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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Setting and bases of discussion
The setting of the discussion
The physical environment
The time factor
Time pressure on the doctor - an insoluble problem?
The climate of the discussion
Setting and bases of discussion
Correct discussion technique is the "tool" which is necessary to lead an interview. However this alone does not guarantee that a satisfactory discussion will develop between the two people involved. This is because discussions never take place in a "vacuum", but in a certain setting which always contributes to the success of a discussion. This concerns the often simple (and therefore often neglected) conditions and surroundings of the discussion, such as the place and time of day, the positions and the distance between the two people, the time that is available (time pressure) and influences which are difficult to examine objectively, such as the effect of the "climate" of the conversation.

A basic requisite for the success of an interview is that the person who is leading it (in this case the doctor) develops a series of abilities which are vital for understanding, effective discussion; the ability to listen actively to the patient, to meet him with empathy (understanding his feelings), to move over to him and to recognize that discovering a common reality is the bedrock of communication between doctor and patient.
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The setting of the discussion
One of the prerequisites for the success of the discussion between doctor and patient is that it takes place in an appropriate setting. This determines the atmosphere of the discussion and whether or not a positive key-note can be achieved. The right setting creates a trustful atmosphere, makes it possible to be open and approachable without being interrupted, and allows a free-flowing conversation and concentration on what is most significant. The ideal conversation is characterized by concentration on the other person, active listening, friendly approachability and obvious interest. This is the opposite of what could be described as the "poker-face syndrome". If the situation is balanced against the patient because noise and hectic activity have taken the upper hand, the doctor is not "really there", under pressure of time, or there are constant interruptions, which only allow snatches of conversation, with obvious time pressure, the conversation is bound to failure. The setting depends on:
  the place (surgery, ward round, house visit, emergency room)
the time available
the climate of discussion
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The physical environment
Wherever it takes place (interview room, bedroom, ward), and under all conditions, efforts must be made to ensure that the discussion can be carried out undisturbed. This is one of the most crucial criteria for encouraging discussion. All interruptions from colleagues, clerks, nursing staff, telephone calls, "beeps" or loudspeakers, or other patients, have to be eliminated or minimized. "Deadly sins" of communication include discussion somewhere on the corridor, by an open door, or "just in passing". Nevertheless, they are daily occurrences.

Anne-Marie Tausch gives many authentic snippets of conversation in her book about conversations to relieve anxiety, written as though they were on a tape recording or film script. The following is a typical example from a patient with cancer: "My professor let me know when the door was open: ".... by the way, I've just got your report. You will have to have an Operation on Monday, as one of your breasts must be removed." I said: "Please? What's the matter with it?" "Yes, you've got cancer." Then the other patients started talking to me about it in the corridor. They had heard everything." There is no justification for this sort of information transfer through an open door.

The correct positioning and distance is described in another chapter link. Obviously, the doctor must not only be physically there, but also actually present with his thoughts, senses and emotions.
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The time factor
The sensation of time pressure should not be allowed to arise, even in cases where the discussion actually is being carried out under shortness of time. There is no doubt that lack of time and the associated time pressure is one of the major practical problems in the daily life of doctors, and certainly stand in the way of good interviewing. It is precisely because of this, that it is extremely important to look at every aspect of medical practice and to differentiate between real, presumed unavoidable and avoidable time pressure.
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Time pressure on the doctor - an insoluble problem?
Ways to save time

"I just haven't got the time!" could be the immediate response of many doctors, as a reaction to the suggestion that they should follow the concepts laid down in this book. However, the quality of discussions between doctor and patient is not a function of time, but of the ability to understand the feelings of the other, as well as employing correct interview techniques. A good discussion certainly does not imply a long discussion, neither does a long conversation guarantee a successful interview. Many doctors will probably only be convinced than understanding discussion does not waste time, when they have had experience in this area.

