Sunday, August 28, 2016

listen up

Storytelling isn’t easy. Even the best authors sometimes struggle to put their ideas into words, and emotions can be hard to express.  Ask any writer.

So it shouldn’t come as a surprise that patients have trouble telling the stories of their illnesses. When they try to tell us about their symptoms, they may not have the language for it. The fellow having a heart attack may describe his pain as indigestion, when the doctor is looking for words like dull, heavy, or tight to describe the discomfort. The patient who is lightheaded may  describe the feeling as dizziness rather that fainting. The provider then has to determine if the patient is experiencing presyncope or vertigo. The patient who complains about pain in his sinuses may be experiencing a migraine headache. Patients don’t know what we need to hear from them about their symptoms, so sometimes the obstacle is language.

Sometimes the problem is denial. The fellow having the heart attack may know exactly what is happening to him, but be so scared by the prospect he unconsciously tries to make a case for something less ominous. He describes his problem as indigestion, hoping the doctor will say, "It sounds like reflux. Nothing too serious."

Fear, then, is another confounding factor. When a patient describes a symptom, the provider has a long list of details he needs to know in order to diagnose the cause of the patient’s distress. However, the patient might be more frightened by the symptom than he is suffering from its severity. Perhaps a coworker recently suffered a disabling stroke. The patient is having some tingling in his right hand so he’s convinced he’s about to have a stroke, too. Carpal tunnel syndrome doesn’t cross his mind. The tingling isn’t severe, but his fear of having a stroke is off the charts. Once the doctor addresses the patient’s unfounded fears, treatment has a better chance of success.

It’s up to the provider to figure out what is what. This explains why health care providers must be excellent listeners. We have to make an accurate diagnosis by listening clinically, and we must understand how the illness affects the patient by listening empathetically.

Listening clinically involves getting the details right. Encouraging the patient to tell us about the onset of his symptoms (sudden or gradual), the duration (hours, days or months), the severity (mild or excruciating), and quality (sharp or dull, constant or intermittent, localized or generalized). A thorough and accurate history of the patient’s symptoms is fundamental to making an accurate diagnosis.

But there’s more to it than that. Empathetic listening enables us to understand how the illness affects the patient, what it means to him, and why. Why is he in denial? What is he afraid of? How will his illness affect his job, his family, his faith? It includes:

  • Reading facial expressions and body language. For instance, if the patient brings his fist to his chest when he is telling you about his heartburn, you need to think heart attack instead. It’s a classic gesture. 

Image result for patient describing a heart attack with clenched fist in chest

  • Understanding the patient’s emotional state. I once had a young woman come in with a swollen black eye. She laughed it off. “I’m so clumsy,” she said. “I was jumping on the bed and hit my eye on the corner of the TV.” In fact, she had a blowout fracture of the floor of the eye socket. When I asked her what really happened, she described the blow she took from her boyfriend’s fist, the fear she felt for her life. She not only needed medical care, she needed social services.
  • Listening between the lines for what the patient may be leaving out. I used to ask my teenage patients whether or not they were sexually active. Invariably, the answer was, “No.” That let me off the hook. I didn’t have to ask about STDs or contraceptive practices. It saved time…but I knew it wasn’t always true. So I started to ask instead, “How many sex partners have you had?” Eight, twelve, twenty-five! I was flabbergasted. But it enabled me to begin a meaningful discussion about body image and the patient's sense of self-respect. We went over the dangers of and prevention of STDs. And I was able to offer reliable contraception. 
What difference does empathetic listening make? It gets us closer to the truth. It connects us with our patients in a meaningful way. It improves patient satisfaction and that by itself helps promote healing. It enhances diagnostic accuracy and the efficacy of treatment. It decreases the physician’s sense of frustration and ineffectiveness. And by strengthening the physician-patient bond, it decreases the rate of physician burnout.

If good storytelling is an art, effective listening is a craft. In these efforts the physician-patient partnership is forged. Health care becomes a mutual endeavor, and everyone benefits from it.
“You are so brave and quiet
I forget you are suffering.”
~Ernest Hemingway~

Sunday, August 21, 2016

a conversation that matters

True story:

Just yesterday a friend and former patient of mine stopped me after church to tell me how much better she was feeling since my husband—the consummate family physician—had seen her at home the previous Sunday. It's true. He made a weekend house call even though he wasn’t on-call that day.

She’d been suffering from incapacitating neck pain and headaches for a couple of weeks, but hadn’t called my husband about it because she was in palliative care for an oppositional defiant malignancy that nothing could stop. She didn’t call him about the pain because her oncologist and hospice nurse had already called in prescriptions for narcotics that hadn’t touched it. She understood the concept of palliative care to mean that nothing more could be done for her so she assumed the pain was part of the process.  

Nevertheless, even though her specialists were not treating the cancer anymore, the goal of my friend's medical care was to keep her as comfortable and functional as possible, for as long as possible. I reminded her that incapacitating pain is not considered by most patients to be comfortable. When a patient who is otherwise still independent becomes housebound because of it, she is not really functioning. She deserved to be treated for the pain.

Her husband was the one who finally called my husband who then took time out of his weekend off to listen to her story and examine her. Based on what he found, it was apparent that her problem was muscular. It had nothing to do with the malignancy. After one day on a muscle relaxant and low dose steroids, the pain subsided. She slept through the night for the first time in weeks. And to her relief, the pain has not recurred, which explains why she was able to get to church this weekend. Why her appetite came back. Why she was smiling despite her generally poor prognosis.


