BOX C-1
Example of an Ineffective Patient–Clinician Discussion

Doctor. “How can I help you?” (looking at chart)

Patient. “I developed another flareup of whatever I have … the fatigue, muscle aches, stomach pain, and terrible nausea, when I came back from vacation … (pause) … (pensive) I …”

Dr. “Was this like what you had before?” (interrupting)

Pt. “Yes … well, almost … I think.”

Dr. “Was it made worse by food?” (looks up)

Pt. “Yes, I think so.”

Dr. “Did you have fever? or chest pain?” (leaning forward)

Pt. “Well, yes, I think, … but I didn’t take my temperature” (looks down)

Dr. “So you had fever and chest pain?”

Pt. “Uh no, well, the pain wasn’t bad … I guess. … Dr., I’m really worried about this.”

Dr. “Let me go ahead and schedule you for some blood work and maybe another X-ray. It’ll probably be ok, but this way we’ll be sure there is nothing to worry about.”

Pt. “But what do I have? I saw on the veterans website that some other people had the same things, and they called it Gulf War syndrome. Is that what I have?”

Dr. “Most people aren’t sure whether that’s a real medical condition, so I want to rule out anything else that we can treat. If the studies are negative, I’d like to put you on an antidepressant to make you feel more comfortable.”

Pt. (looking confused) “I’m not depressed. … I just can’t deal with the pain and nausea. I …”

Dr. (interrupting) “I didn’t say you were depressed. It can help the symptoms. Let’s see what the tests show.”

to why. The doctor’s comment led the patient to infer that the medicine was being used for depression, which he did not think he had.

It is noteworthy that although the number of verbal exchanges is the same in both conversations, the content and the messages communicated are richer in the second one (Box C-2), with far more clinical content and probably greater effectiveness in building the patient–clinician relationship. It is clear that the doctor is fully engaged in helping the patient. The doctor listens actively, gives the patient the opportunity to tell his story, and responds to the patient’s comments and concerns. Validating statements are used (for example, “I can see how much this is really affecting your



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