A common language between patient and doctor. Is it possible? Episode 33

Monika Rachtan:
I would like to invite you to listen to the podcast 'Patient First'. Good morning, I'm Monika Rachtan, and I'd like to welcome you to another episode of the podcast 'Patient First'. According to a report by Eurostat, which was prepared for the Organisation for Economic Co-operation and Development and published in 2022, it shows that 79% Poles believe that their doctor communicates with them in an appropriate manner, and 70% Poles believe that their doctor spent an appropriate amount of time with them at the surgery. I talk to Mr Zbigniew Kowalski about this issue of patient-doctor communication. Good morning, and welcome. Mr Zbigniew is a lecturer and academic, and his speciality is teaching patient communication to doctors, is that fair to say?

Zbigniew Kowalski:
Yes, I teach doctors, mainly practitioners, in collaboration with students. I also have several years of experience, but I am not the only one doing this. Our scientific society
brings together professionals who work on a daily basis to improve communication in the healthcare field, not only doctors but also nurses and pharmacists.

Monika Rachtan:
I would like to emphasise how important it is for doctors to communicate with patients and for patients to communicate with doctors. In Poland, there is the Polish Society for Medical Communication, whose mr.
is a member.

Zbigniew Kowalski:
Yes, I am a member of this society and actively participate in its activities. Within this society, I am in charge of the section on motivating patients to comply with the
therapeutic recommendations.

Monika Rachtan:
So do you tell doctors how to communicate effectively with patients?

Zbigniew Kowalski:
Specifically, we teach doctors to work together with patients and motivate them to comply with recommendations and feel responsible for treatment outcomes.

Monika Rachtan:
This is extremely important. However, let us return to the data from the report I presented. Is the situation really as good as this report suggests?

Zbigniew Kowalski:
Reports based on research have their credibility. However, it is worth noting that patients' subjective feelings may vary depending on the context. For example, when a patient feels that they are included from the moment they take a number at the clinic, they may feel that the waiting time is shorter, even though the data indicate otherwise. This
demonstrates that a good approach to the patient can influence the patient's subjective feelings.

Monika Rachtan:
Indeed, the perception of time can be subjective. However, recent Health at a Glance reports show an improvement in the perception of patient communication over the last 10
years, increasing patient satisfaction by 10-12 percentage points.

Zbigniew Kowalski:
This is good news. I hope that our work has also contributed to this positive trend.

Monika Rachtan:
It makes you happy. Do doctors learn patient communication in medical school? Is there a proper curriculum?

Zbigniew Kowalski:
No, there was no such programme in medical studies, but the Polish Medical Communication Society was working together with other institutions to introduce it.
Many medical schools have now introduced patient communication curricula, which is a positive step forward.

Monika Rachtan:
Do young doctors who are now learning patient communication see the need for this subject?

Zbigniew Kowalski:
Yes, young doctors increasingly recognise that communication skills are crucial in their work. This often comes from experience when they encounter difficulties in communicating with patients in practice or in real work. They realise that it is not enough just to have medical knowledge, but also the ability to communicate properly is
essential.

Monika Rachtan:
Are young doctors learning this? Today we would like to teach patients to gain practical knowledge and new skills by watching our programme. So I would like to ask if we can treat our talk as a workshop? I will present situations that I have read about most often on the Facebook group, and we will answer patients' questions or give advice on how to behave in these situations to communicate effectively with the doctor. I will start with the first patient statement I read on one of the Facebook groups. "I walk into the doctor's office and start talking. The doctor keeps looking at the computer and doesn't talk to me, just clicks. I have the impression that after leaving the
surgery wouldn't know what colour my hair was. He didn't listen to me, so I forgot half of my complaints." How should this patient behave in such a situation?

