Listening
The Foundation of the Healing Relationship of Patient and Clinician
DOI:10.1093/acprof:oso/9780195369052.003.0005
Eric J. Cassell
Print publication date: 2012
Print ISBN-13: 9780195369052
Published to Oxford Scholarship Online: January 2013
DOI: 10.1093/acprof:oso/9780195369052.001.0001
"The Foundation of the Healing Relationship of Patient and Clinician: An illness is a tale of an individual unique life being lived in its quotidian detail, complex interpersonal activities—work, marriage, parenthood, aspirations and purposes—and how a pathophysiology interferes. The importance of the narrative is discussed. This chapter is about listening attentively—what that is, how it is done, and what it is used for. Listening is necessary to know about the illness, the patient, and the illness experience. Listening is most effective when healer and patient are connected through the relationship. A thorough discussion of the relationship is given. Also discussed are the effect of the healer and the relationship on the universal burdens of serious illness—fear, ignorance, uncertainty, and diversion of purpose; the barriers to attentive listening; solving the problem of the time attentive listening requires; the importance of the healer’s courage; and attentive listening as one aspect of a healer’s silent receptive mind.
Keywords: listening, listening, attentively, narrative, doctor-patient relationship, connection, courage, fear, ignorance, uncertainty, purpose, diversion of
CLINICAL MEDICINE IS based on knowledge about individual patients. In the past I would have just added “and the diseases that afflict them.” Now, in addition, clinicians are listening for impairments of function. It is not possible to listen for functional impairment, however, without hearing about function. The story of an illness is a tale of an individual unique life being lived in its quotidian detail, complex interpersonal activities—work, marriage, parenthood, aspirations, and purposes—and how a pathophysiology interferes. In the past clinicians avoided listening to this because it slowed them down and seemed irrelevant to their purposes and goals. Now we go out of our way to hear it (although selectively—time is still a concern) and become efficient in its pursuit. We try to hear what this patient’s underlying or essential purpose is and what well-being is for this patient. The definition of well-being is necessarily patient-centered and because of that healers are also patient-centered.
This is a chapter about listening attentively. Gathering information from the patient through listening will be the basis for knowing who the patient is, knowing what the matter is, and starting toward the solution to the patient’s problem.1 In the process, the clinician should be coming closer to the patient, ideally making the kind of unique very close connection that is possible in the doctor–patient relationship. As clinicians become better and more adept at this special relationship, how it can lead to a kind of knowledge of another person becomes clearer. This knowledge is the basis for the precision in clinical medicine that allows us to speak of our work as clinical science. We become extensions of our patients as we try to discover what is impairing their levels of functioning and interfering with the pursuit of their goals and purposes. We are also trying to discover the meanings on which their actions are based. The secret of discovering this kind of knowledge is attentive listening.
In the technologic medicine of our time clinicians too often act as if finding the disease and making the patient better are the direct result of specific diagnostic and therapeutic activities. In contemporary terms, it is as if the technology does the job. Patients subscribe to the same fallacy. My new patient at her second visit, boasting in the waiting room about what a good doctor I am, said, “He ordered the colonoscopy which is how the diagnosis of Crohn’s disease was made.” I was peeved because I knew she had inflammatory bowel disease within a few minutes of listening to the history of her illness. This patient’s vignette tells less than half the tale. The forgotten part is what makes the whole process work, but it is too often taken for granted or done poorly.
Think about what happened. This woman, an advertising executive, modest and distrustful, is a stranger (although the friend of a patient) who walked into the consulting room worried and in distress because of abdominal pain and loose bloody bowels that she had concealed for two weeks. There is more to it. During this symptomatic period she was frightened at what she thought meant cancer and she slept poorly. She ate little. She did not work well, experienced trouble concentrating, and lost her sense of confidence and power. Worry about abdominal cramps and impending bowel movements became her constant companion. She was irritable at home and afraid to tell her husband why. She avoided sexual activity, and did not want to be as social as she usually was and as her husband expected. He felt pushed aside and wondered what he had done.
Within 20 minutes of the start of the visit, chattering about a mutual friend, she went into an examining room and completely disrobed. Before another 20 minutes had passed, she had been fully examined, including having first a speculum and then two fingers inserted into her vagina and one finger in her rectum. She left the consulting room a short time later feeling much better with a tentative diagnosis, prognosis, and plans for a colonoscopy—another unwanted invasive act. She was ready to carry out the plan we had arrived at together.
The script for her visit and what ensued is primarily cultural tradition. It is a powerful custom. A patient goes to the doctor, relates the story about her illness, and tells the doctor the truth and the whole story (which she had previously hidden). Despite her modesty and distaste for the process, she undresses and permits an examination of her naked body including penetration of her vagina and rectum. The doctor, the recipient of her story and her temporary suspension of modesty, focuses his attention on her “medical” case and does not stray into unrelated “personal” matters. In the examining room he makes no comments and takes no physical actions that are not clearly related to the medical problem. Both the physician and the patient seem to understand the boundaries that circumscribed (p.97) their conversation and their actions. Even the subjects of the physician’s questions fit a traditional mold going back centuries.
Changing the definition of illness requires a different kind of history because it involves aspects of the patient’s life and functions not usually part of a medical interview. Patients will, after perhaps an initial period of puzzlement, accept interest in function and well-being when it is explained. The traditional roles and permissible actions will, however, remain the same. The basic, generally invisible, skill that makes it all work now and for millennia past is listening—attentive listening. In this chapter I am going to describe in detail what it is that clinicians do when they are listening attentively. The discussion is in the service of becoming a more skillful and effective listener and a better healer. When I was a medical student I did not attend my second year lectures. Periodically I worried that the lecture that I missed would give away “the secret of all of medicine.” Of course that was silly; the lectures, according to my friends and their notes, gave away no secrets. There seemed to be, in fact, no “secret of all of medicine.” That is not true, there is a secret. The secret is listen! Of course, it is not really a secret, it is a quiet, in the background, skill too often taken for granted. Listen to what? Listen to the person, listen to what your patient says and how; listen to what the patient does not say (and how). Listen to the family. Listen to other physicians, to the nurses, social workers, the nurse’s aides, and everyone else who has contact with the patient. Last, but by no means least, listen to the body. Actually, there is one more person to whom you must attend—listen to yourself, your words and your thoughts.
