Doctor patient communication Content or process
Authors: Turabian Jose Luis ,   Specialist in Family and Community Medicine, Health Center Santa Maria de Benquerencia. Regional Health Service of Castilla la Mancha (SESCAM), Toledo, Spain.
Published: July 2024

In the doctor-patient interview, there is a tendency to think of a dichotomy between content or background (the patient's complaint, his symptoms, medical decision-making subject to evidence -evidence-based medicine (EBM)-, drug prescription, etc.) and the process or form of the interview (the modality of the doctor-patient relationship, empathy/assertiveness, sympathy, compassion, transference and countertransference, the placebo effect, etc.). This approach is as reductionist as the usual mind-body dualism. And the problem is that, as in the bio-psychosocial (BPS) approach, the holistic content-process approach to doctor-patient communication has not been integrated into the daily practice of general practitioners (GPs) with little time, who care for most patients with acute and chronic, physical and mental illnesses [1, 2]. General Medicine (GM) presents special characteristics that differentiate it from other medical specialties. In GM it is necessary to evaluate the presentation of symptoms, in addition to the symptoms themselves. That is, the reason for the consultation initiates or emphasizes important issues for the pat ient, and not just symptoms, in a communication context [3, 4]. GPs often assume that in consultation the patient will ment ion the most important symptoms and signs in relation to it, and that patients will spontaneously report all their fears and worries; neither of these assumptions is true (5). When a pat ient comes to the office, the GP must face a certain amount of uncertainty about the evaluation and optimal treatment of it. Uncertainty is frequently represented in terms of probability or normative reasoning, and EBM. But, the reason for consultation expressed by the patient is only a manifest content. The GP must transform or complete those ideas that are latent or initially hidden [6, 7]. Symptoms are often "disorganized", not readily recognizable, and can be presented by symbols, as does the arrangement of notes in a musical score. Perhaps the family doctor has to approach the symptoms as if they were "music": like a mysterious constellation; seeking order in disorder, or better trying to understand some of the disorder [8]. The symptom is an indicator of a process that is not always fully visible. The loss of internal balance manifests itself in the body in the form of a symptom. In addition, the symptom is not an enemy whose destruction should be the main objective, but can be an ally to find the disease. In reality, the symptom indicates what the patient “misses” (9). The GP try of knowing the latent material by means of “reading the patient’s manifest signs and symbols”. The messages of our patients contain “facts” and “feelings”, and we must be attent ive and understand the emotional messages. The reason for consultation / symptom / manifest problem that the patient initially expresses is a “symbolic representation” (with universal and particular symbols); and in addition, the doctor looks for what seems to be the cause of the patient's problem in the doctor-patient relationship itself [10]. The process of communication or presentation of the reason for the visit that the patient makes to the doctor is itself a content of the health problem, it gives information about the psychic life, and it can be a signal that tells the doctor which direction to take [11-13]. In order to fully understand the symptom we must distance ourselves from the usual valuations. It is convenient to replace an excessively analytical and rational thought, with another plastic, symbolic and analogical one. Illness is a system of interpretation; and to understand disease we have to see a system of relationships. The emotional response expressed by the patient has the effect of a linguistic transfer from social complexity to psychic complexity. Illness is expressed as a contrast –not as its own unequivocal entity, but as a contrast between relationship systems-, as in painting a contour, a line, appears from the contrast between two colours instead of how a line is actually drawn [14].