March 28, 2013
One of the topics discussed in my book, ‘Talking about health,’ is face-saving. One of the best explanations for why patients do not give or seek information during medical appointments is that they are managing their own and their doctors’ impressions. ’I don’t understand’ is a hard statement to make. ‘I don’t even know that I don’t understand’ — even harder to express. In the face of questions from our doctors, such as, ‘have you been following your diet?’ or ‘when did this rash first appear?’–we may tell the truth but not exactly the whole truth.
For example, I am very susceptible to poison ivy. I blame myself when I get an outbreak because how many times can I study what poison ivy looks like in order to avoid it in the woods on my walks. Still, I manage far too often to brush up against the stuff and then the effects are just plain awful for me. I try to avoid going to the doctor with it until it is in such full blown raging bloom and typically covering more rather than less of my body. Why do I do this when I know the doctor will be likely to give me a prescription to ease the itching blistering experience? Because I feel stupid and embarrassed to have–as I think of it–done it to myself again.
Besides impression management, we also have the desire to ‘do what we want to do’ without others interfering with it. We intuitively know the kinds of information not to give in order to avoid being told not to do something.
In the face of a direct question, such as ‘how much alcohol do you consume each week?’, both managing our impression and wanting to do what we want to do may lead us to be less than completely truthful. A doctor may hedge a bit on such a question by saying, “One alcoholic beverage a day for women has been found to have some health benefits, while binge drinking of four or more alcoholic beverages a day does more harm than good.” In such a statement, I could get a sense of a range of behaviors related to drinking and some of their possible outcomes. If I want to ask for more information about ‘harm’ or ‘benefits’–the door has been opened. If a doctor wants to know how much alcohol a patient is drinking, it is likely in order to decide whether to caution a patient to limit their intake. So the message can be embedded without the more direct and likely face-threatening interaction unfolding. This may help to build positive rapport between a doctor and patient, closing some of the social distance between the two, and opening a space for a patient’s more sensitive disclosures.
So back to that question, ‘when did the rash first appear?’ — does it really matter because it’s here now and raging. Well, yes, it might make a difference when it appeared and help with an accurate diagnosis. So rather than feeling stupid in the face of such a direct question, it is important for us to remember that doctors ask questions to help make diagnoses rather than to embarrass us. But doctors could remind us of that and say something like, ‘In order to have a better idea what this might be, it would help to know when the rash first appeared.’