Sunday, March 09, 2008

Is Anybody Listening?


A 46-year-old Dominican man visits me for the first time, having been assigned to my patient panel by his Medicaid Managed Care plan. He has been suffering from shortness of breath and chest pains, and he fears for his heart. I say to him at the start of our first visit, "I will be your doctor, and so I have to learn a great deal about your body and your health and your life. Please tell me what you think I should know about your situation." And then I do my best to not say a word, to not write in his medical chart, but to absorb all he emits about himself -- about his health concerns, his family, his work, his fears, and his hopes. I listen not only for the content of his narrative but also for its form -- its temporal course, its images, its associated subplots, its silences, where he chooses to begin in telling of himself, how he sequences symptoms with other life events. After a few minutes, the patient stops talking and begins to weep. I ask him why he cries. He says, "No one ever let me do this before."

-- Rita Charon, Narrative Medicine: Honoring the Stories of Illness, p. 177
Dr. Rita Charon founded the discipline of narrative medicine to teach doctors how to listen carefully to patients, and thus how to be better caregivers. Her work strongly supports the contention -- one borne out repeatedly in my work as a volunteer ED chaplain -- that close attention to patient stories is itself a clinical intervention, a powerful way to promote healing. We know that patients do better when they have a support system, when they know that people care about them as particular individuals. It makes sense for physicians and other providers to be part of this network if possible.

And yet the current healthcare system in the U.S. seems to be working against this kind of care.

Last month, I gave a presentation on narrative medicine to third-year medical students. One of them told me that she'd planned to go into psychiatry precisely because she wanted to listen to patients; she'd recently decided against the specialty, though, after learning that psychiatry is increasingly a matter of medication management. Listening is the realm of psychologists, not physicians.

The next day, I gave another presentation -- this one on the related subject of woundology -- to family-practice residents. I tried to encourage them to listen to patient stories, to try to figure out why a patient might be invested in clinging to certain symptoms. Their unanimous reaction was that such patients would be referred to a psychologist: "We only have fifteen minutes with each patient, and we can't bill for depression diagnoses."

During my volunteer shift later that week, I listened to an ED nurse rant about how little time managed care allows providers to spend with patients. "If you have a 77-year-old woman who's just lost her husband and has a list of symptoms as long as your arm and hasn't been to a doctor in ten years, how can you possibly do an adequate job in fifteen minutes?" And she was talking simply about the task of taking a history and making a diagnosis, not about getting to know the patient as a particular individual with her own family, fears, and hopes.

My gut impression is that listening in the American medical system has been relegated to psychologists, social workers, and chaplains (who often have little enough time themselves). But Charon's in that system; furthermore, the patient she describes is on a Medicaid Managed Care plan. She elicits the stories of all of her patients. How can she do it? How does she have the time?

A psychologist friend, when I passed along the medical student's comment about psychiatrists, said, "No, that's not true. Some of them still find time to listen to patient stories." How do these psychiatrists do it, and where are they? In the office where my psychiatrist practices, MDs do medication management: therapy is delegated to the psychologists and MSWs. My doctor's very nice and usually spends half an hour with me, rather than fifteen minutes; we have conversations. But I doubt she'd have the time to do what Charon does.

So here are my questions for my readers:

1. Do you know MDs who make a practice of deep listening? How are they able to do this within the current system?

2. How can we encourage more MDs to do the same thing?

3. If you're a patient who's been listened to -- or hasn't been listened to -- what difference do you think that made in your healing? If you're a physician who's made the time to listen, what difference do you think it's made in patient outcomes?

Thank you!

10 comments:

  1. My GP is fantastic and, every time I see him, he makes time to listen to me. It has made an immense difference to my well being. Because he listens to me, I pay more attention to his words - as in the case where (in the midst of a crisis) I wanted to stop all my psychiatric meds; he listened to why and then gently explained why that might not be such a good idea.

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  2. Man, that seems to happen all the time. I was heartbroken when my family doctor retired because she was the only one I felt comfortable with. I've been over-diagnosed before, even when I knew the problem from past doctor visits and just needed a script from the campus clinic - even the specialist I got sent to was rolling her eyes and asking why the heck I was there because I displayed no symptoms relevant to her.

    But my bigger worry, and it's a constant one, is my bizarre reactions to a wide assortment of drugs. So many times I've been told "They don't do that. Don't be silly." As if I'm just making things up! Maybe I'm paranoid, but the thought of being incapacitated and unable to forcefully convey my wishes scares me like little else. It's so easy to brush aside the sick little voice that's objecting when Doctor Knows Best. I really wish I had a doctor I could trust to listen to me, really listen, and take my concerns seriously. I don't ever want to have surgery or be in an accident or any situation where anyone can assume consent.

    Aaaand, that's probably more than you ever wanted to know.

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  3. I don't know if this is addressing any of your questions, but here goes: I've had the same PCP for 8 years, she works in a group practice under what I'll call an "umbrella company". When I first went to her she listened to my concerns and actually caught the things I left in subtext - this was a breath of fresh air from my experiences with military doctors.

    But over the years I began to notice that getting an appointment with my PCP was getting harder, though when I did it was the same wonderful care. I also began to notice that the patients were usually older then me by 30+ years.

    My last visit to the doctor was with her assigned PA who informed me that I should begin to find another PCP as mine was only going to see patients over the age of 60, because managing both age groups 60+ and under 40 was too much.