Zbigniew Kowalski:
This is a great situation to learn from, because unfortunately it is very common. I want to point out that we talk about it after the fact. I would prefer patients to react during the visit rather than have a reflection afterwards. For example, if you were browsing the internet while we were talking, it would be natural for me to say, 'Excuse me, Ms Editor, but I've come to talk to you. Can we take a moment to be together?" I would have responded. Of course, it's easy to say, because I do this academically and I'm a person of
communicative. But patients, if they are missing certain things, they have to learn it.

Zbigniew Kowalski:
In such a situation, the patient should admonish, but not compete. To say: 'Doctor, I understand that the system is like this and you have to click, but I need you to
talk to me. I have something important to say."

Monika Rachtan:
It's strong. "I have something important to say", but on the other hand....

Zbigniew Kowalski:
Sorry, not competitively. In the question you read, I hear regret: "I cared so much and he treated me this way." There are three attitudes that affect quality
contact. First of all, I would like to draw attention to kindness. I do not assume that the doctor does not talk to me because he ignores me. I assume that he would prefer to talk, but has limitations.

Monika Rachtan:
He wouldn't want that computer.

Zbigniew Kowalski:
Exactly. The doctor has a duty to enter data on the various programmes they are billed for. It is not a matter of pity, but of not assuming that this is directed
against us. Be that as it may, we will not win on this approach. We have limited time to talk, so let's just fight for it.

Monika Rachtan:
I will summarise. It is not ill-will on the part of doctors. Patients think that the doctor is not looking at them maliciously. As a journalist, I have asked doctors several times if I can take a peek at their programme. There is a lot of data to enter there. When a doctor asks about the last time you took a medicine, it is not out of curiosity, but out of obligation. Let me come back to my questions. What should the
a model visit to the doctor's surgery? I don't know if it can be clearly defined, but what should the order be?

Zbigniew Kowalski:
Teaching patients what a model conversation with a doctor should look like is more difficult than teaching doctors. The doctor, as the host, has certain responsibilities. He should greet, invite and suggest a topic of conversation. We will not discover America by saying that good conversation was invented by nature, not scientists. Every good conversation
looks the same: first the fine-tuning, then the concrete, finally the farewell with the setting of an action plan.

Monika Rachtan:
We start with fine-tuning.

Zbigniew Kowalski:
Yes, from tuning in. We are made to show that we are our own at first. Speak the same language, catch eye contact, sit alike. These are simple things,
that we now teach at university and to practising doctors. Every one of us has it. When we talk to someone close to us, it is easier than with a stranger.

I will now begin to revise the second part of the transcription, focusing on improving the sentences so that they are understandable and easy to read, while maintaining the current form
conversation and names of interlocutors. I will not be creating new content or making things up.

Monika Rachtan:
I would like to ask about fine-tuning. You mentioned that the doctor is the host. What if at the beginning of the attunement the patient feels strange and the doctor uses complicated
wording? Can the patient ask the doctor for simpler language?

Zbigniew Kowalski:
This is a unique skill that you mentioned. Not many of us know how to say, 'I'm sorry, but I don't understand that', because we are afraid of being judged negatively. Meanwhile, this is important. Meeting a doctor is only a small part of our lives. I want to stress that doctors have a harder time when they don't tune in to the patient. Their knowledge and work become
ineffective. If the patient is uncomfortable with the lack of fine-tuning, they can call for it.

Zbigniew Kowalski:
He may ask: "Could you explain it differently?" or "What did you mean? I'm sorry, but I don't understand."

Monika Rachtan:
It is difficult for a patient to admit, especially in a stressful situation. Older people take up to a week or a month to prepare for an appointment.

Zbigniew Kowalski:
I would like to point out something else. Patients often speak directly about their expectations: "I demand a referral", "I ask to be released". But this is not a conversation, it is an attempt
negotiation or extortion.

Monika Rachtan:
It's an extortion, a negation of skills.

Zbigniew Kowalski:
Agreement allows us to talk about the needs of both parties. If we are strangers with defensive mechanisms, our demands lose strength and lead to conflict. This should be avoided.

