Rule 24: Talk with, not to patients
Effective medicine is built on supporting your patient's life purpose. For help digging into this, we look to an unexpected teacher.
This rule comes from Dr. Clifton Meador’s A Little Book of Doctors’ Rules, a book I received early in med school. What follows is a deep dive into Dr. Meador’s 24th rule: Talk with, not to patients.
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Throughout my eXtrEMeLy iMPrEsSivE body of work here on “Building Docs,” communication is something I’ve touched on many times. I’ve done so because of the topic’s importance in negating the practice of paternalistic medicine. This is medicine practiced in the sense of “I know best because my degree says so, therefore do as I say.” This is wrong for a couple of reasons. First…doctors are not infallible. Second, patients have a say in their own care. And lastly, paternalistic medicine dismisses opinions other than your own, therefore not giving patients a say in their own care (and that’s not good).
But since I’ve talked about this aspect of communication an annoying number of times, I want this post to go in a different, but equally important, direction. Well that and, I’ve been inspired…by Billy Crystal and the 90s classic cattle-driving comedy “City Slickers” … so dust off your boots, grab your chaps, and let’s hit the trail…
Uhh…what?
Yea, you read that right.
Let’s talk about City Slickers quickly. It’s a “fish-out-of-water” comedy that stars Billy Crystal, Daniel Stern (who you may know as 1/2 of the Wet Bandits), and the indomitable Jack Palance as “Curly” the rugged trail boss who serves as a foil character for Crystal. In the movie, Billy Crystal is stuck in a rut. He’s not doing well at work or home - he feels lost - so he and his friends decide to take a trip out west to drive cattle. Like one of those adventure vacations. Anyway, at some point in the movie, after winning Curly’s respect, the two find themselves talking about life.
In the clip above, Curly points out the need for a person to know what their “one thing” is; the thing that, when fully embodying it in your life, all else falls into place. You could call it an ideal, a mission, etc. This is the idea with which I want to explore Dr. Meador’s 24th rule: Talk with, not to patients.
For Docs
Docs must understand their patients’ “one thing.” Why? It makes it much easier to speak in terms they’ll understand. Let’s look at an example. Say we have a patient named Jedidiah. Jedidiah is a type 2 diabetic. He does not take his antidiabetic medication consistently, he has not made the appropriate changes to his diet and lifestyle, and now he is starting to develop complications: namely, he can no longer feel the bottom of his feet and toes.
Taking his medication, making better food choices, and exercising would improve his condition, which would then improve his life. Your goal - as the doc - is to figure out why Jed won’t make these changes. Generally, you could go about it in a couple of ways:
The “Sterilized” Way: You could simply tell Jed that he is developing peripheral neuropathy due to poorly controlled type 2 diabetes. If he doesn’t make some changes in his life, then he’s at risk of developing other complications like retinopathy and/or nephropathy. (Not that effective of an approach because who knows what those words mean).
The “Shame on you” Way: You could shame Jed by saying things like “your diabetes is getting worse because you refuse to exercise and take your medication appropriately. You have to take your medicine, lose weight, and exercise, or your feet will get worse, and your eyes and kidneys will get damaged, too.” (Not a great way…even though lecturers may be right, no one wants to listen to them. Plus this way focuses on parts [feet, eyes, kidneys] rather than the whole [this will take away from the things Jed enjoys and values]).
Or the “Socratic” Way: You could dig into Jed’s reasoning with some simple questions. This is the one method that assumes good faith and reasoning on behalf of Jed, which is something important when practicing effective communication. For example, no worthwhile “one thing” would support the progression of disease, and Jed’s diabetes is becoming worse, therefore there’s a disconnect there. Jed either values the pursuit of comfort (or something similar) above all else, or his true life ideal isn’t connected with his actions. Either way, digging into that would be helpful because that disconnect is the true issue at hand.
So as a doc, especially when speaking to your patients on lifestyle changes – which is probably part of 90%+ of encounters nowadays – understanding what drives your patients is key to communicating effectively.
For Patients
Your responsibility, as a patient, is to know your “one thing.” You may be asking why knowing this is a requirement for proper medical care. This is a good question and gets at the purpose of medicine which is, very basically, to heal people from sickness and keep people healthy. But why is this important? Why choose to be healthy?
You may offer, “well it doesn’t feel good to be sick.” But to that I say so what. There are plenty of things that don’t feel good, yet people do them anyway. Many people go to a job that doesn’t make them feel good. Many people stay in unfulfilling relationships. Many people choose to do things that keep them chronically sick like not exercising or taking their medications appropriately, etc. No, the answer is deeper than feelings and perception.
Your health is important because it enables you to live out your life’s mission. You cannot live your life’s ideal if you are sick or unhealthy. That is the true purpose of medicine and health: enabling your body to fulfill your mission, to live out your “one thing.” Put differently, medicine can only perform to its potential when you realize yours.
This then begs the question: what is your one thing? Is it God? Virtue? Your family? If you don’t know, have hope. On returning home from his cattle-driving escapades, Crystal’s character could answer that question. He became a better husband and father because of it and lived a more fulfilled life.
Now, if you don’t know, I’m not saying you should go to New Mexico and drive cattle with two of your closest friends. What I am saying is that everyone has value and everyone has a purpose. It is your responsibility to discover what that is, cultivate it, and hold true to it no matter what. When you do that, you’ll see that everything else - your health included - will fall into place…
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Special thanks to Dr. Meador and his fantastic book. See you next time…
I love HOPE! I love City Slickers! Norman, Baaaa......
You will be an awesome doc, Dr. Petersen!
I love the way you study each situation from different angles only to get to a better answer for your patient. With your concern and special care you are going to be a wonderful doctor. The patient will love you also because you show them how much you care and want them to improve their situation.