“We have two ears and one mouth so we can listen twice as much as we speak,” said Epictetus. It’s clear that the Greek philosopher wasn’t a physician in 21st century America. If you watch doctors — and many researchers do — they speak more than listen.
Studies have shown that doctors interrupt or redirect patients within the first half minute of talking. I’m just as guilty. I fear that if I don’t quickly home in on the top priorities, the patient will ramble on ad infinitum.
How long, I’ve sometimes wondered, would my patients actually talk if I didn’t say anything at all? According to a group of Swiss researchers, when doctors did not interrupt, the average duration of their patients’ monologues was 92 seconds. Not exactly the deluge of historic proportions that most physicians fear. But, well, you know the Swiss — reserved, diplomatic, precise. Maybe Swiss patients lack the American gene for self-referential gab.
The day after reading that study I tried it out in my clinic. For each patient I saw, I quietly clicked on a stopwatch after saying, “How can I help you today?” My first patient took 37 seconds, the second 32. But these were basically healthy individuals. The third had more issues: unresolved back pain, plus his glucose, cholesterol, and weight were all creeping up. He took two minutes.
But then came Josefina Garza. A teacher in her native Argentina, Ms. Garza (not her real name) was saddled with a vast array of insoluble pains compounded by anxiety, depression, and irritable bowel syndrome — plus a demanding mother to care for. Exactly the type of patient who can drown you with a list of complaints. I love her droll observations about New York City’s pretensions of culture, which of course could never measure up to the sophistication of Buenos Aires, but they steer us away from crafting her care.
If I let Ms. Garza talk uninterrupted, I feared that the visit would unfurl like a Borges labyrinth. We’d tumble down a dizzying path of her symptoms that would encompass every organ system of her body, plus a list of her mother’s medical woes and a stinging critique of the Metropolitan Opera’s soulless production of “Turandot.”
But I had promised myself I’d let every single patient talk that day. If I eliminated the “difficult” patients, then my data — however informal — would be flawed.
I girded myself for battle and asked, “How can I help you today?” as I reluctantly clicked on the stopwatch.
“Every single thing hurts,” she said, “from my toes to my head.” There were shooting pains in her gums. Her scalp was painfully sensitive. Neck pain was radiating down her spine. Her mother had insomnia and was up complaining at all hours of the night.
Each time she paused I said, “Anything else?” And there always was.
“I’m only 45,” she said, “but I feel like I’m 85. Every step hurts, and my head feels swollen to five times its size. It’s like I’m walking through molasses.”
I scribbled a few notes on paper as she talked but maintained eye contact with her the entire time. “Let’s get everything out on the table,” I said bracingly, “every last symptom and then we’ll … then we’ll, uh, we’ll figure out where to go from there.”
I let her keep talking until she had fully, truly, absolutely come to the end of all that she had to say. In the silence that followed, I clicked off the stopwatch. I estimated that eight to 10 minutes had transpired, but in fact it had been just four minutes and seven seconds. And the Met had come out unscathed. I suppressed the urge to say “Wow!”
Instead, I turned back to Ms. Garza and said, “Is this everything?” She nodded, and I showed her the list I’d jotted down. When viewed on the page, it actually didn’t seem so overwhelming. It was long, but finite.
Ms. Garza had already had the million dollar workup, which was all negative. I explained to her that something was going on. “Medicine is very poor at explaining pain syndromes,” I said, “but that doesn’t mean we can’t go ahead and start treating your symptoms.”
We went down the list together, trying to identify which pains might be helped with ice packs, which might be helped with local heat and massage, which might best be treated with physical therapy, and which might respond to pain medications. We talked about how antidepressants could be helpful and that seeing a therapist could decrease her stress. We discussed how she might get help in caring for her elderly mother. We covered the critical role of exercise in treating chronic pain. And then we wrote up a plan.
At the end of the visit, which didn’t run overtime by too much, she said something I’d read about but never heard a patient say: “Just talking about all this has actually made me feel better.” I wanted to jump up and sing an aria (which, luckily for all parties involved, I refrained from doing) but I was in the process of realizing something else: Just talking it all out had made me feel better, too.
Like any doctor honest enough to admit it, I dread patients with chronic pain. Every visit is taxing and protracted. The patient is often dissatisfied, and so is the doctor. Patients like Ms. Garza are accustomed to having walls erected in front of them. Their clinical issues can be so daunting that doctors react — consciously or unconsciously — by attempting to turn off the spigot as expeditiously as possible.
Perhaps the mere act of getting every last bit on the table made it seem less overwhelming to Ms. Garza. It certainly felt that way to me. Maybe my less-pressured tone of voice lowered her adrenaline level. Maybe ignoring the computer and maintaining eye contact for the entire conversation made a difference. Maybe it was the sense of unlimited time. Or maybe it was simply admitting that passion and culture in New York could never hold a candle to Buenos Aires and leaving it at that.
This was first time I’d ever felt good after a visit with a patient with chronic pain — I was actually doing something to help, rather than just rearranging deck chairs. It’s a reminder that doctors sometimes need to zip it up and let the patient talk uninterrupted. Although it may feel like time is being wasted, it could actually make everything much more efficient.