Listening is an active—not passive—skill. Hearing is a perceptual process using the ears for the reception of sound. Listening is a cognitive skill that at the minimum requires attention to the words (or sounds) and is usually immediately and automatically followed by the assignment of meaning to what has been heard. Just as seeing is a cognitive act in which we see a particular something rather than another thing, we listen to sounds and hear a particular thing and not another thing. When listening to speech, identification of the words in an utterance is almost instantly followed by assignment of meaning to the utterance.2 Sometimes you do not quite hear what the other person said, but, as if hearing was delayed, a few moments later you know the words and understand the utterance. In the brief hiatus of incomprehension your mind has been decoding the sounds and coming up with an interpretation of the utterance that seems to work. That phenomenon, known to us all, is clear evidence of the active cognitive nature of listening.
(p.98) The primary tool of attentive listening is not the ear, it is the clinician. Although listening, at bottom, involves learning about the person of the patient and the illness, it is also about the development of the person of the physician. Clinicians who listen carefully to their patients year after year learn an incalculable amount about people, about what and how they do things, about illness and being sick, about how people deal with sickness, doctors, tests, surgery, hospitals, and their staff, about medications, about how the body works when well and when ill, and about how the world works (at least the social world). Listening to all this enables them to grow as individuals. Listening—attentive listening—is a learned skill at which some will be better than others because of differences in aptitude and the time it takes to become skilled. Differences in native ability are overcome by knowing the importance of listening, knowing what you are listening for, and working at it and practicing. Like all the skills of physicianhood, it is a satisfying pleasure when you know you are doing things well and getting better at them. It may seem strange that it requires effort to become good at listening, because all of us are listening all the time or we could not live our lives. Why, then, do we have to actively learn attentive listening? Listening, in this regard, is similar to learning to communicate in that it takes more than merely knowing the language and using it in speech. The reason, in both attentive listening and communicating, is that we are doing medicine. The requirements of the patient—the person—the doctor, and their relationship, and then the diagnostic, therapeutic, and interpersonal activities require special attention and attentive listening (and communicating) and that moves the endeavor forward.
When setting about listening, clinicians will want to be sure that they are listening to the authentic patient. What does that mean? If you have ever role-played and really gotten into the role you know that you began to act like that person—you will have feelings and responses appropriate to the role. If this were not true, teaching with simulated patients would not work. Actors are especially good at this—they do not just act like the character they are playing, they try to become that person. It is also not surprising that being in a scary situation, in the presence of a dominating person, or feeling uncertain, needy, or diminished might have an impact on how a person behaves or the persona projected. It is certainly true of clinicians. A doctor who does not feel doctory, or who is unsure, feels inadequate, or has no sense of medical authority, is going to have trouble speaking to a patient or taking a history. You only have to remind yourself of your early days in your first clinical clerkship to know how true that is. What this tells us is that the context, the circumstances in which a conversation takes place, has an effect on how the conversation will unfold, from how well the participants listen and talk, or even the words and ideas a speaker projects. We want our patients to be as much their authentic selves as possible as we listen to them because part of our task is to (p.99) know them as they truly are. In bringing that about we modify our behavior and act in such a manner as to encourage the patients to be themselves. I watched a friend of mind, a surgeon who was a tall, imposing man, taking a history from a small woman. As he spoke to her he unobtrusively slid down in his chair until his eyes and hers were at the same level. Somewhat further on I am going to discuss in more detail how we encourage patients to feel comfortably themselves.
Patients have an expectation that they will be relieved of their illness because of the doctor. They feel that expectation on their way to see a doctor and the expectation conditions their responsiveness to the physician’s words and actions. It is important to understand that the openness to being made better pervades the patient—body, mind, and spirit. It is not “just psychological.” Placebos can have a positive effect even when the patient knows beyond doubt that they are placebos if the doctor is strongly supportive of the effect.3 For that expectation (which may not be conscious) to be fulfilled to the degree possible requires the development of a relationship between the two. It also requires physicians to be aware of its benefits and not throw them away by disregarding them. The doctor–patient relationship—the healer–patient relationship—is one of the special social constructions in our culture (and probably all cultures) with important consequences for the effectiveness of clinicians and the outcome for patients. In addition to its benefits, the relationship also imposes responsibilities and restrictions on the behavior of physicians. Unfortunately, the doctor–patient relationship has become iconic and of mythic proportions so that its realities are difficult to discuss. The relationship has also been attacked, vilified, made fun of, minimized, and interpreted as merely an unequal power relationship. What does it matter if on occasion negative things have been true—as reprehensible as that may be—it is not just any relationship, but one between doctor and patient. The relationship is present when there is a patient, a doctor, and an illness, and it exists whether you “believe in it” or not. Patients need doctors to be relieved of the burdens of sickness and doctors need patients to be doctors. Patienthood changes persons, depending in degree and form on the severity and length of illness, the personality, character, and demographics of the person of the patient, the context of the illness, and the interaction with a physician. The role of the physician and the fact of being a physician have an impact on both patient and physician and are also dependent on the circumstances, experience, specialty, personality, character, and attitude of the physician. Like it or not, in caring for the sick person, the doctor is not simply somebody with special knowledge and the patient is not merely (p.100)someone with a bodily affliction. Just as a sickness, whatever it may be is not only an affliction of body parts. The social construction of medicine and the actors and their roles are real and influential. The clinician has the choice of learning how to maximize the relationship with the patient and its impact on the clinical situation or not. Why would anyone choose ignorance?