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  4. My NP does this. My first visit was nearly an hour long. She took a serious health history and wrote down everything. She listened carefully. She asked me what direction I wanted the treatment to take for each health problem.

    She gets her money by doing this in a different visit than the physical exam, and then billing for two visits. Most of the time, patients have to pay for the second visit themselves, and she has payment plans available.

    Despite the out-of-pocket expense, she has clients coming from more than an hour away, just because they feel that she cares about them.

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  5. I know that this sense of being utterly ignored or just being another number or the like is part of my initial huge avoidance of psychiatrists. The first one I went to see basically sounded like he was playing with my drugs and that was it.

    I finally went to another one out of necessity this past autumn and he actually wanted to know a bit about me, and even without the drugs I felt like I was actually being treated on some level, and it was a level that I much preferred. I really found that my trust of his decisions and thoughts went up considerably because he was willing to listen, as opposed to the one who seemed like he wanted me out of there in five minutes flat.

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  6. Anonymous7:37 PM

    I find it quite telling that my insurance company hires a third party company to listen to clients who have many expensive tests with inconclusive results. My 24 nurse on call is helping to coordinate my care because well even Cigna has figured out that the MD's really don't have time to listen to their patients.

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  7. I've been thinking about this post for the last few hours. Yesterday, we took my boyfriend to the doc-in-a-box for a bad sinus infection. The nurses there all cut him off as he was trying to tell them the whole story (as he had food poisoning just before coming down with the current bout of yick, and he feels it important that they know that, just in case it makes a difference), and interrupted him when he was trying to explain that he avoids penicillin because he's got a family history of allergic reactions. They've done that to me, too, and it's frustrating - i know i'm not technically allergic to skelaxin, but it gives me heart palpitations, so i'm not taking it, and it's easier for us both if you know that off the bat. It's very frustrating to try to explain, especially when we're being fairly concise but trying to make sure everything gets covered. As i told the boy, they're going to miss something huge if they keep shutting people down like that.

    On the other hand, tonight at work i've got a patient whose room you can't get out of. Giving pain meds turns into twenty minutes worth of listening to him tell stories. And regardless of how much merit i think his stories have, i really haven't had the time tonight to listen to them. And i'm frustrated by that just as much as i'm frustrated by his insistence on telling long-winded stories about how everyone's done him and his wrong.

    It's very hard to find a balance, sometimes.

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  8. I know one, at a clinic in the underserved part of Madison. There are probably more, but I only know one. He schedules appointments in two time blocks: a half hour or an hour.

    I think he can only do this because he's "done his time" in the system - he's earned seniority and clout through publications and the general grind. Now, he works part time in the clinic part time in academia/administration, and he can schedule however he wants on his part-time days. His patients, needless to say, love him.

    But he's the only one I know who can do this. Except medical students. We can listen to everyone because we're supposed to be a) learning and b) inept at time management. I take full advantage of this. :)

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  9. Been lurking for awhile, but I wanted to chime in on this post.

    I've seen things from both sides of the fence, as a clinical psychologist working in hospitals (though not currently), and as a patient.

    My experience with many physicians is that they view anxiety and other strong emotions negatively, as a sign of dysfunction (as opposed to a natural and not necessarily debilitating reaction to illness, OPs, medications, etc.). Rather than dealing with anxious patients directly, they referred them to Psych Services. This was not necessarily comforting to the patients, who often felt they were being labeled inaccurately -- an additional burden for them. I think one of the most helpful things we as psychologists did was serving as mediators between patients and doctors, facilitating communication both ways.

    As a patient -- for example, postpartum with complications, I was trying to be on-the-ball and intelligently involved about my own care, but dang those hormones played havoc with my emotions. Crying didn't help my interactions with the MDs in the hospital. Another example: being sick as a dog with a sinus infection and having to experience new-to-me ENT procedures that freaked me out and led to involuntary wooziness. The doctor was very impatient with me and wrote uncomplimentary things in my chart.

    To address your questions directly, I honestly don't know how to get MDs to listen better. More training, better role models, and the conviction that listening is worth the time and effort are necessary. If physicians have the skills to deal with distressed patients, they're less likely to avoid them. And if their time isn't penalized (and also if they can experience positive reinforcement in the form of praise, gratitude, better outcomes), then it's likelier that listening will get the position it deserves in medicine.

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  10. Well, I wouldn't consider my personal experience normative. Yeah, my PCP listens to me; but he considers me a friend. Doctors do listne to me, but they can't automatically separate me as patient from me as colleague.

    That said, I do know physicians who do listen to patients. I know one or two who still make house calls. I know more who feel the strain, but try to listen, or at least try to ask questions beyond simple physical symptoms, within the time limits they feel. I also pay attention to those who do their own hospital rounds instead of contracting with hospitalists. In many cases, the hosptalists can actually offer better coordination of care; but patients still miss the relationship with a PCP.

    Those who take more time are usually in private practice, and are willing to accept the reduced income. Those who are employed by a large practice or a hospital-owned practice just tend to run a bit late - something administrators learn to live with, given the relative shortage of PCP's and the high patient satisfaction scores these physicians receive.

    Our central hospital has an agreement with a local med school. One aspect of that is an opportunity for med students to take a rotation on patient care that includes spending half a day with a chaplain, social worker, or psych liaison nurse. They do observe people listening, and have the opportunity to see the value. Historically, feedback immediately after the rotation is positive - students feel they learn a lot and that it's valuable - but I don't think we know how long the effect lasts.

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