Seek first to understand, not be understood.

An argument is an emergency of self definition

In my day to day life I have the pleasure to meet a large number of people from all walks of life, and play a part in helping them through sometimes very difficult times in their lives.  This is the privilege and responsibility of being a doctor.  Usually people are very willing to enter into discussions about how they are feeling, what their symptoms are, how treatment has been going, and then listen when I go on to explain what I think is going on, and make a plan for further investigations or treatment.

More recently I have had some conversations with people that did not follow the usual, fairly polite, and respectful pattern.  In one case, the patient did not appear to want to enter into any form of discussion at all about what symptoms or problems may have brought him to the clinic.

Thinking back to the consultation, it was clear that the usual power dynamic had changed significantly – and, although I was aware of it at the time, it seemed that I should try to get the consultation back to the usual footing – as that is how we operate in medicine.  This resulted in a fairly frank exchange, and both parties undoubtedly did not perform at their best.  However, the plan we arrived at was appropriate for the condition being considered and although the consultation was not terribly satisfactory – it ended up being effective.

Now, why did this small-scale conflict arise?  There were undoubtedly faults in the system that led to communication errors in written information.  But when I really look back at what was going on at that moment – I can see a couple of things.

#1 The patient was really upset at the medical profession as a whole owing to limitations placed on him by medical examinations, which he did not believe were justified.  He had most probably lost out on a significant amount of income, and was therefore not pre-disposed to cooperate with the medical establishment.

#2 I was unconsciously unhappy that the power dynamic had shifted away from me in the consultation – and I therefore tried to re-assert my authority when questioned again and again about each detail of my plan.

So, what will I learn from this experience?

First, that a saying I learned recently and have tried to practice will require more work – namely – “Seek first to understand, rather than to be understood”  By examining more closely the reasons why this patient was unhappy, I could actually identify the likely reasons for the conflict, and in accepting that these were of great importance for the patient, include them in my appraisal of the situation, and allow the patient time and space to express this frustration, and then move on to the other needs the patient had from that consultation

Secondly, to recall that ‘arguments are emergencies of self-definition’ and act accordingly.  I read this phrase recently in a short story (Aftermath – Rachel Cusk), and was struck by it as representing a simple truth.  In this consultation, the ‘argument’ arose because the patient wished to express their feelings or displeasure at previous experiences, irrespective of my lack of role in them, and I wished to assert my position as that of the doctor, and inherently therefore deserving of respect and deference in the consultation.

In the future I need to recognise that there are times when what a patient needs from a consultation may not be entirely relevant to what I think they are there for.  Trying to force the issue down another road is not likely to leave either party satisfied. It is far better to be alert to this possibility and deal with what is most important for the patient – and place my needs slightly lower down the scale until the patient will be in a better frame of mind to work together on the issue I am seeing them for.  Ultimately I would like to get to the position where every one of my clinic appointments is run along the principles of shared decision making – but that is a work in progress.


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