Much of what has been written about the doctor–patient relationship was written in the light of acute illness and solo practitioners and did not make distinctions about the patients’ illnesses or the various specialties of physicians. Acute severe illness or life-threatening injury can create an effective relationship between clinician and patient in less than minutes. In a few instants a person with devastating sickness or injury is converted into someone trusting and willing to follow even the most stringent directives of a stranger who is the clinician. Often forgotten is that in the same few moments the clinician has become intensely personally concerned, fearful, and linked to the fate of the stranger who is the patient. In such circumstances what does the nature of the clinician’s employment matter? In the contemporary world, however, chronic illness is the rule, commonly requiring the care of one (or even several) clinician year after year. The exigencies of insurance plans, forms of doctors’ practice organizations, and even the possible need for very special doctors, surgeons, or hospitals that may be in distant cities mean that a relationship with only a single clinician is the unusual circumstance.4Furthermore, contemporary patients with chronic diseases may have learned a great amount about their afflictions—thus earning the authority of knowledge. All this might make us wonder whether the doctor–patient relationship still has any meaning or usefulness. Perhaps even more so as doctor and patient have come to know and respect each other over (possibly many) years.5 Even in these circumstances, however, because of their skill some clinicians will have much more access to patients and their bodies than will others. These clinicians can make their patients better (by whatever definition) while others fail. What makes the difference?
(p.101) To understand this we have to look again at illness. Although we will be discussing this in detail in later chapters, it necessary to keep in mind some of the general effects of sickness before going further into what attentive listening entails. Fear, ignorance, uncertainty, and changes in purpose are always present in important sickness. Actually, ignorance, uncertainty, and interference with purpose occur in everyday life. What will the weather be this evening? Am I doing a good job? Does my boss (teacher, friend, relative, or anyone else) like me? Can I adapt to the circumstances of a shipboard cruise? Will I miss my flight? Is the plumber competent? Will I sleep well tonight; be able to eat dinner; do I smell bad; do I look good; did I accurately remember yesterday’s events? The list of uncertainties is close to endless, but the form of the social structure and the rules of everyday life will generally provide acceptable answers to these uncertainties. That is, it will if you behave according to the rules—which, although unwritten, you have spent your life learning, mostly outside of awareness. Ignorance? No matter how much education, how much exposure to similar experiences, how much time on the job, or anything else you mention, there will be things you do not know. Who cares? Whatever you want or need to know you will probably learn about it soon enough or it (whatever it is) does not really matter. We commonly say Google it. You may notice, when you do use a computer and its search method to look something up on the internet, on the top of the page it will have some variation of the following: “1–10 of about 126,000 for typhoid fever with Safesearch on. (0.08 seconds).” You would not dream of looking at all 126,000, possibly relevant, entries. You probably found out enough on the first page or so to relieve your ignorance sufficiently. As for the really important things in life—what is in store for you in the future, what will happen to your children, your finances, and so forth, the questions may worry or even disturb you, but you know what you can know and fortunately are usually able to move on with your thoughts or actions.
How different serious illness is. The ordinary comprehension of daily life is inadequate when illness poses threats. Questions about the future and what is going to happen are vital and cannot be laid aside without help. Will the pain stop? Do you really have the best doctor? What can you do about it if you do not? Is the doctor trustworthy? Is the doctor being completely truthful? Will you live through this? Will you work again? How much impairment can you expect? What side effects can you anticipate? You read so much about medical errors, are they happening now to you? And this goes on and on, one question after another. In the contemporary world in which people often act as if they know everything, patients soon learn that they know nothing—or at least not enough to answer all the questions that arise. The internet is of little help (except to cause more fear) because “126,000 entries” basically means conflicting answers—or answers (p.102) that raise more questions. For example, a young woman with rheumatoid arthritis finds that her anti-tumor necrosis factor (TNF) medication is not working anymore. In the beginning it was effective but that has gradually diminished. Other drugs are available and her rheumatologist has offered two alternatives, which she looked up on the internet. “At this point,” she says, “I have decided, through discussions with my dad and my rheumatologist, that I will try the Simponi first. It is a once monthly injection, as opposed to the Actemra, which is an infusion, like my Orencia.” The rheumatologist offered her alternatives but did not discuss the technical issues that bear on the question, but in the contemporary manner left her to make the decision herself because she is an autonomous person. (This is a common, but I believe, mistaken, understanding of the concept of autonomy. See Chapter 13 for a full discussion of the ethical issues.) She is being asked to make a complex technical decision that is in the province of the rheumatologist. She was not, however, questioned about her personal values that bear on the decision and about which no one knows better than she. Together, she and the rheumatologist would make an appropriate decision-making unit. By herself and with her father, an optometrist, she is exposed to unnecessary uncertainties.
The previous case highlights the fact that sick people commonly do not understand what is happening to them. The questions are endless. “Will the bleeding stop and what will happen if it does not?” “Why is the pain getting worse when I was told that things are getting better?” “I saw my wound when the doctors were changing the dressing today and it looks awful—purple and swollen—is that the way it should be?” “I know from the newspapers that minutes count when you are having a heart attack and you are supposed to have a balloon thing, but nobody seems to be doing anything.” “The doctors said that there was nothing more they could do for me, so what is going to happen now?” “They said that I am still having trouble after my heart operation because of pericarditis, but I don’t know what that is, what it means, and what I am supposed to do about it?” What are the consequences of not understanding what is happening to you in serious illness or of not knowing the best thing to do? They cannot be good. In addition to uncertainty, sickness alters purpose. All of us go about our days filled with purposes large and small. As our definition of sickness makes clear, however, the impairments of function in sickness make the accomplishment of purpose difficult. Moreover, the central purpose of all of us is aimed at the being of ourselves. In sickness, purpose is diverted from that usual goal and directed to the relief of distress. Who is to help with ignorance, uncertainty, and diversions of purpose—and the many other questions and necessary actions that come with being sick? The doctor will help, if the illness is serious enough.