Nevertheless there need be no discussion about the lack of time that most doctors have for the fulfilling of their duties. There are two roots for this deficit of time: the objective, immediate multitude of tasks, but also the uneconomical use of time that is available. Ways of saving time will now be described, in order that one can have more time for the primary task of being a doctor, especially that spent in consultations with patients. Most of the recommendations and tips that follow are based on the work of G.F. Gross and R.H. Ruhleder.

Initially however one important remark: Time pressure creates shortness of time. Time pressure is infectious and can itself create further lack of time. Time pressure lowers efficiency.

It is not possible to measure time pressure objectively, as it is the subjective experience of limited supplies of time. This also means that I can influence how I experience time pressure and cope with it. This in turns means that I can train myself to tolerate time pressure, instead of constantly feeling impotent under its influence. Whoever learns to tolerate shortness of time and time pressure will not mention his limited time again and again, thereby releasing the feeling of time pressure in the person he is talking to, and not disturb something very important that has just come up in the discussion.

It has become fashionable not to have much time; full diaries and overcrowded, loaded desks are supposed to be a status symbol; however they are certainly not evidence of an economical way of dealing with the time available. It is also not a sign of composure to brag about one's lack of time and to wear time pressure like a badge of merit.

People vary to a great extent in the way that they relate to their time. Some manage to live better without a watch, whilst others always know exactly what time it is, to the minute, and are still always watching the clock. Check whether in fact you are looking at the clock more than is really necessary. Stick a red point on your watch or clock, and make an exact note of the number of times you glance at the time. Something is wrong if this is more than 5 times in half an hour: this can be either your attitude to time or your way of dealing with it.

The most important time-saving factors in discussion are those which, at the same time, are essential to a good discussion: active listening, empathy, an adequate interview technique and the ability to find a mutual reality.

The amount of time which is potentially available is laid down. If there is any possibility of using this time more economically, a task analysis is its prime requisite, to look at what should actually be achieved within a particular time period. It helps to divide tasks into one of three groups as either "vital", "necessary" and "unnecessary". Even at this point, it can be seen that unnecessary work is the classic time-stealer and that usually much more time is devoted to these tasks than to those which are truly necessary or vital.

Uncompleted tasks set off restlessness and stress. It is only a completely finished assignment which releases this burden. Because of this, it is advisable to complete one task after another, rather than to try to take on too many at one time. In fact, a completed task brings one much further on than 10 which are incomplete. A task which, in principle, will be repeated many times should be carried out the very first time in such a way (even if it takes longer) that the procedure can be used in similar tasks in the future, and then involve the use of less time.

Tasks should be put into blocks. It is an uneconomical use of time to telephone, to talk to a patient, to visit the laboratory, to chat to a colleague and then leaf through a journal in colourful succession. Putting these tasks into blocks of time means that continuous and effective work can be performed in each of these areas. Putting off a more difficult task by appearing busy (clearing up, reorganization etc) is only a substitute for work, and actually only puts off achievement of the major task.

The amount of reading material, which is showered upon the doctor is increasing continually. A closer analysis reveals that only a fraction is really worth reading. It is therefore necessary to employ the classical system, differentiating between:
  Obligatory reading matter and
Reading matter, which can be immediately thrown away unread.

In the grey zone between the two there may be, for example, one article in a journal that does not necessarily have to be read now but which is not completely uninteresting. One can keep this to read for a brief, limited time (not more than one week), but should not store it for longer. The final possibility is to properly file those works, publications or articles which appear interesting or important, but which can not be read immediately (but they need to be disposed of after 6 months).

Nobody has continuous competency or efficiency throughout the day. Analyzing one's personal efficiency curve makes it possible to synchronize difficult tasks to the time when proficiency is maximum, and to perform easier jobs or those that are purely routine, at a time of low efficiency. A doctor, who knows he is "never awake in the early morning", should not arrange a difficult discussion with patients or relatives at 8 am.

The surroundings in which we work play a role in our efficiency, and thereby also in the way we deal with time. The personal environment should if possible only contain that which improves one's mood, increases proficiency, or will be of use for getting on in the future. The permanent stack of unread medical journals is a continual reminder of time-pressure. It can be therefore very useful to undertake a thought-out "spring-clean".

