I used to take praise for being a good listener to heart, but now I realize that there is much more refinement and improvement needed on my part in order to be the best physician I can be. Proper and effective communication is a goal close to my heart: this involves not only getting the right message across, but also making others heard. Some studies have indicated that physicians spend little time listening to patients tell their stories before launching into a focused series of questions . While I might be appreciated as a good listener in the setting of personal relationships, I suspect that I am not in the clinical setting. In the latter, I worry that I may fall prey to the same instinctual habits to which many trained physicians might be susceptible: listening only to what one wants to hear to make a convenient diagnosis, and focusing too much on conveying a message.
The second year preceptor program has exposed to me the deficits I need to correct while demonstrating to me the importance of detecting subtleties in speech and complexities in the physician-patient interaction. During our sessions in the clinic, I have been surprised by what I did not hear. On a few occasions, my fellow students have mentioned details of the patient’s history, whether subconsciously imagined or truthfully heard, that I did not pick up on. More importantly, there have been situations where what the patient did not say was most important. On one occasion, the patient was previously asked not to give away his diagnosis too readily, so though he was content to answer questions, he resisted divulging more information than was needed to answer each question in the simplest manner. Though this arrangement was artificial, it is not uncommon or outlandish: the openness of approach of each patient to his or her interviewers varies greatly. As we proceeded to ask questions, a case for a gastrointestinal infection seemed to present itself neatly to our medical student minds that lacked exposure to gastrointestinal pathology coursework. Half an hour before, our preceptor, a general internist and Infectious Diseases specialist, guided us through the process of taking a more detailed past medical history, family history, and social history. As I looked at my notebook, I noticed that none of us had asked our patient about his sexual history or any previous diagnoses of sexually-transmitted diseases. I thought to ask him on the basis of completeness, but I decided not to since the case, to me at the time, did not warrant what some might perceive as an invasion of privacy. Instead of concern for completeness, however, I should have considered, “What is the patient not saying that can change the framework of his case and thus his diagnosis?” After interviewing the patient, our preceptor revealed to us that the patient was HIV-positive, and that his symptoms were a result of HIV-associated nephropathy. While we had no previous knowledge of this complication of HIV infection, I was very humbled by the awareness of my lack of acute perception of the empty spaces in the patient’s case that held all of the answers.
Though less of a problem at this time, I am concerned that as a practicing physician I may focus too much on sending a message to my patients in lieu of truly listening to them. This, I believe, is an even greater problem than the first as this one is more insidious in development and may not be a habit corrected as quickly or easily. I am an individual who pursues missions and champions causes, and it has always been within my power to convince and inspire through reason as well as passion. However, when presented with great numbers of the afflicted or affected, it becomes easy to be impatient and formulaic in approach with the individual. When it becomes harder to remember the names of patients and their individual stories, my mind may develop archetypes and patterns to explain their behavior, discounting idiosyncrasies and personal feelings and motivations. In doing so, again, I would only be listening to what I want to hear to make my case. Knowing this, patients may tell me, and other physicians, only what we want to hear, keeping silent potentially important details that might hold the key to successful improvements in health.
Listening to another person requires the assigning and acknowledgement of value to the words and thoughts of the other person. As physicians, this task may be more difficult to achieve than we might initially suspect: our colleagues and mentors advise us to take the words of our patients with a grain of salt and to always second guess the reliability of information conveyed by our patients. However, physicians and patients must always remain equal partners in the pursuit of improved health, and the first step toward this aim in our medical culture is the empowerment of patients by bringing them into the discussion on level terms with the physician.
1. Langewitz et al. (2002) “Spontaneous talking time at start of conversation in outpatient clinic: cohort study.” BMJ 325(7366): 682-683.