We do not usually think of ourselves as going to physicians to resolve such issues; we seek the aid of physicians to treat our disease, as people have done (p.103) in Western cultures for more than two and a half millennium. It is only since 1925 (insulin) and 1937 (sulfa drugs) that physicians have been able to treat diseases decisively.6 From the beginnings of medicine in ours and all other cultures medicine has had specific treatments for diseases, however defined, which people (including doctors) believed were effective. From our contemporary vantage point we know that those old treatments were almost always worthless—or worse.7 As Oliver Wendell Holmes, Sr. said in 1883: “If the whole materia medica, as used, could be sunk to the bottom of the sea, it would be all the better for mankind and all the worst for the fishes.”
Contemporary medicine is marked by the effectiveness of its treatments and the endless wonder of diagnostic and therapeutic technology. One medical specialty after another—cardiology, gastroenterology, nephrology, oncology, and pulmonology—is preoccupied with its technologies, instrumentalities, and its treatments, which are effective to a greater degree than ever. The current materia medica (and, more practically, the Physicians’ Desk Reference) is filled with effective medications that would still be “worst for the fishes” but are very useful for humans. As noted many times in this book, this armamentarium and the physicians who direct it are focused primarily on diseases or their symptoms. The goal is the cure of disease. Chronic diseases, the problems of the disabled, and the infirmities and functional losses of aging are not amenable to cure. And everybody dies.
Were all doctors, in times past, worthless and did patients get no help from their physicians? Was every benefit merely “psychological” or a placebo response? Are the fear, ignorance, uncertainty, and obstruction of purpose that characterize sickness “only psychological”? If I could create in you a state dominated by fear, ignorance, uncertainty, and an inability to pursue your purposes, would not your being as you know yourself be profoundly altered? I believe that the impact of that state on your being would reach every aspect of you—physical, psychological, personal, social, and spiritual. “We are of a piece, what affects one part affects the whole and what affects the whole has an impact on every part.” A vital aspect of healing is the effect of the healer on those characteristics of sickness. With this in mind, we can better understand the utility of the doctor–patient relationship that allows a sick person to reach out to a doctor, who may be a stranger, with the (p.104)expectation of relief. To the patient the doctor is knowledgeable, knows what to do, and is larger than the problem. The doctor is without fear in the face of the sickness, no matter how terrible, and is unafraid to act despite uncertainties.8 That is, with reason, the cultural expectation of doctors. The error that gets in the way of understanding is to equate sicknesses with the diseases that are believed to be their cause. Late in my fourth year of medical school, I had what appeared to be a respiratory illness, although I was sicker than I expected to be. Still, like most of us, I paid little attention to it. I lived in a hospital then and I was talking with a friend in my room. Thirsty, I took a drink of Coke and it came right back out of my nose—soft palate paralysis. That really scared me and I started to look things up in my neurology textbook. One thing was worse than the next and they all seemed to be fatal. Panicky, I called my doctor who was attending at the hospital. He came, examined me, found my soft palate paralyzed as expected, and then discussed the problem, minimizing nothing. He thought we should go to Bellevue (where I was a student) because they had a respirator. (This was 1954, when a respirator was a Drinker respirator—the iron lung.) Despite the discussion I calmed down and the fear went away. The head of student health was alerted, and when we got to Bellevue and I saw how frightened he was, my fear returned. Again my physician calmed me down by talking about the problem, its seriousness, and what would be done.9
Relieving these universal burdens of sickness is, unquestionably, valuable in itself because it allows each patient again to be the person she knows herself to be. Then the person is able to do the things that she thinks are important to being herself. Of course serious illness modifies goals—so do aging, education, frustrations, and other exigencies of life. Persons sick or well know this, even if it sometimes takes them time to come to terms with these facts. (The following chapters will deal specifically with these tasks.)
If the generic doctor of the doctor–patient relationship can relieve some of the impact of sickness, it makes sense that a clinician who knows the patient can be more effective. This is because the general characteristics of sickness that (p.105) I discussed may be different and show themselves in different degrees in different patients. We are not all ignorant to the same degree and about the same things; some tolerate uncertainty better than others; fear and its impact are variable, and our investment in our purposes differs. There is no better way to discover this about patients than to listen attentively to what they say and question them carefully. As the goal of healing has enlarged, more knowledge about the person of the patient is required. What it means to say that it “Allows each patient again to be the person he knows himself to be” requires questioning and listening—not just listening, but attentive listening. This, in company with observation, allows the construction of a narrative—inside and unspoken—so that the narrative’s shortcomings urge further exploration. All of this is efficient and is done in limited time. In discussing the young woman with rheumatoid arthritis I suggested that she and her rheumatologist “together would make an appropriate decision-making unit.” That would have been better than just turning the decision over to her, but I meant to imply something more than the two of them making the decision in consultation with each other. I wanted the rheumatologist—with his clinical skills—to create a close connection with her. As a consequence, her values, needs, and concerns as the person she is (with a chronic painful disease and as a psychology doctoral candidate) would become merged with his technical knowledge and knowledge of persons and issue forth as her autonomous decision, while he remained firmly within the boundaries of being her rheumatologist. Do I know how to go about all these techniques and goals? Yes, generally, but I, we, still have much to learn. Let’s go on.