Monika Rachtan:
When I tell the doctor about my complaints, should I mention any medication I am taking, even if it is not related to the appointment?

Zbigniew Kowalski:
Yes, it is a good idea to inform your doctor about all the medicines you are taking. Patients do not always know what drug interactions may occur. Informing about medicines can
avoid problems.

Monika Rachtan:
What if the patient is taking medication that affects cognitive skills? Should the doctor adjust communication?

Zbigniew Kowalski:
This is an ideal situation. It is a good idea to talk about all medications to avoid problems. We should always inform the doctor about the medicines we are taking.

Monika Rachtan:
I will quote a parable from a patient who told about a visit to a rheumatologist. He asked me if I was taking other medications or going to other specialists. I told him about the cardiovascular treatment, but did not mention the proctologist, thinking that these problems do not mix. What risks do you see in this behaviour? You have spoken about it, but does hiding the
information is common in Polish society?

Zbigniew Kowalski:
We are brought up on the failings of the health care system. Therefore, a visit to the doctor, from the patient's perspective, is not only a concern for health, but also an attempt to find oneself in administrative dependencies. The patient thinks: "If I talk about this medicine, I won't get a referral". This is a problem of the organisation of the health system, not just communication. W
It is in the patient's interest to talk about everything that ails him or her and what he or she is taking, regardless of whether the specialities merge.

Monika Rachtan:
Do patients not say certain things to the doctor for fear of being judged morally?

Zbigniew Kowalski:
Yes, unfortunately it is. But this is not an affliction of just doctors, but of people in general. We judge doctors the way patients judge them when they leave the surgery. In 2009
I conducted a survey among Polish patients: "What does a good doctor mean?". 53% respondents answered that it is the one who cares about my health.

Monika Rachtan:
What does this mean?

Zbigniew Kowalski:
It's subjective, but it's about feeling that the doctor really cares about my problem. Being judged by the doctor is a disadvantage because it makes it harder for the doctor to make the right decision.
The doctor should be a signpost for the patient, not a strict parent.

Monika Rachtan:
Doctors often see patients with problems like smoking or addictions that are routine for them. Are they unimpressed by this?

Zbigniew Kowalski:
I ask doctors if they think their patients don't know that smoking is harmful. The problem with smoking is not one of ignorance, but is more complex. I will cite a situation that occurred a few weeks ago. I was teaching a class for doctors that included bariatric surgeons. One of them said: "These patients are to blame themselves". This
I was frozen. Doctors are not there to judge, but to help.

Monika Rachtan:
If there is an effective treatment, as in the case of obesity, then there is nothing to think about.

Zbigniew Kowalski:
Yes, but the 'you're to blame yourself' mindset is detrimental. Most adults have some sort of lifestyle-related cardiovascular risk. The doctor should be for
patient signposting.

Monika Rachtan:
A doctor is a human being too, and we should remember that. There are smokers, drinkers, overweight people among them.

Zbigniew Kowalski:
Exactly. I would like the doctor to be a beacon for me, to understand human imperfections.

Monika Rachtan:
There was a doctor on our programme who admitted that she was a smoker but had quit. She said that doctors also sometimes buy wine or crisps, which is normal. Back
for the workshop. I have had abdominal pain, vomiting and diarrhoea for several days. What key information should I give my doctor in order to receive valuable advice?

Zbigniew Kowalski:
Include how long the abdomen has been hurting, where exactly it hurts, what kind of pain it is - whether dull or stabbing. It is also important to be honest. Often patients conceal how long
are persisting with their complaints, fearing the doctor's reaction.

Monika Rachtan:
What about answers to the doctor's questions about diet? Patients often answer in generalities, which forces the doctor to ask more precisely.

Zbigniew Kowalski:
Rest assured that I do not need to know the patient's entire life. It is important to answer questions truthfully. In the case of pain, don't be afraid to say how long it lasts,
even if you are afraid of the doctor's reaction.

