Listening

The exam room is a sacred space, one in which people  bare themselves both emotionally and sartorially.  It is a secular confessional, a chapel for the examination of sinew and sin, pain and disbelief, intimate failings and mortal fears.  Sometimes it is a place to share joy, but more often it is a place to explain one’s physical and emotional imperfections in hope that someone will hear and understand in a concrete way.

The interaction between patient and doctor isn’t that well-studied.  There are strong suggestions in the literature that the more we allow our patients to set their own agendas and to answer open-ended questions completely, the more likely the patient’s problems are to be addressed.   But what takes place in the exam room?  What is it that allows a patient to bare soul and body and allows a physician to really understand what a patient is saying and feeling?

One popular notion is that empathy, like good looks, is something some people just happen to have. I perceive myself as being an empathic physician (which of course may not be entirely true) and I’m curious what makes me so.  When I think of my own interactions with patients  I notice a few things.  In addition to standard listening techniques, I try to imagine how a patient feels—viscerally, literally, physically.  If a patient describes chest pain, I try to imagine what it feels like as described.  I try to imagine the emotions they felt when they had it, the fear, the uncertainty.  And I try to gauge the patient’s reactions to my reactions.  My facial expressions and posture can promote fear or give comfort.  If I want the patient to continue to be concerned, my words and actions can purposely fail to give them complete reassurance (always telling them, though, that we will do whatever we must to get to the bottom of things).

I don’t presume that this always works out for me and my patients—this is necessarily an empiric exercise, a muddy one that goes on from minute to minute and is measured in subtleties.  I’m also not sure how deeply this should be studied formally.  While I’m certain that empathy can be taught (or at least a reasonable facsimile of empathy), I’m also certain that there is not one sort of “empathy” that works for all doctors and patients.  There will always be some mystery in the exam room, and that is what makes it sacred.

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5 Comments

  1. TGAP Dad

     /  November 13, 2010

    Rule #1: Burn the paper. One of the most unpleasant activities for me is the stack of papers to fill out prior to a visit. Don’t try and convince me that the name of a relative not living with me is necessary for my medical care. This is the first experience with your office, and it’s glaringly obvious that it’s all about the money. You want to know who’s paying, who’s next in line of #1 fails to provide, etc. And I have to give my name and address how many times? Am I really going to move between page #1 and page #3? And my social security number is in no way related to my health or medical needs. And you need a copy of my insurance card and driver’s license every time I set foot in your door? WTF? All this does is infuriate me – right before you take my BP and pulse.

    Rule #2: Show your work. It applies with math beginning in the 7th grade, and in medicine with the first clinical visit. I detest a doctor giving me a quick once-over without even an explanation of what’s going on as it is happening. I know a basic neurological exam takes a few seconds looking at the eyes, skeleton movement, or whatever. How about a little narrative while it’s going on so that we (non-physicians) can grasp just how comprehensive it is.

    Rule #3: Take your time. I know we’re all in a rush these days, and doctors are under production pressures like all service providers. Sit down next to the patient and meet his or her eyes. Respond to each thing your patient tells you, regardless of whether it’s relevant or not. If you simply grunt or mutter “uh-huh” as you busy yourself with the exam, it has the appearance of being ignored.

    Rule #4: Avoid blanket directives. Explain the various nuances and risks with a treatment or drug. I’ve had doctors insist that we use cool-mist dehumidifiers and not steam vaporizers. These fill the air with tiny water droplets, not steam, so the air feels clammy and misty. Once you explain the rationale – that steam vaporizers present a scalding hazard – we can probably minimize the risk.

    Rule #5: Talk your way through it. If you’re going to hurt us, let us know. Be candid about how badly and for how long, and what our ongoing limitations may be. Tell us beforehand, and give us a moment to let it sink in. I don’t want to go into details about my toad of a doctor did to me during a vasectomy – with no forewarning, or explanation. (FYI: ex-doctor now).