Each person in ordinary society is generally considered as a separate individual in his or her own space. Atomistic is the word for that idea. Members in a family are not thought of as atomistic; they are connected with one another; close connections between family members are common and commonly accepted. Connected individuals behave as though they share, to a variable degree, thoughts and feelings and frequently express this idea. It is not unusual for one family member to report awareness of or participation in the feelings of another. Sometimes each seems to know what the other is thinking. The same very close or intimate connectedness is common in very loving relationships, especially where sexual connections are present.
Sick persons need other people to help them, particularly their physicians. Their need may be so great—particularly in serious illness or injury—that they are willing to lower their boundaries (although outside of awareness)—to connect closely to others and to allow others to merge with them. The degree of connection between sick persons and clinicians is variable and is dependent on the needs of the patient and the characteristics of the clinician involved. This kind of interpersonal connection increases the ability of physicians to influence their patients’ (p.106) thinking, ideas, meanings, and also their bodies. Such connections facilitate care as the caregiver is also more cognizant of the needs of the sick person. Effective clinicians may or may not be more consciously aware of the need to make a connection to patients than others, but they have in common certain effective behaviors. The scientific community in Western cultures does not regard telepathy as a real phenomenon, so these common happenings between the sick and their caregivers are simply there to be learned and utilized by experienced clinicians. This closeness, however, requires very careful respect for boundaries. (There is a more complete discussion of this in Chapter 2, “The Person.”)
David Schenk and Larry R. Churchill, in their excellent book Healers: Extraordinary Clinicians at Work, questioned 50 clinicians considered by their colleagues to be the best healers, to see how they worked with patients. They discovered that these effective practitioners mostly all did the same things. First, they introduced themselves by name in a personal manner, shook hands, smiled, sat down, and made eye contact. They took time and were patient—they did not act rushed or impatient. They were quiet—creating a quiet conversational space for the patients’ utterances. They acted obviously and genuinely interested. They allowed the patients to be as authentically themselves as possible. After an initial and inviting word or two (I usually say “How can I help you?”) they made themselves open and they listened without interrupting. What does it mean to be open?
Schenk and Churchill do not discuss this kind of openness in their book, but this is how it has worked for me. What does it mean to “be open?” What I am about to describe can be taught in lectures and in person; let me try in print. To learn to do it, sit opposite someone else (start with a spouse or a close friend) who will be doing the same thing. Both palms facing inward, fingers curled, and the backs of the fingers of both hands touching, place the tips of your curled fingers on your mid-sternum. And then, as though you are opening a pair of doors to your heart, pull your curled door-opening fingers in a small arc about 8 inches away from your chest and say—to yourself—“open.” Then with the “door open,” make yourself as fully receptive to the other person as possible.10 You will probably feel a sort of light pleasant feeling in front of your chest. The other person, doing the same thing, will also feel that light pleasant sensation. You are now “open” and receptive to the other person. If this were a personal maneuver between you and someone emotionally close, it might be felt as a mildly loving feeling. It is not like (p.107) that with a stranger or a patient. To some doing this it will feel threatening—as though vulnerable or unguarded. In this state of “openness” you are more fully aware of the other person and the other person’s feelings. If it is at all threatening, swing your curled finger tips back to the sternum and say—to yourself—“close.” The feeling will disappear. Then repeat the maneuver of “open,” and then “close.” It cannot really threaten you if it is that simple to “close the door.” Practice this until you have the confidence that you can really do it, and that that feeling of openness is within your conscious capacity. When you are sitting opposite a patient, particularly in the opening interview, make yourself open (unobtrusively). The patient will experience you as “really listening,” trustworthy, and caring. Patients used to say to me after only a few minutes of that “openness” before I could possibly have actually manifested it in any other way, “You’re the first person who has really listened to me.” Ultimately, that is the way you should always be when you are with patients. If you find a particular patient threatening, simply close the “door.” (And think about what it is that is threatening.)
We all know that when you are with patients the telephone can be an obtrusive presence. Sometimes it is not possible to stop calls. Here is how I solved this common problem. I had read that Henry Kaiser, whose company built Liberty ships during World War II, taught himself when interrupted to come back to exactly the same point in the conversation as before the interruption. I thought that I could also learn to do that. When the telephone rang, I would memorize the few words I (or the patient) said just before the call, and return to exactly those words and continue the conversation. It took awhile to learn. Now, many, many years later I still habitually do the same thing. Sometimes, I repeat to the patient his or her exact words prior to interruption, and wait for them to continue.
There are almost always barriers to attentive listening and things that intimidate the patients and keep them from feeling like themselves or speaking freely. Learn what they are and get rid of them. That is not so easy to do, especially when you are less experienced or working in a group work space. When starting out we rarely have the confidence that goes with our authority. We are often—in the beginning—happy to have the desk between us and the patient so we do not feel so exposed (or ignorant). As soon as you can, get rid of whatever is getting in the way of your experiencing the patients. Sometimes it is something the patient says that seems to require comment. Must you say anything? Most often you can let it pass. Sometimes it is the feelings—anger, sadness, suffering—that may be swirling around the patient and the dangers they may seem to pose to you. What are the dangers? Anger can seem very threatening, but the patient cannot really be angry at you, there has not been time. Sometimes, in the face of obvious anger, you may ask quietly, “Why (do you seem) so angry…” You will almost certainly learn something about the patient that is important. Then there is the depth of (p.108) the sickness itself and its awfulness in which you will soon be caught up. Be courageous even in the face of impending death, agonizing pain, terrible malignancies, dangerous infection, awful dyspnea, and overwhelming jaundice and ascites.
