He only wanted her to take her medicine. He did like the old lady, but he was much too busy to make more time for her ..."

Disorders in communication between doctor and patient are as old as medicine itself, as speaking with another inevitably entails basic misunderstandings. However, misunderstandings between doctor and patient have a particular significance. As the potential of medicine, especially technical and pharmacological knowledge, increases so does the danger of extensive disorders of communication. More and more specialists are appearing in all areas of medicine. However many doctors do not go beyond the level of a self-taught amateur with regard to their ability to speak to patients. There are of course some doctors who have a natural talent for guiding conversation. However there are very few who excel.

Thomas Bliesener (1986) writes about one of the basic causes of the problems that doctors have in dealing with patients: "Whoever wants to sell a computer, shares or a beta-blocker, receives a much better training in leading discussions than the doctor who is attempting to help his patient towards health. Salesmen, representatives and public relations staff from all product areas receive highly specialized training in speaking. There is no such speech training for the doctor. He remains almost completely isolated with his problems in managing consultations."

The ritual of the brief, friendly but factual discussion apparently completely devoid of problems, takes place every day at innumerable times in surgeries or during ward-rounds. This ritual however is particularly good at hiding the true communication disorder between doctors and patients. M. Hertl: "How often does the doctor induce a feeling in the patient that he can only answer the question "How are you?" briefly and rapidly with "Okay!", in order not to create even more disturbance for the busy doctor. If he tells the truth, which is that he is not feeling well, then the doctor will have to stop and talk about it, ask more questions, think about it and get help. The patient doubts if the doctor will carry on being in a good mood if he is required to spend his valuable time doing this. So it is that the greetings between doctor and patient, which appear superficially to be creating friendly communication, are in fact lies and have no hope of success."

In an essay entitled "There is no substitute for discussion", W. Cyran critically analyses the way medicine is being lead astray by technology, and the consequences: "In an attempt to attain complete objectivity, it has become forgotten in the welter of results delivered from the machines and laboratory tests, that life is equally both objective and subjective. It is not only in medical practice that this Illusion of objectivity leads to destructive and dehumanizing results, because everything that is subjective or emotional is considered unimportant ... The mechanistic machine model should also not be employed for the diagnosis of disorders of bodily function because this leads to even more unselected data gathering. It is curious that the model of the machine, which first arose from the study of physics in the 19th century, is still maintained in modern medicine, even though modern physics has moved on to a completely different position. A major part of this is certainly due to medicine becoming more technological; but a result of all of this is the emotional speechlessness of the doctor mirrored by the desperation of the patient."

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Unsatisfactory discussions between doctors and patients are not exceptions but, if considered critically, a daily occurrence. Bliesener neatly refers to the ward round as "handicapped dialogue". Nearly all communication disorders in medicine can be traced back to 3 basic causes:

1.	Not recognizing that speech is the most important instrument possessed by the doctor,
2.	Poor discussion technique,
3.	Disorders in the doctor-patient relationship.

Based on these 3 causes, a list of reasons can be drawn up, which is certainly not complete, but which can all lead to misfiring of discussions between doctors and patients:

•	Incorrect initiation of discussion
•	Insufficient structuring of the discussion
•	Incorrect closing of the discussion
•	Inability to listen actively
•	Language which is incomprehensible or ambiguous
•	Inappropriate frame for discussion (place, time, surroundings)
•	Vague diction as a result of vague notions
•	Discussion not encouraged; interruptions allowed
•	Use of generalizations, vague communication and "killer phrases",
•	Not picking up the various messages in a communication
•	Rebuffing strategies
•	Orders instead of motivation
•	Induction of anxiety
•	Regarding the other person as "difficult"
•	Lack of metacommunication
•	Inability to construct a common reality

Many doctor are only vaguely aware that their discussions are not really running satisfactorily, that is unsatisfactorily for them as well as the patient. A consultation can be unsatisfactory for the patient if he feels that his problems, situation, or conflicts are not understood or accepted. He may be aware that his doctor sees his illness in another way to that which he is himself experiencing it, and that his world and that of the doctor cannot be reconciled. The doctor is also left feeling dissatisfied; he was unable to make the patient really aware of his view of the patient's illness. As a result, the patient did not completely follow what he was saying, he refused obviously necessary investigations and therapy, and his compliance left much to be desired. These discussions are very trying to the doctor, leaving him tired, unenthusiastic and/or aggressive, for he, too, knows or is aware deep down that the reality of his patient is not identical to his own reality. He then finds that discussion is a heavy burden which he must take up again and again, day after day. He never realizes that speech is the most important instrument he has; that to speak and to hear and understand what is said, is a unique privilege of being human; that medical practice which does not use all of the possibilities is futile, and that speechless medicine is ultimately inhuman medicine.

A brilliant exposure of the power of speech, in the example of manipulation by words is found in George Orwell's novel "Nineteen Eighty-four":

The vocabulary of Newspeak "was so constructed as to give exact and often very subtle expression to every meaning that a Party member could properly wish to express, while excluding all other meanings and also the possibility of arriving at them by indirect methods. This was done partly by the invention of new words, but chiefly by eliminating undesirable words and by stripping such words as remained of unorthodox meanings, and so far as possible of all secondary meanings whatever. To give a single example. The word free still existed in Newspeak, but it could only be used in such statements as 'This dog is free from lice' or 'This field is free from weeds'. It could not be used in its old sense of 'politically free' or 'intellectually free', since political and intellectual freedom no longer existed even as concepts, and were therefore of necessity nameless".

Syme says to the protagonist of the novel, Winston Smith:

"Don't you see that the whole aim of Newspeak is to narrow the range of thought? In the end we shall make thought crime literally impossible, because there will be no words in which to express it. Every concept that can ever be needed, will be expressed by exactly one word, with its meaning rigidly defined and all its subsidiary meanings rubbed out and forgotten... Every year fewer and fewer words, and the range of consciousness always a little smaller."

"Speech" according to the renowned American linguist, Benjamin Lee Whorf, is the "best skill that mankind has. It is completely his "scene" on the stage of evolution, in which he appears from the wings of the cosmos and really plays his part."

Speech is the reference system within which people think and within which they experience their own reality, within which they meet one another and come into contact with the other's reality. Wittgenstein summed it up in a few words: "The limits of my language are the limits of my world".

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This book shows simple methods which make it possible for doctor and patient to speak to each other better than is usually the case. Improved discussion have been shown by personal experience to lead to fewer unsatisfactory consultations and ultimately more successful discussions.

The success of satisfactory discussions between doctor and patient depend on three skills:

1.	The correct approach to the patient,
2.	The use of an adequate discussion technique and
3.	Both doctor and patient finding a common reality.

If these requirements are fulfilled, it is possible to have that type of discussion which is related to successful medicine, which is understanding discussion. 

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