The Listening Path - Part 3
The third assignment in my listening experiment required my attention to others. Piece of cake, I thought. I’m a good listener, I thought. Can’t I skip this chapter? The first and most obvious setting to explore my listening skills is at work with my patients. Research shows that doctors are not great listeners. They interrupt their patients at an average time of eleven or twelve seconds. That’s not a very long time for the physician to gather the information needed to try and help the patient with a complaint. And no one, patient or otherwise, likes to be interrupted. It’s disrespectful and sends the message that what the patient has to say isn’t important or even necessary.
In medical training I learned how important the HPI is, the history of the present illness. It’s a story, in the patient’s own words, of how and why he or she ended up in the hospital that day, or why he or she is sitting there in my office chair. It’s the what-when-where-and-how components of the story. If I give the patient enough time, the pieces will all fall into place, guiding me to come up with a list of possible diagnoses that explain the patient’s complaint, which then guides me to order certain tests or imaging.
A good HPI can give the physician an accurate diagnosis 80-85% of the time. With the changes in today’s practice of medicine, however, with reliance on the electronic medical record, documentation and insurance requirements, as well as the financial need to see more patients per day, the art of taking a good HPI has declined. These pressures encourage a physician to interrupt her patient, especially if the patient isn’t a good storyteller, goes off on tangents, telling you her things that are not relevant to the current complaint. In these cases, it’s often just easier to interrupt and pepper patients with questions that efficiently gather the necessary clinical information in order to come up with a list of possible diagnoses and treatments.
I have opportunities every day to practice my listening skills with my patients as well as the incredible fortune of working in a healthcare environment that allows me the necessary time to spend with patients to hear their story in their own words. I am not limited to a 10-to-15-minute visit in a clinic, part of the reason I went into hospital or inpatient medicine rather than outpatient or clinic medicine.
The other day I saw a patient in his room who was resting in bed, taking a much-needed break in between his physical therapies. He was at the rehab hospital recovering from a stroke that caused him to have a paralyzed left arm and a weak left leg.
“Morning, John, how are you feeling today?” I asked.
“I’m really tired today for some reason, Doctor Brooke,” he replied.
“Oh? Why do you think you’re so tired?” I countered.
“Well, I didn’t really sleep well last night,” he admits.
“Tell me more John,” I prompted.
“Well, my roommate kept trying to get up, so his bed alarm would go off….”
I wait for him to go on.
“And I’m embarrassed to admit, but I had to urinate a lot last night and couldn’t hold it until the aide got here, so I had an accident in the bed. Then the aide had to clean me up…and I laid in the bed afterwards and just couldn’t get back to sleep.”
“What kept you from falling back asleep?” I asked.
“Well, I had to urinate several more times, and honestly, I’m just really worried that my arm and leg won’t get strong. I need to be able to go back to work to support my family. And. . . .” He stops and silent tears start to fall down his face.
I again wait as he cries, then starts to sob. I hand him a box of tissues and again wait until he’s ready to go on.
“I’m so sorry, Doctor Brooke. I don’t mean to fall apart on you, and I know you have other patients to see,” he comments as he tries to pull himself together.
“John, it’s okay to feel discouraged and sad about your impairments. Let it out. Tears are healthy and healing. You will get some recovery of your arm and leg function although I cannot tell how long it will take or if you will have 100% recovery. Would you like to talk to our psychologist about how you are feeling?” I gently ask.
“Yes, I guess that would be a good idea. I don’t want to be slobbering all over myself every day,” he responds with a wry smile.
“Ok, I’ll ask her to see you tomorrow. And would you like to try a sleeping medication tonight to get some better rest?” I ask.
“No, not yet. I’d like to try and sleep on my own as I don’t like to take medications,” he responds.
“Sounds good, John. I do want to check a urine sample today to make sure you don’t have a bladder infection which is causing you to have to urinate frequently. I’ll check in with you tomorrow, let you know the results of the urine sample, and see if you are able to sleep better tonight. Is there anything else you need from me today, John?”
“No Doctor Brooke, thank you,” he replies just as his occupational therapist steps into the room to take him to the gym.
It’s amazing to me, and somewhat sad that he felt he needed to apologize to me for taking up my time, and he’s not the only patient who has expressed that to me. It’s like my patients are not used to physicians really listening to them and see it as an anomaly.
My style of interviewing patients is similar to the style I use to write up the patient’s story in the medical record. I remember a teaching physician I had during my residency whom I worked with for a month on an outpatient pain rotation. He did not care for my style of note writing as I wrote out the HPI in the patient’s chart. After interviewing the patient and getting the necessary information regarding her pain complaint (which he later told me took up way too much time), I wrote up a paragraph, which he told me was not “readable.” (I remember thinking, ummm, it’s in English; it tells a story of her complaint, and I think the grammar is okay). He made me erase the paragraph and then use his bulleted template that filled in the blanks. I did it of course, as that’s what you do as a resident, whatever the attending or teaching physician wants you to do. But I decided then that I wasn’t going to use his templated style once I was on my own. It didn’t work for me.
This physician also advised me that I needed to choose one thing that would be the most important thing I did with every patient, all the time. I went home that day and really thought about his question. When I returned the next morning and we discussed what my one thing would be, he looked at me like I was bat-shit crazy. I told him that I was committing myself to ask every patient to tell me something about his/her social life that had nothing to do with the disease--such as, what did they do for work? How did they meet their spouse? What did they do for fun and recreation? What did they want to do in the future once they felt better?
He obviously thought this information was irrelevant to the HPI or the patient’s complaint. I wholeheartedly disagree. Listening to my patients, whether it’s by giving them adequate time to tell their story or by allowing them to tell me something about their actual lives, which often makes them smile or brings a tear to their eyes, is powerful medicine. Medicine that I am happy to give out, freely. Am I a good listener to my patients? Most of the time yes. And yet, I can always listen more, listen better, and listen deeply.