You learn courage by facing these things and discovering how well you did. Courage is catching—so, in the other direction, is fear. Family dynamics can be very challenging. Patients or others commonly want to draw you into difficulties that may have been going on since childhood. Fights, unknown unhappinesses, unmet needs that seem to be hanging off the patient, and others—the last thing you want to do is to take a part. Still, you should become aware of these things, especially in serious illness. Looming over everything else may be the awful thoughts of your own ignorance. When you start out you may be trying to be the super chief resident, as though that is the goal of patient care. Chief residents know a lot of medical science and about diseases and their management; this is necessary knowledge—given a disease problem. Of the things in this chapter, they are as ignorant as everyone else. Worse, because they may think they know more than they do. We all, to a person, hate to appear dumb. Ignorance is not good, but ignorance of ignorance is reprehensible.
Patients today often come to us thinking they really know a lot about medicine and doctors in general, the failures and faults of medicine, their own symptoms, and treatments in particular. They may react to their physician, especially a doctor new to them and young, as though they know just as much (and maybe more). Physicians find this very irritating—who would not? Physicians want to tell their patients that if it was so easy to know so much, why were they in training so long. Under these circumstances it is even more difficult than it has been since Hippocrates to sit and listen—really attentively listen—as you let the patient explain the illness and tell you all about everything. The doctor should be asking only occasional short clarifying questions that get at the meat of things and yet not let the interview go on and on. My favorite questions are as follows: “Oh…” “And then…” “So…” “And…” (All with an upward ending inflection—this is a request for an answer.) “Why do you think that was?” “That must have been upsetting…(Or painful…or distressing…or awful…)” “Wow…” Very specific questions, although, of course, sometimes necessary and productive, cause the patient to answer within the framework and words of the question, which may miss the important facts. Questions asking for a yes or no should be used sparingly—only when checking something—“Did you say it was swollen?” Especially with a crucial issue, you do not want to be in a situation in which the patient says no and you think the answer is yes. What are you going to do, call the patient a liar? My favorite follow-up questions—maybe just my favorite question is “What does that mean?” Remember, the patients know what the matter is and what you need to learn; they just do not know that they know. Your questions develop (p.109) their knowledge. Clinicians who can patiently listen, listen to the fears and the outrages, listen to hopes and expectations, are unusual and patients know this, especially if the clinician is open. Patients also know that clinicians who are not defensive, who can allow patients to “look good,” who do not have to display how much they know, probably are, paradoxically, really knowledgeable.
If you are working in a group space, there may be a lot of people going back and forth, sometimes actively interrupting and sometimes just noisy. There may be no actual office but only a desk, chairs, and an examining table. Focusing intently on the patient in the personal manner described and making yourself open to the patient create a circle of privacy enclosing the two of you that is surprising impermeable. This is also true for interactions that take place in Emergency Departments, hospital rooms with more than one bed, and other public places. Move in closer in these circumstances so that you hear what is said and so the patient knows beyond question who your primary interest is. When necessary, include the family or others also present. Some clinicians widen their circle of intimacy to include these variably important others. I do not. The patient and I are going to be working together over some time period—I want us to be and see ourselves as welded together for the coming struggle with sickness.
It has become common for clinicians to present themselves as part of the team and to introduce everyone to the patient and indicate that it is “the team” that will be caring for the patient. Realizing that the days of the lone clinician fighting off disease are over has been part of a big step forward. We know now that the nurse, nurse practitioner, social worker, and others together are necessary for good patient care. I do not believe, however, that a team takes care of a patient. I believe individuals with various skills each working with the same patient and coordinating their efforts provide the best care. The relationship with the patient, however, is an individual matter. There should be one person with whom that patient has the primary relationship. Where possible, that person should be the physician. Having said that, sometimes it is the nurse, the social worker, the physical therapist, or sometimes another to whom the patient will look as his or her primary caregiver. Each has to learn to listen, not only to the patient, but to each other—as attentively as to the patient.
Physicians are sure that attentive listening takes up a lot of time and they are very aware that the clock is always ticking. They do not have the time, they think, to really listen attentively. The evidence is that attentive listening is the most time efficient way. I have seen it written many times that in most patient interviews the doctor interrupts after 20 seconds or so. That is very inefficient, especially if you want to find out from the patient what the problem is. It takes longer than 20 seconds for people to tell their story. Mostly physicians ask a set of directed questions requesting specific information. Those questions usually have the possible (p.110)answers already specified. Give the poor souls a chance, and they will tell you what is important. If you cut them off, they will keep trying to tell you and more time will be wasted. Doctors sometimes wonder why patients do not disclose the real reason for the visit until they are on their way out the door. It is because they were not given a chance to talk earlier or to tell it their way. So as they are about to leave the visit their question is still unanswered. It may be difficult to realize that patients have been thinking about what they wanted to say—even rehearsing the words—on the way to seeing the doctor, and maybe even the day before. Time-wasting interviews come from doctors who talk too much, use too many words, and ask unnecessary questions, from clinicians who do not know what they are after and as a consequence are inefficient, and from patients who ramble and are allowed to talk too much. Respect, patience, and attentive listening do not mean surrendering control of the interaction. You and the patient have a common goal, and the two of you working together with shared authority toward that aim (which you have made clear) allows you to direct the process, albeit unobtrusively. When there is a talkative family member or friend present and you have demonstrated your attentiveness and concern for the patient, you are permitted, if necessary, to directly request silence.
