Patient styles, distress, and what they get

Dr Mary Wyatt

How patients communicate has an important influence on the treatment they receive.

Distressed people get more investigations, more treatment, and can have poorer outcomes because of this.

Back in the 80’s there were some good studies on how patients communicated.  Through videos of consultations (with the patient’s consent!) researchers looked at patient behaviour and how they communicated with the doctor.  And then looked at the influence this had on the way the doctor dealt with the patient and the time they were given off work. 

It’s not just verbal communication; the patients’ nonverbal clues had an important impact on the consultation and outcomes.

Patients who are dramatic, dominant, contentious, and animated are more likely to have longer periods of time off work. 

It is interesting to reflect on this dynamic and why such communication changes the doctor’s approach.

Some say the doctor considers that the patient’s problem is worse if they are more expressive about the condition.  Others say that the doctor interprets the patient’s communication as a greater need for treatment, and others say that because the patient becomes the dominant influence in the consultation, the doctor becomes subservient.

These type of patients are often more difficult for a doctor.  The doctor who can handle the situation is confident, capable of leading the consultation through challenging periods, and capable of active listening.  A distressed patient is distressed about something, but sorting out what  can be hard.

The pain is terrible doctor, the tablets you have given me are not helping.

There is great pressure on the doctor to do more in this scenario, often the medication dose will be increased, or a new and stronger tablet is tried.  In a small but significant group of patients more and more tablets are added until the patient is heavily drugged and not capable of much more than getting themselves dressed.  Their lives go on hold, and they’ll tell you after they have come off the drugs how unworkable the situation was.

It can be hard to separate a patient’s distress from the severity of their condition.  The quality of the language can help differentiate.  A person using emotive terms, such as “dreadful,” “terrible,” “agonizing,” while sitting without looking to be in significant pain is likely to be a patient in the distressed category.

Listening to the patient is essential.  Asking the right questions is just as important.  Asking the person about the greatest fear or what they are most worried might happen can be telling.  The story of the neighbour who had back pain for four months before cancer was diagnosed, or the friend who had a shoulder problem and had three operations and never recovered, will influence most people’s level of concern about their own condition.

Patients who come to me for an assessment sometimes say they wished that their history could be gleaned from other reports so they don’t have to tell it again.  But at the end of the day it is not just a factual account of events that the patient provides, it is the way they talk about it.  Their experience of the condition, the treatment, and their approach to the overall situation that gives the doctor the best insight into their situation.