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One of the most important therapeutic things we do as physicians is to affect the patients attitude about their problem. For example, if the patient presents with a painful complaint and we provide a diagnosis and more importantly a prognosis, the patient experiences a significant change in their experience of the pain without the physician actually doing a thing. In particular what is removed is the unchecked anxiety that accompanies the experience of pain especially pain of unknown source. Even pain of known source however can produce anxiety enough, specifically anxiety about how bad and how long. With the worst of the anxiety removed there is an opportunity to engage the patient in the process of improving their condition.
There is something of the original shamanistic symbolic exchanges which seems to happen with every day patient encounters in the office practice. Shamans and traditional healers seem to employ a strategy of symbolic exchange whereby a totem of object, an herb , an mark on the body, is delivered to the patient and the problem, the disease is removed. This basic exchange paradigm seems to be at work in our offices, whereby a successful encounter is judged by whether or not such an exchange has taken place, regardless really as to the efficacy of what was presented to the patient in exchange for their problem. The use of antibiotics for viral illnesses is just one example.
The therapeutic effect of laying on of hands can constitute a symbolic therapeutic exchange. It is conceivable that many techniques osteopathic and chiropractic techniques may work in this way even if they do not impart a physical change to the patient by virtue of the method, just the laying on on hands in a ritualistic process can succeed as a therapeutic exchange. This is not to say that what is offered to the patient is entirely arbitrary. The object of exchange must have certain attributes, but actual efficacy is not necessarily required. What is equally important is that the patient believes the item of exchange will allow the patient to leave behind the problem they came in with. The placebo effect then looms large in any patient encounter and extends well beyond what we provide in pill form.
It is not surprising then that you can talk to a patient on a rational level, offering in essence information, certainly from the point of view useful information, even powerful information to the patient, and yet, from the patient's point of view, the encounter with you the physician is unsatisfactory. Is this a failure to communicate or is the problem that the patient did not really come so much for information as for some other purpose, some sort of healing magic. We tend to assume that something is wrong in the manner of delivery, perhaps overestimating the patients ability to absorb all that is said, perhaps insufficient metaphorical power, talking too fast, failing ot verify the understanding or simply limitations upon what a patient can recall 5 minutes after the encounter.
Communication is a process. When we consider this process we tend to emphasize the role of the provider of information rather than the role played by the target in the process. Without the participation of the target there is no communication but only utterances. Much of what we think of as communication in our offices consists of utterances on our part. An example would be the notion of informed consent. When studied it is evident that in the case of a complex medical decision the patient actually understands what he is consenting to only 17% of the time. Improving upon this while maintaining some efficiency in the process will be aided by simplifying our information making it understandable in terms which reflect the life experiences of the patient rather than jargon filled information requiring a life experience includes a working knowledge of physiology and anatomy which is likely lacking in our patients.
An understanding of the information needs of our patients and the hierarchy of those needs based on their circumstance is helpful in delivering the information when it is relevant to the immediate needs of the patient at any particular time in the process. As an example, a patient in acute pain with a fracture dislocation of the wrist has need of coping information which relates to what is immediately to be done to relieve the pain and correct the severe deformity. Leave discussions as to the length of recovery the nuances of anatomy and such for later.
coping information helping information empowering information enlightening information edifying information
It may make more sense to keep the information as simple as possible rather that showboating the depth and sophistication of our understanding as to the complex interplay of anatomy and physiology and disease. If we spend the whole encounter this way the patient is liable to feel dissatisfied. We would be better off to ensure first that a human to human connection has been made, and then set about the process of providing a conceptual framework just sufficient to allow the patient to segregate themselves from their problem. This is the power of a diagnosis, no matter how nebulous, no matter how accurate in many cases. The encounter then moves on to seek to validate what has been said verbally and to enable the patient to potentially leave their problem behind, at least in part. It takes more than just voluminous information dump.
How can a diagnostic process such as a physical exam alone be therapeutic? The answer perhaps is that the process, narrows the scope of the problem for the patient. Conceptually a mysterious entity that the patient arrives with becomes, a spur or a bursa or whatever else the exam allows for the physician to apply as a specific name for the problem. The problem is then objectified, segregated and seems all together closer to being eliminated simply by this process.
This concept presumes an attitude toward disease which most of us in western culture hold to which is that when we have an affilction we have some "thing". We objectify the problem, compartimentalize it and separate it from us, as something separate from "us". This follows from the fact that since Descartes we have a body, rather than we are a body, tends to be how we think of things. We tend to approach our health problems in this dualistic way. The enlightenment philosophy which leads to the science which leads to the technology tends to fall short when the problem is an undesirable emotional state, wherein it becomes difficult to separate the problem from the self. Obviously if you cannot separate the problem from the self it is difficult to leave the problem behind.
There is logic then in the notion of conceptualizing problems of this sort, behavioral, psychiatric, as the patient being possessed by an intrusive entity, a malefactor to be extricated. The symbolic exchange of the therapeutic encounter is one strategy to accomplish this extrication. Even the somatic problems which lend themselves to the heuristic approach which objectifies the problem then extricates it fail in accomplishing the same success in resolving that aspect of the problem which cannot be readily extricated, and that remains a part of the self, be it, the emotional imprint of the traumatic experience, or the seemless interaction of intent and function with which we customarily interface with our bodies, consider here the loss of physical capacity of a parkinsons patient struggling to consciously do what for all of their life has flowed effortlessly. Consider too the impact of body image which a post surgical patient or traumatically deformed patient must reestablish to once again feel fully integrated. Until this reintegration is accomplished our results fall short of establishing wellness even if they have successfully healed the problem, and the patient is no longer really sick.
The encounter between a healer and a patient then is characterized here as an interaction which alters the relationship between a patient and the disease process they are dealing with. The healer is a helpful ally, but the primary conflict is between patient and disease. What we call a change in attitude on the part of the patient may appear to have psychological benefit, might be characterized as a placebo effect, but one day we may understand the net effect to be more substantive than that as the manner in which changes in central nervous system function influences metabolic immunologic hemodynamic or other processes within the body in a way which can favor resolution of the problem.
Communication is most likely to occur when utterances (information) are delivered when a patient is about to encounter a transition point in the process of their care and when that information is of immediate practical use in negotiating that transition. All clinicians develop efficient litanies of information that dispel immediate confusion and then adumbrate the future course of treatment to begin the process of dispelling the penumbra in which the patient and family find themselves as they work through the system, and the injury or disease process.