Monika Rachtan:
When the doctor does not ask for details, is it worth going into them?

Zbigniew Kowalski:
The doctor should guide the conversation. If he does not ask, there is no need to go into detail unless it is relevant.

Monika Rachtan:
You once made the mistake of telling doctors that abdominal pain is due to food.

Zbigniew Kowalski:
Yes, I described my symptoms too convincingly, which resulted in a misdiagnosis. It is important that doctors check the information given by patients.

Monika Rachtan:
Another question from a patient relates to a situation where she had additional tests done at her own expense and the doctor asked why she had done them.

Zbigniew Kowalski:
Patients should discuss the need for additional tests with their doctor before they have them done. The doctor should be informed of the patient's plans in order to make a decision together.

Monika Rachtan:
Do doctors sometimes fail to inform patients of all options, worrying about costs?

Zbigniew Kowalski:
Yes, there are times when doctors keep quiet about certain options, fearing the patient's reaction. This is not good practice. The doctor should inform the patient of all
options available.

Monika Rachtan:
At the beginning of the interview, you talked about motivating patients to take care of their health and follow their doctor's recommendations. Often we think that going to the doctor and getting a medicine, perhaps the one we imagine, is what determines our recovery or improvement in wellbeing. But it turns out that just having the medicine, or even taking it, does not
is always enough. Because the whole environment of drug treatment is important. So how do you motivate yourself to take comprehensive action?

Zbigniew Kowalski:
I would like both your editor and our audience to be convinced that taking medication is one thing, but pharmacological adherence is only
challenge. Unfortunately, the world is more complicated. Taking medication regularly is a powerful challenge, with one in two of us not taking it.

Monika Rachtan:
So they don't accept them at all?

Zbigniew Kowalski:
Exactly, not at all. Or one in two of us only takes every other tablet. Let's think about the last time we took all our prescribed medication. Half of us have
problem. This often surprises doctors. For example, I ran an educational project on the treatment of leukaemia.

Monika Rachtan:
With a disease as serious as leukaemia, I don't think you can afford to have ineffective treatment.

Zbigniew Kowalski:
One might think so, but the percentage of patients regularly taking drugs in Europe to treat chronic bone marrow leukaemia is only 13.3%. This is due to difficulties in
adapting the dosage regimen to everyday life. It's not that people don't know how to treat themselves effectively, but changing their lifestyle is very difficult.

Monika Rachtan:
But after all, leukaemia is a serious disease. Why don't patients follow the recommendations?

Zbigniew Kowalski:
The problem is that treatment requires a change in daily habits. For example, when they rearrange the shelves in a shop, adjusting to this change is difficult. Similarly
patients feel confused when treatment requires them to change their routine.

Monika Rachtan:
This is difficult.

Zbigniew Kowalski:
Any patient to whom a doctor recommends treatment is in this situation. But on the other hand ...

Monika Rachtan:
When we have a disease as serious as leukaemia, which is a fatal disease that can kill a patient in a matter of months, it seems to me that it's not...

Zbigniew Kowalski:
But today I don't feel it yet. I don't feel it yet today.

Monika Rachtan:
That is to say, there is not yet this fear, this...

Zbigniew Kowalski:
Maybe it is, but it's not like I'm in pain here today. If I don't take a tablet, I don't get out of bed. It's not like that yet. We have plenty of illnesses where we don't feel them
daily. The most serious in the sense of the most represented disease is hypertension.

Monika Rachtan:
Right. With hypertension, which, as I recall, affects around 11 million Poles, there is a problem with mobilising treatment because symptoms appear
only when it is already very bad.

Zbigniew Kowalski:
It depends on how you count. We also have about 3-4 million people with diabetes and other pre-diabetic conditions. As for lung disease, it is apparent that the drugs used to stop the attack
dyspnoea are used better than those designed to prevent attacks.

