Cristian R. Montenegro: Improving interactions between clinicians and patients

Sociology has tried, with mixed success, to define a realm of analysis that goes beyond the individual, and to grasp what is “in-between,” using names like “interaction,” “structures,” “communication,” or “culture.” I mention this because, if we want to come up with ways to improve the relationship between doctors and patients, we need to try to think in terms that go beyond the individual doctor, and the individual patient.

Recently I was invited to take part in the Salzburg Global Seminar session 553 called “Toward a Shared Culture of Health: Enriching and Charting the Patient-Clinician Relationship” (Jemma Bate wrote an excellent piece on transparency, based on the same event). And within the seminar, I worked with a team specifically looking at the interaction between patients and doctors.

It was easy to engage in a deep conversation about the clinical encounter and its problems, we all shared personal anecdotes and formal knowledge about patterns of indifference and dehumanisation across a wide spectrum of settings and in different countries. We also agreed on the possible sources of the problem, including time constraints, organisational dynamics, and larger trends in society. However, it was very hard to identify practical ways to address this.

More specifically, it was difficult to overcome the tendency to frame the “solution” in terms that fall either on the side of the clinician (as empathy) or on the side of the patient (as empowerment). On the one hand, this is exemplified by an almost infinite reliance on the medical curriculum in its potential to change the way clinicians communicate with patients. On the other, it’s increasingly common to locate the responsibility on the patient, who is expected to “break the ice,” asking their clinicians the right questions, and using their time wisely. And while I think there’s still plenty of potential in both areas, something was missing, the “in-betweenness”: how do we make sense of the interaction itself?

In this context I came up with the idea of a “mini-biography.” Before the clinical encounter, both patients and doctors could have access to a brief (100 to 200 words) self-description of each other. This means that every clinician (and other members of staff) working in a health facility, and every patient attending that facility would produce a publicly available mini-bio. This could contain information that goes beyond formal qualifications or professional achievements: hobbies, favourite things, or even a quote from a book. The most important thing is that both the clinician and the patient are free to choose how to describe themselves in 100 words.

The medium to make this information available could be flexible. For the patient, depending on resources and technological conditions, the information could be provided online, it could be displayed on digital screens in a waiting room, or it could be a printed booklet available in the waiting area with a collection of pictures and mini-bios of the clinicians working in that facility. The doctor, on the other hand, could access the patient’s mini-bio directly on his health record—in a digital or physical form.

The idea was well received by the mix of clinicians and patients gathered in the session. It was observed, nonetheless, that some doctors might be reticent to disclose this kind of information, for personal reasons, or because they value a degree of professional distance. While this might be the case for certain areas of healthcare, in general patients can feel routinely ignored by professionals in the health system. This was clearly revealed by the massive popularity of the #HelloMyNameIs campaign initiated by terminally ill Kate Granger, whose simple aim was to encourage healthcare professionals to introduce themselves. Studies revealing the role of “onymity” (the contrary of anonymity) in the development of trust and cooperation give added support to this idea.

If only knowing each other’s name improves the interaction, having access to a mini-bio before the clinical encounter takes place could create what sociologist Werner Nothdurft calls a “conversational space” that allows for types of questions and answers that go beyond the identification of a medical problem and the definition of a course of treatment. More specifically, if we follow Wiener and Schwartz invitation to “listen to what matters”, as well as information, the bio could provide conversational cues for the doctor to explore aspects of the patient’s life in an un-invasive way, for the sake of a diagnosis and a treatment plan that is truly “patient centred.”

Cristian R. Montenegro, PhD Student, Department of Methodology, London School of Economics and Political Sciences.

Competing interests: None declared. 

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  • Mark Taylor

    Thank you for this. It was a facinating read. The idea of a mini-bio exchange is intriguing but would it really work considering the breadth of backgrounds a patient population would cover? Is there a danger that a mini bio could reinforce a perceived social / cultural distance between patient and doctor (“I am too busy surviving my illness and trying to pay down my mortgage to go marathon running like you”)?

  • Cristián R. Montenegro

    Hi Mark, thanks for your comment. I think the issue you raise can only be resolved through practice and with time. Eventually, if wrong perceptions or misplaced expectations are created then the mini-bio could be updated accordingly. But beyond this, even if the mini-bio is used by patients and clinicians to compare each other lives and social status (which is not the aim but is kind of inevitable in our social-media influenced culture), that is better than unilaterally creating an attribute-less persona, only to avoid making the patient feel bad about himself. The mini-bio is a gesture of openness regardless of how is going to be interpreted… at lease, there is something to interpret, there is a human being that values, enjoys or hates this and that.

  • Tom Nolan

    Interesting idea. Could this be coupled with a self affirmation exercise? There is some evidence that getting patients to write positively about themselves before a consultation they are more likely to be receptive to behaviour change. (If i had time I’d find you a reference) Completing a bio before an appointment describing what they like and are good at would be V interestong to study, looking at compliance, activation etc

  • Cristián R. Montenegro

    Hi Kelly, many thanks for your thoughtful comments and for sharing your blog.

    In a way, the idea behind the mini-bio is the need to find ways to change things that don’t involve a transformation of either doctors or patients “minds”. What I mean is that sometimes, as you said, there are limits to how a patient can induce the right attitude in a clinician. Even the most outspoken or empowered patients are at risk of being treated in a dismissive way (maybe precisely because of that!).

    So for me, the question is: Is it possible to create a context or a setting that facilitates different, better and richer conversations? Owners of a pub or a cafe know very well and work in this way, they don’t want to convince anybody of anything, they just work to create the best possible conditions for people to feel comfortable and relaxed. So in my view, we need to think about those conditions, and if we frame them like that then their implementation becomes a matter of standards and design, and not of transforming clinicians minds. The transformation will be an outcome of the context (that’s the sociologist in me speaking).

    I’m not sure if this addresses your concerns, the mini-bio is really a very minimal tool that should be accompanied by other things in each context and of course, it won’t solve the problem of explicitly and systematically rude clinicians (or patients).

  • Cristián R. Montenegro

    Hi Mark, thanks for your comment. I think the issue you raise can only be resolved through practice and with time. Eventually, if wrong perceptions or misplaced expectations are created then the mini-bio could be updated accordingly. But beyond this, even if the mini-bio is used by patients and clinicians to compare each other lives and social status (which is not the aim but is kind of inevitable in our social-media influenced culture), that is better than unilaterally creating an attribute-less persona, only to avoid making the patient feel bad about himself. The mini-bio is a gesture of openness regardless of how is going to be interpreted… at lease, there is something to interpret, there is a human being that values, enjoys or hates this and that.

  • Cristián R. Montenegro

    Thanks Tom. Your idea makes full sense. Actually, in an initial version of this text I wrote this (It’s a bit long, sorry for that):

    “it might be the case that we, as researchers, lead patients, policy-makers, academics and clinicians, are so used to the idea of the “mini-bio” that, actually, it doesn’t excite us in the way other kinds of innovations do. We have had plenty of space to shape our own public identities, in websites, twitter accounts, CVs, blogs, articles, etc. Describing ourselves in written form is part of what we do all the time. But we need to consider a broader context, where large groups are permanently locked in a state of anonymity. People that never had a chance to spell out, for a wider audience, who they are. People that never had a chance to add something of their own creation to the hundreds of documents, text-fields and platform carrying their identities from one database to the other”

    I think a next step to strengthen the idea is to define the measurable differences that a mini-bio or self-presentation exercise could do. Your suggestion is very relevant.