Rita Charon, in her ground-breaking book, “Narrative Medicine—Honoring the Stories of Illness,” presents an unconventional approach to gathering information from the patient. She simply invites the patient to “tell me what you think I should know about your situation.” Then she listens. She doesn’t scribble down notes or tap away at her keyboard while the patient is speaking. She listens.

Had my friend’s oncologist or nurse used this approach, I think she would have told them, “I’m having severe pain in my neck. I can’t move it when the pain comes on. Then I get a severe headache. It’s so bad I can’t leave the house. I can’t eat. But they said nothing more could be done for me so I didn’t want to bother you about it." 

That miscue resulted in weeks of unnecessary suffering for a woman who had already suffered enough.
“Be brave enough
to start a conversation that matters.”
~Author Dau Voire~

Thursday, August 18, 2016

can you hear me now?

Clearly, storytelling is important in the practice of medicine. All day long patients tell us their stories. During hospital rounds colleagues discuss interesting and difficult cases. This often continues over lunch, after office hours, even on the golf course…wherever health care providers convene.

We tell stories hoping that someone will listen, and by listening, understand…and by understanding, come to care. This helps patients make sense of their illness, find meaning in it, and begin the healing process. Storytelling helps answer the questions: Why me? Why this? Why now? It enables providers to share information and experience, to celebrate when patients recover, and to bear the loss when they don’t.

We all benefit from telling our stories…but who benefits from hearing them?

In fact, listening connects us in extraordinary ways. Not just cognitively and emotionally, but physiologically. This is a measurable phenomenon. Yay for technology!

Functional MRI scans detect changes in blood flow and oxygen uptake in different regions of the brain. It has been shown that when listening to a story, changes occur in the listener’s brain that coincide with or mirror the pattern in the teller’s brain. This is called speaker-listener neural coupling. The greater the coupling, the greater the understanding. The extent of speaker-listener neural coupling predicts the success of the communication. (Here is a link to a highly technical paper on this subject for any skeptics out there: )

The concept of neural coupling has enormous implications for narrative medicine. If we want to understand a patient’s illness, we need to listen to his story. Not interrupt his narrative. Not redirect him to satisfy our own agenda. Not fix our gaze on a computer screen and check off boxes.

Miscommunication between patients and health care providers can lead to misdiagnosis, and misdiagnosis can lead to inappropriate treatment. The patient’s condition can worsen because the doctor doesn’t understand the patient's illness. He didn’t listen to the patient’s story.
"Histories must be received, 
not taken."
~Sir Richard Bayliss~

Sunday, August 7, 2016

primum non nocere

I learned something new today. This is a good sign because some people like to joke about my incipient dementia. At least, I hope they’re joking.

I was toying with the topic for today’s post when the phrase “primum non nocere”—first do no harm—came to mind. I learned that the Hippocratic Oath is not its source. It actually comes from Hippocrates’ writings in “Epidemics”: “The physician must…do no harm.” These words are the bedrock of medical ethics and practice. Hippocrates is regarded as “the father of medicine” for good reason.

In fact, many of the traditions that influence the way we practice medicine today were passed down to us by men. Not because women were excluded from the practice of the healing arts in ancient Greece. On the contrary, women were highly respected as physicians and healers. Even Plato held them in esteem. Though they were few in number, patients sought them out. They were regarded as the “wise women” of the community. Their “soft hands” were considered to be “healing hands.”

But as the science of medicine advanced, the feminine ethic lost credibility. Its wisdom and power to heal were dishonored in favor of dispassionate technical expertise—testing, procedures, and proofs. Today speed and efficiency reign, and reimbursement issues drive the system. Over time, tradition has suffered. As a result, patient care has suffered, and even physicians have suffered.

One of the time-honored traditions that survives today expressly prohibits the physician from entering into a personal relationship of any kind with his patients. This, of course, is an impossibility. It disavows the emotional intimacy that is the inevitable fruit of shared suffering. It contradicts the compassionate physician’s experience and denies him a powerful tool.

Today, the physician is taught that it is unprofessional to share personal experience, insight, beliefs or values with the patient. This rule of non-engagement is hammered into our heads during training when we’re still easily moved to empathy, at a time when connectedness with other human beings is still something to be desired and defended.

Sadly, this means that patients may know more about their hairdresser or mechanic than they know about their doctor—the person they trust with their health and their children’s health. With their lives. Most patients know nothing about him but what they can gather from the plaques and certificates displayed on the walls in his office—what schools he attended, when he graduated, what honors he earned…which speaks to his intelligence but what about his inspiration, his motivation, and his conduct?

This can be troubling for patients. They have little choice when it comes to selecting a physician and, except for the credentials hanging in his office, they may know nothing at all about him. They worry about it, and they should. Is he competent? Is he caring? What motivated him to undertake years of grueling study and training? What sustains him? How does he manage it all?

This precedent distances us from our patients at times in their lives when what they may need from us more than anything else—more than another prescription or another test or another procedure—is our presence with them, our strength, compassion and support especially at times of serious illness and suffering. At times when fear and grief cut deep. At times when they may need to understand that nothing more can be done for them…or for someone they love—a friend, a spouse, or a child. When our patients need us the most—that is, when there is no hope for them—we are trained to turn their care over to the nurses, or the family, or their pastor.

We leave the bedside the way we approached it—as strangers, not storytellers.
“Some patients, though conscious that their condition is perilous,
recover their health simply through their contentment
with the goodness of the physician.”
~Hippocrates (460-400 BC)~