It can be very difficult to observe the virtues that go with attentive listening when you dislike the patient. Some patients (some people) are really obnoxious. More often, however, the unlikable patient is someone who, as they say, “pushes your button.” Then you have the interesting problem of figuring out what it is about the patient that got to you. It is interesting because it changes the subject from “I don’t like…” to introspection and that always teaches you something—if only how to self-examine. Sometimes it is because the patient is just like some unpleasant relative, or has outspoken political opinions that are upsetting. Looking for who or what becomes the problem. Solving the difficulties raised by an unpleasant patient represents an interesting issue in itself. However, a patient interview is not a debate. If you do not like what the patient said about (say) doctors, medicine, your office, staff, Democrats, or whatever, learn to be silent. Let it pass. Stay focused on the interview (and not on the clock, the crowded waiting room, another patient, money, difficulties at home, or whatever). I often ran behind my schedule so patients would complain about waiting. I told them, “I am sorry you had to wait, but let’s make sure I spend enough time with you so that we can solve your problem.”
It may seem strange, but even when you are examining the patient you should be attentively listening. Here is when a quiet mind, always helpful, is most important. There may be, as it is said, no such thing as telepathy, but there is no question that information is pouring in during a physical examination. Your conscious attention may be focused on the eye-grounds, and now on the ear (through the (p.111) otoscope), and now the mouth and throat, but outside of awareness you are registering other facts (say) about the face or skin—color, texture, lesions, healthiness—that never come to consciousness. And so it is about the neck, chest, ribs, general motions, abdomen, and so on, and so on. If you are talking, or your mind is filled with other thoughts, this wealth of information probably bounces right off and does not register even below awareness. Suppose you finished your history and thought that there was something wrong—the patient was sick. On examination you find nothing that would indicate what worried you. But you are still uncomfortable about the patient and you continue to think that something is not right. You may well be correct—something is wrong. Reassure the patient that the examination is negative—but say, “I want to be on the safe side so I think we should get a…(naming another test or suggesting a consultation, or whatever). If you get the strong feeling (in the same setting) that the patient is fine, that is also probably correct. These are intuitive thoughts, but do not confuse them with magic or allow yourself the happy delusion that you have magical fingers. Intuition is an excellent source of ideas, but it should never be the sole reason for action. If you think something is true, as noted below, there is probably a reason. Now, go get the information from another source that will nail the thing down.
In attentive listening, in addition to the patient, you yourself are always both subject and object of your attention. You are the subject because you are attentively listening to the patient’s responses as they occur—not just to their meanings, but to the language. You are focusing on the pauses, pitch, and speech rate (called the paralanguage), the words and word palate (simple, fancy, educated, sick, etc.), the sentence structure, and the logic of the utterance (which reveals the patient’s underlying premises). You are accomplishing this at the speed of natural speech—hard to do until you train yourself. You are also the object because you are observing yourself in the interaction. This requires paying attention to your own words, mannerisms, and presentation to the patient, which is another taxing skill. There is a reason it is called attentive listening. It is fun to learn to do all this at the same time as you are listening to hear the patient’s problem and clues to its solution. The impediments also clarify why it is so useful to have a quiet mind. If you are listening to all the speech and its meanings flowing from you and the patient while at the same time attending to the ideas and noise of your own wayward thoughts, that seems like too much to ask. (See Chapter 2 footnote 5 to learn the skill of a quiet mind.)
While you are attentively listening you are also observing—seeing what the patient looks like—all the details that tell us so much about other people.
When you are listening, asking questions, and listening again, you may be uncertain about what was said. Check what you think you heard with the patient. “Do I have this right? The pain first started the night before you began coughing? (p.112) Tell me.” Or “Tell me again why you are having trouble with your friends since you got sick.” “I’m sorry to have to ask you again, but I want to be sure I understand…” Remember, you and the patient are in this together and you want to understand the patient and the patient wants to know you know. Some people speak in a way that can only be called opaque. You do not want to appear like a dope, but if you fail to question again (and again, and again) you will not know what happened. It will not be the first time such patients experienced others as not understanding them, but it may be the first time they came across a doctor who really wanted to comprehend.
This widely diverse information comes together to form a narrative—a story with a timeline about a person and his or her sickness and life. You should tell yourself this story inwardly to see if it hangs together and to see whether it seems reasonably attached to this patient (person) about whose way of life and being you have discovered so much. Instead of relating the narrative to yourself, you can tell the story to the patient so that the two of you are together in checking the authenticity of the narrative. There are many times when you are writing the history of the illness and describing the patient and the pertinent details of a life that you will want to go back and ask more questions. Although in the hospital you can probably do this, in other settings the opportunity has probably passed. That is why getting in the habit of telling yourself or the patient the story is useful. Some believe that what needs to happen is not recounting the story to yourself or to the patient; rather it is not shortcutting the information-gathering process before you really have all the relevant facts. Either way, the question you are asking is, “Do I really know the story; do I have all the details?” If the answer is no, or there is doubt, you are not yet finished asking questions and listening to the answers
This vast amount of information forms itself into the pattern(s) that are the basis for the remarkable pattern recognizer that all physicians contain within themselves.11 In the next chapter there will be a more complete discussion of pattern recognition and the part it plays in the clinical thinking of clinicians.
For attentive listening to do its best you must learn to trust your mind. If you heard it, you heard it. If a pertinent idea comes to mind, if you suddenly want to ask a strange question and are not sure why, if you seem to get an idea about the patient or the case out of the blue, pay attention. If you get an intuition as noted above, do not dismiss it unless you have reasoned the matter through. Pay attention to emotion that arises as you talk with a patient. Anger? Why? Whose anger is it, yours or the patient’s (which you have caught). Warm or loving feelings, perhaps sexual feelings—this is the way connecting closely to the patient announces (p.113) itself—are not about sex, they are about connection to the patient. There is a reason something comes to mind. Perhaps, the ideas or feelings are screwy and wrong; if so, why did they push into your thoughts at that time? On the other hand, as you have been asking questions and attentively listening, your mind has been processing and the processing does not always go in a direction you would have consciously chosen. Cognition does what it does for good logical reasons. Logic here means a set (however small) of premises leading to a conclusion. We, as a profession, have become so enamored of the objective, that I believe we have actively devalued the subjectivity of unspoken cognition—quiet thoughts and emotions working in the background. If this kind of mental activity, like intuition, leads to conclusions that seem dubious, find objective evidence that supports or defeats them. Pay attention to the evidence, all the evidence, inside and outside of you. Some people love intuition. That is fine as long its conclusions are put to the test of evidence for and against. Be careful of strongly held opinions that seem so true that it does not matter what other evidence says. One time, in a sick patient with abdominal pain, I became convinced that he had pylephlebitis—infective phlebitis of the portal vein. Nothing, but nothing could change my mind—including a normal white blood count. He did not have pylephlebitis. I learned my lesson. Diagnostic hypotheses are just that, hypotheses open to test.
