The strategic doctor: between strategy, communication and relationship

Words are the most powerful tool a doctor possesses, but words, like a double-edged sword, can mutilate as well as heal.
(Bernard Lown)

We consult the doctor for the most varied problems, from juvenile acne to Parkinson's disease, from gastritis to heart failure: we can be frightened, worried, pained, anxious, irritated, suffering. In all cases we hope that the doctor can solve our ailment, or at least help us to clarify the symptoms that afflict us. We expect him to have the knowledge and experience necessary to solve our problem, that is, to have a strategy, but implicitly we want much more: to listen to us with attention and interest, as if our malaise were his; that he understands us, that he shares our discomfort, that he inspires confidence, that he shows empathy.
Strategy alone is not enough if it is not accompanied by good communication and relationship. Strategic medical intervention is based on these three pillars.

The strategic approach to the anamnesis: attuning to the patient's point of view
The anamnesis, that is the collection of the data necessary for the diagnosis, is a fundamental part of the medical intervention: it traditionally consists of closed questions, addressed to the biological characteristics of the disorder. The doctor follows his own logical thread and guides the patient in a directive manner, ignoring all information in his opinion that is not pertinent or relevant. The patient, tuned to a more emotional register, is usually interrupted after a few seconds and pushed in spite of himself into the so-called "anamnestic trap": pursued by the doctor's questions, he takes refuge in increasingly laconic answers until he is reduced to simple monosyllables. This mere collection of data responds only to one objective, the cognitive one: however, in order to acquire the power to intervene on the patient, it is above all necessary to establish a good relationship with him.

The strategic doctor will therefore have to explore, in addition to the biologically understood disease (the dimension of the disease), also the patient's point of view, his emotional and social experience, his ideas or opinions on the disease (the dimension of illness), in so you can tune into his perception. Adding this dimension can initially lengthen visit times, but translates into medium and long-term savings, because it improves the relationship, therefore compliance and patient satisfaction, and reduces the possibility of error and conflict. This confirms the value of one of the most important stratagems in the strategic field, “starting later to arrive earlier”.

Use evocative language
Even when they avoid technical-specialist language, doctors tend to use "indicative-explanatory" language, the language of science that explains, describes and conveys information. They strive to induce change (drugs, diet, physical activity) by leveraging the patient's cognition. Strategic tradition teaches us, however, that the quickest and most effective way to induce change passes through not cognition, but the perception of reality: once the perception has changed, the patient will naturally modify the emotional and behavioral reaction and, as a final effect, also cognition.

Especially when the resistance to change is very high, therefore, it is essential not to limit oneself to "understanding", but to make the patient "feel" the need for change.

The strategic doctor must therefore combine the indicative or digital language, of which he is an expert, an evocative or analogical language (aphorism, metaphor, anecdote, narration), naturally fitted both to the person in front of him and to the desired effect: to create emphasis towards what one wants to induce to do and aversion towards what one would like to interrupt. In the words of the great persuader Blaise Pascal: “before convincing the intellect it is important to touch and prepare the heart”.

Take care of non-verbal communication:
As the pragmatics of communication teaches, "you can't not communicate", and most of the message is transmitted non-verbal. The strategic doctor will therefore have to take care of his own appearance and learn to use the gaze, the facial expressions, the smile, the posture, as well as to modulate the tone, the rhythm and the volume of the voice. For example, during the interview he will put the patient at ease with a "floating" look and with nods or winks, while to emphasize the prescription, he will focus his gaze and use a slow, well-marked speech.

Avoid denials
Against common "common sense", reassuring phrases such as "don't worry" or "you won't feel bad" increase both anxiety and perceived pain. Reorienting negative formulas in the positive ("rest assured") is just as simple and much more effective. Negative summons should also be avoided, unless they are used strategically to create aversion to unwanted behavior.

The strategic approach to physical examination
The anamnesis is followed by the actual "visit", that is, the physical examination. In recent years, this phase has gradually lost its meaning for the doctor. Once upon a time it was necessary to examine, auscultate, and carefully palpate the patient: now patients arrive equipped with CT scans, ultrasound scans, sophisticated blood and urine tests, and so on. The computer screen or the reading of the reports quickly provide the doctor with more numerous, accurate, and detailed information than the direct examination of the patient. Technology has thus replaced the "touch", sacrificing however important relational aspects: in fact, the patient, whatever his problem, wants to be looked at, touched, examined. The touch of the doctor symbolizes taking charge, gives intimacy to the relationship, already carries within it a healing component.

 The strategic approach to sharing information: summarize to redefine
At the end of the diagnostic investigation, the physician must share the information with the patient and prepare the treatment agreement, avoiding the temptation to move on to prescriptions immediately. The fundamental aspect of the agreement is often overlooked by the medical profession, which mistakenly believes that it is enough to give a patient an indication for him to follow it. This approach can work with very frightened or suffering people, fear and pain being great persuaders, but it is doomed to fail in most cases, especially when the sufferer considers the disease itself to be the most burdensome indication. The doctor must therefore be able to identify and manage the patient's resistance, which will be greater the greater or more urgent is the change required.

Attunement to the patient's perception allows both to manage his resistances and to identify and provide the information relevant to him (will I be able to drive?), As well as objective and technical data (the type of disease, the stage, the type of treatment). The quality and quantity of the information given have a significant impact not only on patient satisfaction and compliance, but also on the outcome of the medical intervention itself.

It will therefore be useful to summarize in a coherent plot what emerged from the interview, from the physical examination and from other possible exams, to create a communicative bridge with the next step, the prescription.

The strategic approach to prescribing: prescribing as a joint discovery
If the dialogue has been conducted well, the doctor and patient will now have reached, through a series of small agreements placed in sequence, the final agreement on the problem and its eventual solution. The prescription will therefore no longer be an imposition from the outside but the natural evolution of what has been said and agreed together. The doctor must therefore, using another strategic stratagem, "put his foot in the door and then make room with the whole body". The patient's resistance will be at a minimum. The alliance between doctor and patient is explicit. The doctor will have made the change not only desirable but inevitable.

Dr. Simona Milanese (Doctor-Official Psychotherapist of the Strategic Therapy Center)

BIBLIOGRAPHY
Milanese R., Milanese S., (2015), The touch, the remedy, the word, Ponte alle Grazie, Milan
Nardone G., Salvini A., (2004), The strategic dialogue, Ponte alle Grazie, Milan.
Nardone G., (2015), The noble art of persuasion, Ponte alle Grazie, Milan
Watzlawick P., Beavin JH, Jackson Don D. (1967), Pragmatics of Human Communication. A study of Interactional Patterns, Pathologies and Paradoxes, Norton, New York; (tr. it. Pragmatics of human communication. Study of interactive models, pathologies and paradoxes, Astrolabio, Rome, 1971).