There’s absolutely no good reason why Sally should have been in the hospital. Not a day over 60, she had come to the emergency department for severe gastrointestinal pain and was then moved to a bed on the 10th floor of one of the hospital’s two towers.
I met Sally (not her real name) during my first year in medical school. Every Monday, my job was to take the medical history of one patient. Our class was short on patients that afternoon and my professor, an attending physician at the hospital, had left me to help another student find a patient to interview.
That meant I was alone as I walked into Sally’s room. I greeted her and sat down in the chair next to her bed. Monitors on either side of her bed beeped steadily as they kept track of heart rate, blood pressure, and the amount of oxygen in her bloodstream.
I gave her the one thing that first-year students can offer that few others in the hospital can: my undivided time and attention.
“What brought you to the hospital?” I asked.
Sally told me that she suffers from Crohn’s disease, a condition in which the body’s immune system continuously and relentlessly attacks the gastrointestinal tract from the inside out. She had landed in the emergency department because the disease had spontaneously flared up a few hours after dinner, sparking a high fever and intense abdominal pain. The emergency physicians stabilized her, but I could see that she was still distressed.
I asked her if she had any ideas why her Crohn’s might have flared up. Sally replied that she had stopped taking her new Crohn’s medications a couple weeks earlier, then added, “You are the first doctor to have asked me that question.” That caught me off guard. How could it be that I, a student with only four months of medical experience under my belt, was the first person to ask what seemed like a basic question?
I followed up with the next logical question, “Why did you stop taking your medication?” Sheepishly, she told me that it had been making her nauseous and dizzy, but she had been afraid to mention the side effects to her doctor.
Sally isn’t alone in not disclosing important information like that. Many patients hesitate to speak up to their doctors out of the fear that they might be viewed in a negative light and consequently receive worse care.
For those who do speak up, doctors often don’t have the time to listen. Seeing dozens of patients a day, and doing the companion paperwork, can make it difficult to spend a few extra minutes listening to patients. A report in the Annals of Internal Medicine put this in context: For every hour that physicians spend seeing patients, they spend two writing notes in electronic health records. Even when clinicians do get time with patients, many — and I’m guilty of this myself — often simply cycle through a checklist of questions, fearing that any deviation will lead the patient on a 20-minute tangent down memory lane.
This disconnect in communication between physicians and patients causes tens of millions of Americans to unnecessarily suffer each year and costs the US health care system as much as $300 billion a year. The missed diagnoses, emergency visits, and silent dissonance over treatment decisions that stem from this disconnect place a significant emotional and physical strain on patients and their physicians.
How do we help patients open up and give doctors more tools and time to listen? The first-year medical school curriculum might have an answer.
In my Patient Doctor I class, the first skill we were taught as doctors in training was to establish rapport — a mutual feeling of harmony, confidence, and trust — early in conversation with a patient. It could mean anything from mentioning the score of last night’s New England Patriots game to celebrating a mutual love of baklava.
Sally and I were both dog people.
Rapport fosters honesty and opens up patients to deeper conversations. Asking patients about what they hope to achieve from their care, their long-term health goals, and what’s most important to them helps align goals traditionally favored by health care professionals (healthy vital signs and lab test results, better control of illness, and good quality of life) with the goals that are on the minds of patients like Sally (will I have enough energy and be steady enough on my feet when I go home to take care of my puppy?)
Physicians who manage to spend extra time listening to patients with chronic conditions heavily influenced by human behavior, such as type 2 diabetes and smoking, find that promoting preventive habits that are in line with their patients’ own goals increases the likelihood that their patients will follow their treatment plans and improve their long-term health.
Another way clinicians can establish rapport is by sharing stories with their patients of others who have been in their shoes. This might be something along the lines of, “Many of my patients like you have been happy with this medication and course of treatment.” This gives patients space to confirm similarities and voice differences that can help guide their care. Sharing accounts of patients with similar illnesses can create a sense of community in what, for many people, can be an isolating experience. It also makes it evident that the doctor has taken the time to understand what makes his or her patients happy.
The bottleneck that often impedes such interactions is time. To give physicians more time to listen to their patients, health care organizations need to rethink the value of each hour of a physician’s workday. Giving doctors more time with patients and easing the burden of other tasks, such as recruiting medical scribes to document visits, automating discharge paperwork, off-loading lab orders, and streamlining care transitions, will move the needle toward better long-term patient care and away from the treadmill of efficiency.
As more health systems transition their focus of care from volume to value, it will be well worth it for them to give physicians extra time with patients to learn their goals, align outcomes, and prevent care complications down the road.
I believe that it will ultimately fall to a new generation of clinicians to reconcile the modern patient-provider relationship. Although this bond is fluid and constantly evolving, it should encourage physicians to do what idyllic first-year students are wont to do: lend an ear, give their time, and gather important information about their patients’ health and satisfaction.
Luckily for Sally, there are a variety of drug classes to help manage Crohn’s disease that may help her avoid nausea, unnecessary pain, and an emergency room visit. But if she doesn’t feel comfortable and at ease speaking up about her goals and her concerns, and her care team doesn’t make it abundantly apparent that it will be there to listen, we’re more likely to see — but not hear — her again next week.
Nisarg A. Patel is a third-year student at Harvard Medical School and Harvard School of Dental Medicine.