    Rule #6: We aren’t as stupid as you think we are. I have literally had a doctor draw a city traffic on the exam table paper to illustrate sinusitis. Trust me, most of us will get it if you simply say “congestion.” (Especially in Michigan.) Just because we lack the medical training and clinical experience, doesn’t mean we’re stupid.

    Rule #7: You’ve “been there, done that,” but we haven’t. We hear conflicting directions all the time. Should I see the doctor or not? Do I need to be seen right away, or can it wait until Monday? If H1N1 is prevalent in my region, and I’ve got flu symptoms, do I go to the doctor or not? I have been admonished for both not being seen when I should have, and for coming in when I didn’t need to. I want clear guidelines on this, but what I hear when asked is “well, if you feel like coming in, you may.” How the hell am I supposed to act on that?

    My wife had a worry while in her second trimester of pregnancy once, and wen in to be seen. The nurse told her – verbatim -“you know, we see these all the time; you don’t need to come in for these.” Another incident, my son had gotten a little too aggressive with his food and bit off a small piece of his tongue. I went to the nearby urgent care, checked in, paid, waited, got called back, waited, had nurse check vitals, waited some more, and when the doctor-lite (PA) finally came in she informed us that they really don’t deal with tongues and that we should see our dentist. Is it possible that we could have been informed of this before they collected our copay and made us wait 90 minutes?

    The conversation about doctor-patient relationship dynamic, as you can tell, is for me more about what pisses me off than anything else. Once we start ticking boxes in that column, it’s probably not going to get better.

  2. Excellent set of observations.

    However:

    The annoying bureaucratic crap you brought up at the beginning is not optional. Insurance fraud is a problem and most offices and institutions will verify a patient’s identity and insurance every single visit. This is not only to avoid helping commit fraud by billing services given to an imposter, but also to survive economically. Doctor’s offices run on very thin margins—if we get anything wrong with the insurance, we don’t get paid, or payment gets delayed.

    If we had a single payer system, all we would need is a quick verification of participation (in Ontario, eg, you show your health card, which has a photo on it). But here, not so much.

    And quite honestly, we don’t collect next of kin info for billing purposes. In our business, we sometimes need to get in touch with people quickly for rather important reasons.

    • TGAP Dad

       /  November 14, 2010

      I understand that the “bureaucratic nonsense” is (mostly) a monster unleashed on us by the insurance companies. And without getting into the virtues of a single-payer system, or playing “who’s fraud is bigger – pharmaceutical companies and insurer’s or ours,” I’ll just point out that I included it since it is part of the patient experience and interaction with your office. It is usually the first interaction a patient has with your office. FWIW, this presents an opportunity to improve the experience by – among other things – streamlining the paperwork. Like only making me enter my name and address once.

    • I know there’s gotta be paperwork, but it really doesn’t have to be as painful for us patients as it sometimes is. Here’s my list of things that could make that part of the visit better:

      1) Keep an original to make copies of your forms. That 175th generation copy that’s skewed so badly part of it is missing and barely readable makes me wonder about the general efficiency and care given to all tasks. It also says “this really isn’t important” which I was wondering about already.

      2) Use forms that can be filled out. Even DOB is hard to fit in a 1/2″ space.

      3) Don’t ask me lots of questions you have absolutely no intention of even glancing at. (ie, an orthopedic surgeon shouldn’t borrow forms from his friend the gynecologist.)

      4) When you do need lots of info, make the forms available for the patient to fill out at home, if possible.

      All of the above is fresh in my mind from a visit to a new doctor yesterday. Though I arrived 17 minutes early, I could not fill out the questionnaires before being called back (right on time and he gets multiple bonus points for that!)

      I never finished the forms, but was told by the nurse “Oh, that’s OK.” That just means to me that they weren’t very important. I really liked the doctor and felt a good rapport with him. He was very good at explaining everything.

      And there was no television in the waiting room so he made up for the forms fiasco in ways important to me.

    • I liked TGAP Dad’s list too. I agree with PalMD that single-payer is about the only way to fix the bureaucratic mess.

      Re: Rule #6. