‘‘Screw-ups’’ 115
Thus, doctor-patient communication emerged not as static, with each
party conveying statements to the other. Rather, decisions on what and
how to communicate were very much affected by perceptions of how each
party (a) thought the other party would respond, (b) wished the other party
would respond, and (c) thought the other party in turn wanted to respond.
Patients often responded to what they thought their doctors wanted to hear.
However, these patient perceptions may not be accurate. Patients may react
to their own misperceptions or misunderstandings of what they think their
doctors wish. Patients may fear physician replies that do not in fact occur.
Such assumptions can further hinder optimal communication and care.
Patients tried to affect their doctor’s reactions toward them, yet faced
conflicts. The establishment of trust is a mutual process. Yet a desire to
establish trust may compete with a mandate to disclose the whole truth.
At times, ill doctors faced tensions as to whether to: please versus dis-
close disappointing news (e.g., about nonadherence or symptoms).
These doctors were surprised to observe these processes in themselves;
previously they had been unaware of seeking positive feedback from pa-
tients. These physicians encountered conflicts, too, over whether to ex-
press versus conceal their displeasure or disappointment with their own
providers and patients.
Doctors’ and patients’ desires can clash. Patients may want to disclose
information and prolong or extend interactions, while physicians do not.
Patients’ desires to please doctors, doctors’ desires to be pleased, and phy-
sician arrogance also can combine, further impeding discourse.
Such dynamic processes have been explored in other contexts. The
French postmodern theorist Jacques Lacan argued that in psychoanaly-
sis, four entities are always involved: the patient, the doctor, the person the
patient thinks he/she is talking to, and the person the doctor thinks he/she
is speaking to (3). Who each party thinks he or she is talking to may differ
from whom he or she is in fact talking to. These multiple distinctions
complicate subsequent interactions. The narratives here suggest that mod-
els such as Lacan’s, highlighting the complex dynamics of provider-patient
communication, apply in medical encounters beyond psychoanalysis.
Patient Time versus Doctor Time
After becoming sick, these physicians became more aware of conflicts
between doctors and patients regarding time. Specifically, they became
more alert to differences in availability, experiences, preferences, and