Safeguard yourself from the "time thief". Folk who belong to this group mention that they want to "come by and see you", and "only need 3 minutes", but this goes on to 30 minutes. Whoever really needs 3 minutes should of course have them, but not a minute longer. The more that one is known, the more people want to steal your time. They initially appear with great show of admiration and affection. You are apparently the only person in the world to whom they can turn to perform the task that they are burdening you with. You are "The expert" or "The opinion-former". There is certainly no obligation on you to do what they ask immediately; this appointment lies a very long way in the future.

It is human weakness to succumb to these attacks on your time, if it first appears that your immediate time is not interfered with. The decision to undertake such tasks usually comes back to you with a vengeance and leads to the most unpleasant form of achieving work, which is to do it under major time pressure at the last minute. It is usually illusory to think that this task could perhaps be delegated to somebody else (assistant, laboratory technician or consultant).

From this it can be seen that one of the important abilities that one needs in order to save time is that of being able to say no, only saying "yes" when you really mean it. Much time can be saved with an unmistakable and reasoned "no".

As you deal with patients who give you the impression that they are taking too much time, try to analyse what the reasons are. These are often so called difficult patients (see chapter on this subject link) and it is only by analyzing and dealing with the reasons for their behaviour (unspoken anxiety which could be dealt with etc) which results in your time not being involved excessively.

Many people demand your time, but you yourself can not extend your time by a millisecond. One way out of this situation is to make a clear offer of time, and stick to it whatever happens. This forces the other person to make his objectives and requirements clear without beating around the bush. If you have made it clear to your discussion partner that you have only 10 minutes available, it is not impolite to signal the dose of the discussion at the end of this time. It is much more difficult if you did not make this clear before the discussion commenced. This is one of the ways in which you can determine your own time schedule, and not let others do it for you.

Many tasks which you believe you have to do yourself could be delegated. Most people are unwilling to delegate work, either because they do not trust those with whom they work or haven't trained them well enough, or because they have the attitude that they are the only person would could do it all correctly. In fact new tasks can often motivate those that work for you and can be an incentive for a more responsible way of working. Not only the task, but also the responsibility for it should be delegated. The stress is removed when both are passed on. There are however two classical objections which can be raised by those involved when a new way of working is suggested, both of which are only sham arguments: "We have always done it this way" or "We have never done it that way".

Check list: to save time
  Examine your own attitude to time
Learn to tolerate lack of time
Do not infect others with your time-pressure
Classify tasks into vital, important, and unimportant
It is better to complete one task than start ten
Work in blocks of tasks
Develop an efficient system of reading
Don't put off tasks by substituting bustle
Match tasks to your own daily efficiency profile
Spring-clean your surroundings
Recognize "time thieves"
Be able to say "No"
Make clearly defined offers of time
Don't let others interfere with your time plan
Learn how to delegate both a task and responsibility for it
Remember: The best time-saver is the successful discussion between doctor and patient
Finally, a very important factor for efficiency and the associated way of working is the degree of your motivation. Tasks which are approached with less enthusiasm and motivation need an over-proportional amount of time. However pleasure in the work is the result of experiencing satisfaction with the results of one's own work. This completes the circle: the discussion which is successful is the one which is understanding" therefore an understanding discussion is not one that steals time. In fact the successful discussion between doctor and patient represents the optimal economy of time.
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The climate of the discussion
The bases for a fruitful climate of discussion are: a trusting atmosphere, openness and willingness to listen, as well as the ability to relate to the patient and to be on the "same wavelength". No aggression arises in such a discussion, which is factual and not driven by emotions, allows recognition of resonance and does not create anxiety. Respect and appreciation characterize the relationship between the two people, and the discussion proceeds symmetrically.

Where the conversation is optimal, both partners are at the same level in discussion of the subject matter, and are communicating emotionally on the same level. Both sides profit from such a discussion: the patient because he feels that his problem has been accepted and the doctor, who finds it easier to obtain the necessary information. 

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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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