Some Humble Views on Doctor-Patient Communication

Medicine is an extremely special profession. Doctor-patient disputes are widespread across every country in the world, not excluding the most developed nations.

What American doctors dread most is being sued over doctor-patient litigation. In recent years, in Germany and Britain as well, medicine has become a high-risk occupation. This is not unique to developing countries like China.

Insufficient communication is a major precipitating factor in doctor-patient disputes. There is an inherent gap between doctors and patients in their understanding of medical matters. For example, in expectations about treatment outcomes and treatment costs, patient expectations often run higher than reality.

When money has been spent but treatment fails, and the patient suffers or dies, some emotionally agitated patients or family members take extreme measures against the doctor.

Therefore, taking on a patient rashly without adequate communication is a cardinal sin for a doctor. Unfortunately, China's current medical system is not yet ideal enough to allow doctors and patients the opportunity to understand and communicate deeply with each other.

In recent years, many doctors of good medical ethics and skill have died at the hands of emotionally agitated patients or family members. Once reported by the media, these cases have drawn the attention of all colleagues in the medical community and have had a certain negative impact on frontline medical staff.

Medicine is a very serious matter. Both doctors and patients ought to take it seriously, be open and honest with each other, and understand and support one another.

But at present, before a doctor-patient relationship is established, it is quite common for both sides to lack sufficient understanding of each other.

Moreover, doctors are basically in a passive position of being chosen, with no freedom to choose their patients. This plants the seeds of future doctor-patient disputes.

Over the years of practicing medicine, I have experienced all kinds of doctor-patient disputes. About three or four of them were crises that threatened my personal safety. Fortunately, in the end I basically escaped disaster each time, but every time I think back on them I still feel a deep chill.

So over these years, I have become more and more cautious in my practice.

After many failures, I have gradually worked out a set of techniques for communicating with patients.

First, the doctor should not rush to take on any patient. He should carefully and thoroughly assess the patient's situation. If a patient's condition is already so critical that the doctor feels unable to relieve the patient's suffering, the doctor should tell the patient and family honestly; he should not rashly take on such a patient just to covet consultation and treatment fees.

Critically ill patients in particular often live or die in an instant, and doctors can easily suffer fatal consequences after failing to rescue them.

If a doctor does not recognize that his profession is high-risk and fails to guard against it, his own safety is hard to guarantee.

Many famous doctors in history, such as the renowned Hua Tuo, died at the hands of patients or their families. Patients and family members killing doctors is a problem of long standing, without exception across time and place. Clearly it is a social problem that is very hard to solve.

Once a doctor gains a bit of fame, many patients are drawn blindly by reputation, and their expectations of such a famous doctor are especially high.

Xu Lingtai, a famous physician of the Qing dynasty, wrote an essay titled "On Why Being a Famous Doctor Is Not to Be Undertaken." He pointed out that ordinary patients usually seek out famous doctors only when their condition has become critical and other physicians are helpless. But when everyone considers a case untreatable, no matter how famous the doctor, there is little he can do to turn the tide.

I now turn away more than eighty percent of those who come seeking my help. The reason is none other than that their illness has already reached a stage beyond what I can treat.

They hope I will create a miracle for them, but I myself know that the chance of a miracle is slim, while the probability of bringing disaster upon myself is much greater.

When I first started practicing, my risk awareness was poor. I took on several patients in extremely critical condition; only after several mishaps did I realize that I had already been fortunate not to have died at the hands of a patient's family.

Although most patients and their families are reasonable, according to a statistic cited by Dr. Dennis A. Casciato in the Handbook of Clinical Oncology, about 15% of the patient population are "difficult patients" who may turn on the doctor at any time.

So now I have chosen to detach myself from the existing medical system. While being chosen by patients, I also carefully choose my patients. For those whom, after assessment, I believe I cannot treat, I make sure to inform the patient and family in good time, so as to avoid forming a disastrous relationship.

Second, for patients whom we may be able to treat, we must also carefully assess the likely efficacy, risks, and side effects of treatment, as well as the costs the patient will incur during treatment.

The patient and family should have a fairly clear understanding of both the risks and expectations of treatment, and should also know what financial burden they may face. That way, before accepting treatment, patients and families will think things through carefully; if they feel it is not suitable, they will leave on their own.

Third, in the process of communication, one should discern the personalities of the patient and family from small details.

Before taking on a patient with a major illness, the doctor should spend as long as possible in conversation. During the conversation, the doctor should gain an understanding of the basic personality traits of the patient and family, and must be extremely cautious with patients and family members of extreme personality types.

I myself have been through two major crises, one of which nearly caused me serious bodily harm. Both arose because I failed to handle properly my relationships with family members of extreme personality.

Nowadays, when I encounter such patients or family members of extreme personality, I basically deal with them with extreme care.

We must acknowledge that, due to differences in education and other factors, some people really are in an extreme state that is hard to reason with. In every case of medical killing, one can find the shadow of an extreme personality involved.

Actually, people of extreme personality are very easy to spot, because their words and deeds really do differ noticeably from ordinary people.

Fourth, understand the patient's and family's psychological expectations for treatment. If the treatment cannot meet the family's expectations, do not take the case.

For many diseases, it is extremely difficult for doctors to achieve results that satisfy the patient's family. Patients and families often have very high expectations of treatment outcomes.

For example, I often encounter family members of cancer patients, or the patients themselves, who expect me to cure them. Some even expect me to give them an absolute guarantee that I will cure them.

This is something I simply cannot do. So when I encounter such families, I decline to treat them, in order to avoid future trouble. Looking across the whole world, no doctor can guarantee curing any cancer patient. Even for early-stage cancer, there is no such thing as a 100% cure rate.

I once worked in clinical practice under a teacher who was highly skilled and had researched cancer treatment, but cancer patients who came to her were basically turned down tactfully. She told me that the main reason she declined was the family's unrealistic expectations.

I specialize in treating cancer, so of course I cannot turn away every cancer patient who comes to me. But now I gradually approach patients and their families more cautiously. When I am still a stranger to the family, during our conversation I ask them about their psychological expectations for the treatment outcome.

Oncology is not an easy specialty; patients die frequently. The impact of failure on our inner lives is not something outsiders can understand. Oncologists suffer so many setbacks that many develop depression, and in severe cases some even commit suicide.

Sometimes we do our utmost to treat a patient, and the result we achieve was already hard-won, yet the family and the patient often have higher, unrealistic expectations. They will beg the doctor to think of a better way to further solve their problems. At such times the doctor truly has no more tricks up his sleeve and nowhere to hide. Those with slightly weaker psychological resilience can only become anxious and depressed.

The feelings of patients and families are not hard to understand, but the power of medicine is limited. Often, taking one more step forward not only fails to yield better results but is like adding feet to a snake—the efficacy already achieved cannot even be guaranteed. I encounter this kind of thing constantly.

Sometimes treatment is such that once there has been improvement, one can only patiently wait for a miracle to occur. Yet patients and their families, in their anxious fear, cannot accept the present reality so calmly. So the most common thing is that families will seek doctors and remedies everywhere, pursue multiple treatments simultaneously, and try all kinds of folk remedies on their own. Many accidents occur because of such experimentation.

Therefore, finding patients with whom there is a high degree of mutual compatibility is, for a doctor, also a very happy thing.

Overall, close to ninety percent of patients and their families get along very happily with their doctors. So, after we strip away the factors in the doctor-patient relationship that might trigger conflict and unpleasantness, being a doctor is still a very happy thing for those who love medicine, because we can help patients.

Watching a patient's suffering relieved is a deeply rewarding thing. Especially when we have solved some problem that ranks as a world medical challenge, that kind of joy is beyond words.

Finally, a special note: being a doctor, do not put making money first. As long as you persevere patiently, a doctor's income will never be too low; supporting a family will not be a problem, and more income is actually unnecessary.

Any doctor who is in a hurry to make money will inevitably lose his rationality under the temptation of profit. And within the medical profession, once rationality is lost and vigilance against medical risks is gone, accidents occur all too easily.