It’s Not Just Chit-Chat

Paul Teie
January 30, 2020

I typically dislike euphemisms.  For an excellent primer on how euphemisms can subtly change the meaning and impact of language, look at the late, great George Carlin’s brilliant comedic essay on how “shell shock” eventually became “PTSD”. 

His point is that euphemistic language can sometimes soften and “tame” difficult concepts.  Perhaps we would do well to not hide the pain behind these mitigating terms.

I would like to do the opposite to a term that I think trivializes a very important concept – chit-chat.  Oh, boy do I dislike that term.  It just sounds frivolous. There is a fingernails-on-the-chalkboard quality to it that grates me.  Not to mention the fact that I find the act of chit-chat mind-numbingly tedious. I have known people who can spend literally (and I use that word literally) hours talking about absolutely nothing of any consequence.  

This kind of conversation serves an extremely important purpose. Perhaps it deserves a better moniker than “chit-chat” or any of its cousins: small-talk, chatter, pleasantries etc.  “Colloquy” may be too pretentious an option, so I guess we will have to come up with some new term.

The function of *** (we will decide on a worthy term shortly) occurs when we first meet our patient.  I think many downplay the importance of this critical moment. If all goes well, in these first minutes we are establishing a relationship that could well last for decades. During the course of this relationship we will necessarily be discussing intimate details of our patients’ lives.  The kinds of conversations we have with our patients, concerning relationships, communication, emotion, and more, among health professionals rival only those of psychiatry and psychology in depth and confidence.  

We have all heard the Will Rogers chestnut, “You never get a second chance to make a first impression.”  Its validity is in its chestnuttiness; there is an axiomatic truth at its center. 

Whether a first impression is accurate or not, fair or not, the result of having a bad day or not, we are seldom able to overcome that initial sense of a person.  Our first impression is out there and will soon calcify into the others’ permanent opinion of us.  

I had a doctor (notice the past tense), who in the opinion of nearly everyone else that knows him is walk-on-water great.  He rubbed me the wrong way from the beginning and now another representative of his specialty takes care of me.  

So back to ***.  It deserves a better appellation, more in keeping with its status.  Our patients want to be seen by someone they know and like. Hence, our first job should be to be knowable and likeable.  “Rapport” gets a bad rap in some quarters because it is sometimes seen as superficial and trivial. But we can’t get from total stranger to forging a deep connection in a single leap.  *** serves as a critical transition.  

There are some people are not able to easily negotiate this most basic of human interactions.  I was in that category. My dislike of shallow conversation used to get in my way of using *** at all.  After all, we were here for an important purpose and I thought it necessary to get right down to business.  I didn’t consider how jarring that could be to many of my patients.  I had to learn how to be personable. Working with kids helped a lot.  With them I was able to drop my pretensions, get down on the floor and take on a silly persona, all in order to answer a very serious question: Does this child have a hearing loss?

*** is important if only to put our patients at ease.  Many have no idea what to expect when they come to see us.  What we do and what we concern ourselves with are black boxes to many of our patients.  Our patients frequently avoid conversations with family and friends about their hearing because those conversations tend to become uncomfortable at best and contentious at worst.  They often fear that (and sometimes express out loud) “you are going to make me get hearing aids.”   They don’t think needles are involved but can’t be sure.  A few minutes of *** can do wonders at putting our patient at ease.

So how do we accomplish this important first step in our patient / provider relationship?  By paying attention!  


Since we don’t know them, we are required to initially notice superficial things.  All we have to go by is their appearance, who they are with, and their intake paperwork. (That is unless we have a particularly insightful and helpful patient care coordinator who can fill us in on other details.  The PCC has already established a relationship with our new patient and can be our go-between.). 

One advantage is that superficial things are usually (not always) devoid of serious negative emotional baggage:

  • That is a lovely (pin, scarf, coat, blouse, hat) you are wearing.  Where did you get it?
  • I see you are wearing a (professional sports team) hat.  Did you see the game last night? (Do you think they will make the playoffs?  How about that run the Jackson had in the last game? Etc.)
  • I understand you just came from lunch with your granddaughter.  How many grandchildren do you have? (Grandchildren are always a sure-fire positive topic, if we know our patient is blessed with them.)
  • Janice [the PCC] tells me you do yoga.  That’s wonderful! How long have you been doing that?  

Open-ended questions are as useful here as they are in the rest of the needs-assessment.  The common thread of these conversation-starters is the notion that “I am interested in you.  As my patient, you are the alpha and the omega. I want to know about you first as a person, and then we will proceed to our therapeutic relationship.”  The few minutes spent in *** at the beginning of our relationship will pay dividends many times over and in a variety of ways. 

So what shall we call *** that will give the concept its due value?  The thesaurus is my friend, so I came up with several options for word combinations that could do the trick.  We can just mix and match and see what works.

Foundational Dialogue
Opening Conversation
Initial Exchange
Introductory Talk

I am partial to “foundational conversation” because it speaks to the importance of this conversation as a “foundation” to the emerging relationship.  But whatever it is called (even should you want to stick with “chit-chat”) we need to recognize the importance of this under-appreciated step in our patient encounter. 

This could be the beginning of a beautiful friendship – or at least, a mutually beneficial and rewarding therapeutic relationship. All it takes is a little care in its initiation.

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