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  F E A T U R E S  
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  Drug Advertising a Springboard for Good Discussions Between Physicians, Patients  
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  Oversight of Drug Advertising Needed to Ensure Balanced, Accurate Messages  
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  FEATURES
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HUMAN INTERACTION, COMMUNICATION KEY TO GOOD MEDICINE

 "" PHOTO — Faith Fitzgerald, UC Davis assistant dean of medical humanities and bioethics, advocates that a good diagnosis begins with listening to the patient tell his or her story and watching how it's told. "One can get a completely different impression that way than by reading the history on a computer screen."
 
Faith Fitzgerald, UC Davis assistant dean of medical humanities and bioethics, advocates that a good diagnosis begins with listening to the patient tell his or her story and watching how it's told. "One can get a completely different impression that way than by reading the history on a computer screen." .
   

When Alice S. brought her young son to a private specialist, she was surprised that the doctor sat across the room throughout most of the appointment, keying information into his computer. Tests were ordered, drugs were prescribed, and at the end of the appointment, a computer printout was given to her "that explained everything."

Other patients may not even make it in for a visit. A Texas-based company, for instance, has taken the "plugged-in" physician out of the exam room altogether by developing a communication tool that allows patients to provide a medical history in the waiting room or even from home online. A computer program prompts patients to answer questions based on previous positive responses, shortening the exam time or eliminating it all together.

Technology, time constraints and financial pressures have altered how doctors and patients across the nation interact, and how diagnoses are reached. It's no wonder that patients are feeling increasingly disconnected from their physicians.

Despite such trends, there is a groundswell in medicine today — coming from both sides of the examination table — to bring the human dimension back into medicine. "Patient-centered care" is an emerging topic of interest that recognizes that the interaction between a doctor and patient can be as important in health and well-being as a physician's technical competence.

Messenger loses the message

Richard Kravitz, UC Davis School of Medicine professor of internal medicine and director of the UC Davis Center for Health Services Research in Primary Care, says "ignoring the human dimension has real consequences, both in terms of patient satisfaction and health."

Kravitz studies how doctors and patients communicate in the office and through the media and how those interactions impact their satisfaction and care.

Patients sometimes complain that they seem to have a different "agenda" than their doctors. And when patients feel unheard, they may end up not following their doctors' advice. Such was the case with Alice, whose doctor, she felt, paid more attention to his computer than to her. Excluded from a meaningful discussion, Alice decided on her own that medications weren't needed for her son and chose not to fill the prescription he gave her.

Kravitz emphasizes that patient-centered care involves more than just the doctor spending more time looking at and listening to patients. It also requires that patients and doctors work together toward health goals. When patients and doctors share the same perception of a problem, compliance with a treatment regime is more likely.

Ironically, research indicates that while doctors with a more patient-centered style do spend more time with patients, overall costs actually decrease as a result. Peter Franks, UC Davis professor of family and community medicine, has paid particular attention in his research to costs and health outcomes resulting from different physician styles. "A doctor can either reach a diagnosis by spending more time with the patient or by ordering more tests. Doctors who aren't as patient-centered need to order more tests and refer their patients to specialists more often," says Franks. "That is what really drives up health-care costs."

Curriculum focusing on patients

A patient-centered style can be successfully taught to students and physicians. Michael Wilkes, School of Medicine vice dean of education, has created the Doctoring Program at UC Davis to help develop students' communication skills and expose them to a wide range of patient encounters. Interactions are observed and students receive feedback from their professors, other students, and most importantly, the patients themselves. The popular program is incorporated into the first three years of the UC Davis medical education program.

Faith Fitzgerald, UC Davis assistant dean of medical humanities and bioethics, agrees that spending more time with patients is especially important for students. "Some 35 years out of medical school, what I remember from my student years is not lab tests, X-rays or contents of lectures," she says. "What I do remember are interactions with patients and their families."

Tech vs. touch

Fitzgerald expresses concern about efficiency-oriented devices that take time away from face-to-face interactions with patients, such as the computer program that allows doctors to screen patients online to determine whether they need to be seen. "I begin my physical exam by observing the patient as he or she is telling the story," she says. "One can get a completely different impression that way than by reading the history on a computer screen."

But she also stresses that this does not mean that the human touch is all that is needed in patient-doctor interactions. Technology has a role, but not necessarily the primary role.

"We need to understand the power inherent in both doctors and technology," says Fitzgerald, "But in fact, we tend to have less confidence in human ability."

She decries the fact that many doctors feel as if lawyers are looking over their shoulders, making sure they've ordered diagnostic tests to cover every possible eventuality. While tests are important, she asserts, so is human judgment, but this quality tends to be undervalued in a lawsuit. Human skill, she emphasizes, should not be held to a lower standard than technology.

Elevating human judgment

"We must require that what the doctor brings to the table is as accurate and fully functional as what we require from diagnostic tests," she says. "When the interaction of the physician and the patient is deemed less important than the contribution from tests or 'labor-saving' computer programs, this is a real problem. And that holds true for all aspects of diagnosis and patient care."

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  There is a groundswell in medicine today — coming from both sides of the examination table — to bring the human dimension back into medicine as evidence grows that the interaction between a doctor and patient can be as important in health as a physician's technical competence.  
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