Monika Rachtan:
We are under enormous stress when such an attack of dyspnoea occurs. I would also like to touch on specific communication. I recently heard from a nurse that she would prefer patients to come for chemotherapy at a designated time, instead of waiting for two hours in the waiting room where they talk among themselves. These conversations can
introduce doubts and problems. How do you think it is worth talking to other patients about illnesses, and does this affect relationships with doctors?

Zbigniew Kowalski:
Each interaction influences the next. If patients wait two hours, the clinic is badly organised. We patients, having learned to function in an imperfect system, often come earlier. This can be a kind of support group. People feel comfortable among those who have similar problems. This is part of our culture, where
People are bidding to see who is sicker.

Monika Rachtan:
Yes, this used to be the case when the best hospitals were military hospitals, inaccessible to ordinary mortals.

Zbigniew Kowalski:
And now the question is, is this good or bad? Are there risks of someone spreading unverified information? Such risks exist everywhere. You can't ban patients from meeting each other. And one more thing - contact with elderly people. Removing them from society leads to emotional deprivation. The best way to repair the system
nervousness are games or breaking the barrier of intimacy.

Monika Rachtan:
This is amazing. This could apply to older people who are seen as unpleasant supplicants.

Zbigniew Kowalski:
They are alone more often than younger people. Therefore, visiting the doctor is a way for them to repair their nervous system.

Monika Rachtan:
I think we've analysed the whole waiting room, so now I'm going to ask about practical information for patients that they can find on the internet, but reliable, or in some
guidance. Where to look for this? Is there a guidebook? Has someone published something like this?

Zbigniew Kowalski:
I used to publish it, but it can't be found now because it was a long time ago. It was a guide written for leukaemia patients and for haematology doctors. About how to improve the collaboration between them. This handbook reached patients through the National Association of Chronic Bone Marrow Leukaemia Patients and hematology clinics and departments. Doctors who read it said it was written in simple language for patients. Patients found it excellent, written in medical language
for doctors. And it was the same handbook.

Monika Rachtan:
I understand.

Zbigniew Kowalski:
I am somewhere in the middle.

Monika Rachtan:
We also try to speak in simple language that is easy for patients.

Monika Rachtan:
That's why I try to be a bridge when you start using concepts that patients may not understand. I always enquire, ask follow-up questions, because there are no stupid questions in this programme. We answer questions from patients of all ages, whether it's the 80-year-old who comes in to fix his nervous system or the young girl looking after her health, being on a vegetarian diet and doing yoga. We try to answer all the questions. But let me come back to an important point. Our programme partner is the Institute
Patient Rights and Health Education, which talks a lot about the humanisation of medicine. What do you mean by the humanisation of medicine?

Zbigniew Kowalski:
For me, humanising medicine means focusing on the human being. I will tell an example of the lack of humanisation. A friend of mine, sadly now deceased, contracted COVID. He was a university lecturer and was supposed to be vaccinated, but he got sick before he was vaccinated. His whole family got sick, so he didn't do the test. When his condition worsened, an ambulance was called to take him from hospital to hospital, but they would not admit him anywhere because he did not have a positive test. Despite the obvious symptoms, the lack of a result on paper was
The problem. This was not the fault of the rescuers. It's an example that we don't treat the outcome, we treat the person.

Zbigniew Kowalski:
Humanisation is treating the patient as a human being with all their problems and concerns. It is the ability to see the human being in oneself and in the patient, not just the results and
procedures.

Monika Rachtan:
We wish medicine was closer to the people. Finally, could you give three tips for our viewers on how to communicate effectively with a doctor?

Zbigniew Kowalski:
Yes, the first piece of advice is to be kind. Do not assume that doctors are working against you. The second is openness. Be open to talking to the doctor, don't come with a ready-made
conviction. The third is responsibility. You are the one who has to take care of your health, the doctor is only a signpost.

Monika Rachtan:
Mr Zbigniew, thank you for these tips. I hope they will make future visits to the doctor easier for our viewers.