I have written about pattern recognition as an inherent part of how physicians think. Pattern recognition provides the basic diagnosis and opinion about the patient based on facts gathered primarily by listening attentively to what the patient says in recounting the story of the illness—and in response to careful questions. It is the beginning—not the end—of the medical thought processes. The large literature in the field of clinical epidemiology that was born of Alvan Feinstein’s writing in the 1960s provides many tools that markedly increase the sophistication of medical decision making (Feinstein 1967). So much of value has been written about the subject that we have become much better in our diagnostic thinking and its tests. Jerome Groopman’s book has much of value on the subject (Groopman 2007). Although generally forgotten, Feinstein wrote that clinicians were involved in a science that is characterized by an N = 1. To most of us, a science of N = 1 is an oxymoron; medicine has left behind sciences like the old botany that consisted of finding and characterizing plants like a new species of violet. Medical science, moving forward, has embraced mechanism and reductionism and objective measurement of both qualitative and quantitative dimensions. We forget too often that what makes contemporary reductionist medical science important is that it came into being because of the individual sick patients that inspired it in the first place. Yet each of our patients, the subjects of clinical medical science, is an individual—particular and unique—which is a description of an N = 1. Understanding starts with knowing what has happened to a particular patient—the experience—to the degree possible. Alvan Feinstein (1967, p. 312) wrote, “Thus, the clinical counterpart of qualitative precision in measurement is effective communication of the sensation [the patient’s experience of symptoms]; the clinical counterpart of quantitative precision (the “significant figures” of the measurement) is specification of detail.” (Italics in the original.)
Yes, there is a primordial truth in medicine, knowledge of the individual sick person. The secret of knowing that truth is to listen, and listen attentively.
(p.114) References
Bibliography references:
Feinstein, A. R. (1967). Clinical Judgment. Baltimore, Williams & Wilkins Co.
Groopman, J. (2007). How Doctors Think. New York, Houghton Mifflin Company.
Schenk, D., and Churchill, L. R. (2011). Healers: Extraordinary Clinicians at Work. New York, Oxford University Press.
Notes:
(1.) Chapter 6, on the Evaluation of the Patient, discusses what a diagnosis actually is and how it is arrived at.
(2.) What an utterance is does not have a precise linguistic definition. As used here it refers to a natural unit of speech bound by pause or silence. We tend to hear speech as one or a series of utterances. Sometimes it is used to denote linked phrases that together form what speakers say in their turn (perhaps followed by someone else’s utterance).
(3.) The placebo effect and the anticipation of improvement at the doctor’s hands are positive. A small number of patients have a negative placebo effect and an anticipation of the doctor doing nothing salutary for them.
(4.) Many insurance plans or other payment mechanisms in the United States have made it difficult for the patient to keep the same physician over long periods of time. It is as if the patient’s relationship with a doctor—contrary to long held belief—is really unimportant. In this view, medicine is about technology, the body, and disease and personal issues are not essential. This has been and still is the deep-rooted fallacy of medicine since the last quarter of the twentieth century.
(5.) The patient will come to know the doctor as a doctor and the doctor know the patient as a patient. Patients will sometimes comment about how little they really know about the doctor even after many years. Similarly, having taken care of a patient for many years, something surprising may happen in the patient’s everyday life that reveals how little the doctor knows of the patient.
(6.) Surgeons have been able to treat diseases decisively, but until anesthesia (1846) and the beginnings of antiseptic surgery in 1867, the results were often horrendous. It was probably not until the beginning of the twentieth century that surgery was routinely painless and infection uncommon.
(7.) One of the wonders of medicine is that in almost every era doctors have discovered that what went before was wrong, without the equivalent recognition that we must also be wrong-headed about some beliefs we hold dear.
(8.) Of course doctors have fear, uncertainty, and ignorance. But they learn to hide these from patients no matter what the personal cost. Burdening the patient with the doctor’s doubts or anxieties is not helpful. And doctors always have purpose in which patients share—the patient’s well-being. These abilities are learned, sometimes at a high price. If clinicians cannot master these things, they simply should not care for the sick.
(9.) It turned out to be some unnamed encephalitis and over the next few weeks the illness resolved. This is not how we expect to learn in medical school, but I never forgot the lessons. My own physician telling me all the dangers did not frighten me; he demonstrated that he was knowing and able to act. The student health physician frightened me because his fear implied his ignorance, uncertainty, and inability to act, which implied that things were even worse than I thought (which would have been difficult).
(10.) You are not actually opening a door—there is no door to open. I find that when I teach this it is easier to visualize yourself actually opening a door and closing it. When you are comfortable doing the maneuver you can simply consciously think yourself open or closed without your hands doing anything. It may take some time to learn.
(11.) Pattern recognition is a universal attribute of thought. It has been copied by automated systems, computer diagnostic programs, and all sorts of algorithms. It can also be very sophisticated, so do not let others or yourself disparage it.
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