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."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.
-- Rita Charon, Narrative Medicine: Honoring the Stories of Illness, p. 177
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?