Once patients feel confident they have been heard, there are fewer surprises later. And when all the data are on the table from the outset, there’s a much better chance of getting the diagnosis right on the first go around. Most importantly, a few minutes of solid listening can form a crucial connection between doctor and patient — one of trust, respect, and confidence. The dividends of this connection can pay off for years.
“When people talk, listen completely,” Ernest Hemingway wrote. I can hardly imagine a better lesson in communication.
Danielle Ofri, MD, is a physician at Bellevue Hospital and an associate professor of medicine at the New York University School of Medicine. This essay was adapted from her new book, “What Patients Say, What Doctors Hear” (Beacon Press 2017).
I’ve taught listening skills to clinicians for 20 years, and published 4 books on the topic. I can tell you few of us have a clue about what we don’t know we don’t know when it comes to skillful listening. Listening is an acquired, learned skill, much like learning to play the cello. And like playing the cello, you need masterful instruction in ways that profoundly change, grow and strengthen the processing circuitry in the brain. And also like learning to play the cello, you need to practice, practice, practice.
I’m a disabled English teacher who wrote an article for Word Press called, “Dealing with a Bad COPD Exacerbation & Maybe Dodging a Trip to the E.R.” Fortunately, I shared it with my Facebook support group, Better Breathing Buddies. For starters, they warned against my frequent OTC choice: phenylephrine (Sudafed). The editor said to beware because such nasal decongestants impair expelling chest phlegm, such as beloved guaifenesin (Mucinex).
February 9, 2017
Re “The day I zipped my lips and let my patients talk” by Danielle Ofri printed Feb. 7.
As self-evident as it may sound, giving patients time to talk is important. And good physicians try to do it most of the time.
When they fail it is because many doctors see too many patients in order to survive financially. This because insurers underpay them greatly for their labors.
Too many patients means too many interruptions by phone calls and too many last-minute “fit-ins” of unscheduled patients.
And as many patients know from first-hand experience, when doctors are tapping away on their computer keyboards because insurers insist on electronic record- keeping, their mental stamina is focused less on listening, real listening and more on inputting to their computers.
This is one reason why physicians don’t listen as much as they should. Of course even before insurers forced doctors to be over-busy in order to make a living there still were doctors who just didn’t listen.
Why? Because listening, really listening is hard and wears one down. Not just for doctors. Think of a friend who just talks and talks and never gives you a chance to respond. It can wear you down. Imagine that happening all day long and trying to muster the composure to be concerned and compassionate!
Listening, real listening will always be important. It is the only way for doctors to really know their patients and gain their trust.
Francis W. Peabody MD, (1881-1927) a highly esteemed professor of medicine at Harvard medical school wrote an essay “The Care of the Patient” which is often quoted because of its focus on the importance of doctors connecting with their patients.
It has great relevance to this piece by Dr. Ofri and I have extracted a few of his words and include them here:
“…Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient…”
Some physicians by nature are good listeners. Others have to learn. Both types however cannot achieve what Dr. Peabody so rightly advocated for if they are forced to see too many patients.
What’s the solution? Limit the number of patients in one’s practice and accept the decrease in one’s income.
It’s that simple.
Edward Volpintesta MD (general practitioner)
I manage a group of women, (19,000, gaining 250-300 a week) with severe chronic pain from endometriosis and for whom most treatments are steeped in myth not science. When they do not work the patients are dismissed as neurotic. There is a bias when they come in the door of neurosis, and ineffective treatments when they do not work further the notion. The common thread when I get them into more skilled care, finally someone who listened to me.
Bravo, Doctor. I wish medical professionals would understand how frustrating and offensive and infuriating it is for us patients to be talked over and cut off when we are trying our best to communicate to the doctor/PA what we think is pertinent or important for them to know, or to try to ask a question and not be allowed to ask without getting chopped off in the middle. I’ve even spent a huge amount of time rehearsing in advance of an office visit the correct way to ask a question of one specialist without having him cut me off – I tried so hard, but I never did succeed in getting the question across, much less hear an answer. That doctor is no longer my doctor, and I basically turned to the Internet to answer my question. I’ve also noticed that sometimes when I ask a question, instead of getting a direct answer I get a sort of mini-lecture on anatomy and physiology that basically bypasses what I actually asked. Really listening would go a long way!! Also, not only would better listening improve patient/doctor interactions and possibly health outcomes, but maybe science-based medical practitioners wouldn’t find themselves losing patients to con artists selling things like reiki and fake cancer cures. That four extra minutes might be worth dragging up the extra internal fortitude to hear your patients out. Think about it. Who would you choose if you were the patient: the snake-oil salesman who treats you with courtesy or the mainstream doctor who says, “Yeah, yeah, honey” (actual words) and slams the door in your face in his hurry to leave the room?
Great article. Apparently the million dollar work up missed fibromyalgia, not surprising since its a purely clinical diagnosis. With several effective (non-opioid) medications available, this poor woman deserves appropriate treatment for her pain. I hope that’s how the story ends, either that or she was referred to a pain specialist.
There is nothing like a good patient interview, with out the distraction of technology. While you listen, you can watch their hands, eyes, facial expressions, body, all important in making a diagnosis. We need to train/re-train clinicians to listen to their patient without a cell phone, iPad, sitting in front of a computer, etc. Patients are also paying for the time with us.
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