This unusual book is written for patients but it immediately struck me as having two opposite, unstated purposes: to help physicians understand what can go wrong with patient relationships and to illustrate--and analyze--how that happens.

Barbara Korsch, MD, Professor Emeritus, ret., University of Southern California, is a physician with 50 years of experience. She has tape-recorded interactions between doctors and patients and then spent a long time thinking about what goes on between them. She opens with the questions, "Why do we complain about our doctors? Why do they complain about us?" Frequently, her method is to use direct quotes from both sides to illustrate how problems develop and can quickly escalate. She nicely illustrates with quotes how we physicians, when uncomfortable, "escape into technology." Moreover, she points out, "... When all is said and done, it is not the health care that people complain about in this country. We have perhaps the best technical expertise available. What people complain about is the lack of communication and the psychological issues." The purpose of this book is to help patients repair the problem. Are we as physicians so hopeless that this approach has to be taken?

We often hear physicians speak of patient noncompliance. Indeed, whole articles are written on this subject! Dr. Korsch demolishes the solace we find in this categorization by quoting her studies showing that the strongest predictor of compliance is the quality of the relationship between doctor and patient.

The chapter titled, "Why Don't I Follow My Doctor's Advice?" discusses the symbolic value of "getting something" from the doctor as a way of validating the patient's need to be there. This attempt at validation reminds us that self-help clinics do not acknowledge this common aspect of human behavior. It also helps us understand the expectations underlying the wish, often stated by patients, for "an antibiotic."

The chapter titled, "Where is the Truth" is an excellent discussion of why--and how much--information should be provided to patients and how the inevitable limits of our own understanding affect this process. The author's example (p. 98) of a physician's convoluted explanation of treatment options for a badly sprained ankle reminded me of our great difficulty in trying to provide patients with an understandable explanation of the pros and cons of PSA screening for prostate cancer. The author comments, "I emphasize that the kind of information patients are given will make a difference in their attitudes about illness, their treatment, and their overall health in general." This statement suddenly made me wonder whether Kaiser Permanente's current financial losses are our real problem or are simply an easily quantified marker for a more profound but obscure failure to communicate more adequately with our patients.

Dr. Korsch begins a memorable chapter on the origins of nonproductive doctor-patient interchanges: "If the emotional dilemmas encountered by medical students in training are disregarded or dealt with only incidentally or accidentally, the students will stumble in their desperation into the maladaptive roles seen all around us in graduate physicians...They will take refuge from human responsibility in obsessive attention to detail." Who among us can not relate to this, concealing it by silence or--worse yet--by naively redefining "obsessive" into a supposedly desirable character trait for physicians.

Physicians with young children will find interesting a chapter advising parents how to act on behalf of their children when they face pediatric office visits or hospitalization. Children certainly see things differently from adults. If adults are frightened and confused by doctors, what must the medical system be like for a child? "The children and young people visiting the pediatrician today are going to be the adults who will set the tone for health care and behavior in the next century."

That direct recordings of doctor-patient interchanges are useful for self-development is clearly illustrated by this book. Any of us can buy an inexpensive microcassette recorder and start analyzing what we say to patients. Are we responsive to their questions and needs? Are we as good as we want ourselves to be? How much would we pay a doctor for the kind of advice we give? One immigrant patient's piercing insight is shown by this exchange with a doctor: Q: "Do you think if you ask, we [doctors] don't like it?" A: "No. I think they like to talk but they don't want to have responsibility of what they're talking."

Many people are bright, but only some are helpful. This is a helpful book written by a clear-sighted, experienced physician about the most basic problem of our profession.

The Intelligent Patient's Guide to the Doctor-Patient Relationship: Learning How to Talk So Your Doctor Will Listen. Barbara M. Korsch MD and Caroline Harding. New York: Oxford University Press; 1997. ISBN 0-19-510264-9. 272 pages $25.

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