BMJ  2007;335:514 (8 September), doi:10.1136/bmj.39325.646887.94

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Pleasing doctors: when it gets in the way

"You want your doctors to like you," she said. "You want to be a good patient and sometimes are afraid to rock the boat." The woman speaking to me was a physician with cancer. I was interviewing her as part of a study of doctors who had become sick with serious disease.¹ To my surprise, she and others I talked to described repeatedly how they hesitated to be aggressive or "pushy" with their own healthcare providers and instead tried to please them.

"If I trust the doctor," another doctor with cancer told me, "he feels good. The fewer questions I ask, the happier he is and the more positive he'll relate to me. I want him to know he's a good guy."

In general, people want others in social interactions to feel positively, and doctor-patient interactions are no exception. Unfortunately such behaviour can hamper open communication between patients and their providers and hence impair care.

The best doctor-patient communication can enhance interpersonal relationships, information exchange, medical decision making, informed consent, and patients' satisfaction, adherence, understanding, and, possibly, health outcomes.^{2 3 4}

As another physician with cancer recently told me, "When the doctor stops on rounds and says, ‘How are you doing?' and the patient answers, ‘Poorly,' the doctor has a long face. When the patient says, ‘Fine,' the doctor smiles and waves hello." These ill physicians shed light on how doctors encourage patients' efforts to be pleasing, and patients may then be conditioned to give doctors positive feedback.

Doctors may simply be busy, overwhelmed, or eager to get through their day as quickly and efficiently as possible. Doctors may also seek to protect themselves from difficult medical or emotional interactions. But patients seek such cues from doctors that prompt or discourage discourse—and patients may respond accordingly. One doctor told me how he had often hugged patients to show support and only now, as a patient himself, realised that this gesture could unintentionally silence them—"I'm really giving them physical cues to shut up!"

Communication may be hindered by patients too. They may hesitate to talk about certain topics, especially perceived taboos such as depression, non-adherence with treatment, or sexual dysfunction. They may play down problems because of embarrassment, denial, or the wish to avoid giving what they see as "bad news" to their providers.

These complex dynamics in communication between doctors and patients are of ever growing importance in the United States and elsewhere, as managed care may limit the amount of time doctors have with many patients, and high tech treatments (as opposed to low tech human interactions) become ever more profitable and common. Being assertive and proactive may potentially help patients fight disease, but these dynamics of communication may lead to patients feeling disempowered and failing to assert themselves.

What (and how) doctors and patients decide to communicate seems to be shaped by their perceptions of how they think the other party will reply, how they wish the other party will reply, and how they think the other party wants to reply. For example, patients often tell their doctor what they think they want the doctor to hear, but they may misperceive or misunderstand their doctor's wishes, fearing negative responses. Such assumptions can further impede care. The desire to establish trust can conflict with the imperative to disclose the whole truth. Patients face a tension between pleasing doctors and divulging disappointing news.

Yet professional training and public education do not address these issues. Indeed, the ill doctors I interviewed were generally astonished to see themselves engaged in these processes and were previously unaware of seeking positive feedback from their patients. Their surprise surprised me.

Doctors, too, often face tensions between expressing themselves and concealing their disappointment with patients. Moreover, doctors' and patients' desires may clash: patients may want to disclose information and prolong or extend interactions, while doctors do not. Patients' desire to please doctors, doctors' desire to be pleased, and doctors' arrogance can amalgamate, further impeding discourse.

The French postmodernist philosopher and psychiatrist Jacques Lacan argued that in psychoanalysis four entities are always involved: the patient, the doctor, the person the patient thinks he or she is talking to, and the person the doctor thinks he or she is speaking to.⁵ Whom each party thinks he or she is talking to may differ from whom he or she is in fact talking to. These multiple distinctions complicate subsequent interactions. But Lacan's model, highlighting the complex dynamics of provider-patient communication, may apply beyond psychoanalysis to medical interchange more broadly.

Additional factors may facilitate or impede these dynamics. Patients may think that their symptoms are too mild to mention, even though they may be important in the clinical assessment. Still, at a certain point, increasing severity of symptoms may outweigh patients' reticence, prompting patients to convey bad news more fully or directly.

Such dynamics have been seriously underexamined and need to be further researched to explore further how, when, and to what degree they operate: how they shape disclosures and restrict the process and content of communication. Awareness of and sensitivity to these phenomena also need to be incorporated into public and professional education. Doctors should be as aware as possible of gestures, whether verbal or non-verbal, that can impede communication with patients. More careful consideration of these issues will be in the best interests of patients and, in the long term, doctors as well.

One doctor told me how he had often hugged patients to show support and only as a patient himself realised that this gesture could unintentionally silence them

References

1. Klitzman R. "Post-residency disease" and the medical self: identity, work, and health care among doctors who become patients. Perspect Biol Med 2006;49:542-52.[CrossRef][ISI][Medline]
2. Waitzkin H. Doctor-patient communication: clinical implications of social scientific research. JAMA 1984;252:2441-6.[Abstract]
3. Roter D, Hall J, Katz N. Patient-physician communication: a descriptive summary of the literature. Patient Educ Couns 1988;12:99-119.[CrossRef][ISI]
4. Sutherland HJ, Llewellyn-Thomas HA, Lockwood GA, Tritchler DL, Till JE. Cancer patients: their desire for information and participation in treatment decisions. J R Soc Med 1989;82:260-3.[Abstract]
5. Lacan J. The Four Fundamental Concepts of Psychoanalysis. New York: Norton, 1978.

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