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Q&A with Zackary Berger, MD, PhD: Author of Talking to Your Doctor

Rowman & Littlefield Publishers, 2013

Your book is called Talking to Your Doctor but really it’s doctors who need to learn how to talk to patients. Doesn’t this expect too much of us? After all, our doctors don’t have enough time to talk to us anyway.

Our intuition tells us that doctor-patient visits are subpar because there’s not enough time. However, research shows that patients and doctors can have satisfactory visits in countries where the general practitioner has even less time for the visit. In the book, I point out that it’s not so much the “clock time” devoted to the visit as it is the “visit time”: the attention, mindfulness, and concentration each party brings to the interaction.

Do you think health care reform will help doctor-patient communication?

It depends on which part of health care reform you’re talking about. The PPACA (“ObamaCare”) won’t help doctor-patient communication by itself. More patients will have access to care, which is a wonderful thing, but we still have to make sure that those provider-patient relationships are on a sound, communicative footing.

The ACA does include a section – which wasn’t funded – to encourage shared decision making. This has been termed by some as the pinnacle of patient-centered care. The NPA’s work in promoting the availability of primary care is a key enabler of good communication in the setting of SDM; in the book, I talk more about the interaction between the two.

What is more important: technical competence, knowledge, or emotional sensitivity and communicative ability?

All of them! I think we are at a cultural moment where technical competence and knowledge are overrated. This is especially applicable to quality reporting of doctors and hospitals. Just as in the educational system, health care providers are graded on things that are easily quantifiable, but those quantifiers aren’t necessarily stable, unbiased, or reflective of a patient’s (or population’s) real health.

Isn’t it unreasonable to expect doctors to communicate better with the increasing regulatory requirements placed on them these days?

I’m not sure if the regulatory burden on doctors is greater than it used to be. Regulation, and restructuring, has an important role to play in remaking, and improving, our interactions on the individual level. My approach shares a lot with the agenda of the NPA: if we can leverage the relationship with our primary care provider, we can make better choices. That means picking the health interventions that actually feel right for us. Those choices, in turn, will often tend to be the ones that are less burdensome to the health care system and less afflicted by overuse.

What can you do to improve the relationship with your doctor if you have no choice in the matter – for example, if you would like to pick another doctor but can’t due to your insurance plan?

This is hard. I think some investment in the relationship will bring benefit – but it has to be done by both parties. In the book, I talk in the detail about possible strategies. In brief, they involve making the most of a visit through mindfulness techniques; being open about roles, expectations, and concerns; setting the agenda; and acknowledging potential barriers and discordances between doctor and patient.

You are pretty skeptical in this book about a lot of what passes for medical evidence. If doctors don’t know as much as has been supposed, how is better communication supposed to help?

The hierarchical imbalance between doctors and patients has to be leveled. But it is unreasonable to expect patients to make medical decisions on their own – that would be equivalent to abandonment.  One possible direction, in the face of incomplete information, is to recognize patients’ preferences as a bridge between imperfect evidence and medical decision-making.

Can doctors be good healers without being good communicators?

Healing is more than technical proficiency or life-saving interventions – it means making someone feel whole. A good communicator and try to do that even in simple, day-to-day interactions, through exercising respect and helping the doctor-patient relationship be a true partnership.

How can doctors and patients of different races bridge the gap between them?

First, we have to recognize the existence of bias in our health care system and unconscious racism on the part of doctors. Then, we have to take ownership of diversity as a way to confront such bias. We need diverse doctors taking care of diverse patients. While not looking away from the difficulty that racial or cultural disparities pose, we should be confident that an appeal to universal human values and needs can help ease that difficulty in the visit. Of course, large-scale social problems require large-scale social solutions. But even (or especially) in the world of health care, large-scale solutions might start in one-on-one meetings.

What are some of your own communicative deficiencies as a doctor?

I have poor eye contact (a congenital condition), which I always have to remind myself to warn my patients about. Also, I don’t look forward to phone conversations. But I absolutely love e-mail!

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Zackary Berger, MD, PhD, a primary care provider at the Johns Hopkins School of Medicine in Baltimore, maintains an active adult medicine practice there, as well as being a preceptor in the housestaff clinic. His research involves doctor patient communication in the hospital and the office, especially the role of the PCP in cancer care.

Dr. Berger’s new book, Talking to Your Doctor: A Patient’s Guide to Communication in the Exam Room and Beyond, is available at http://www.talkingtoyourdoctor.org

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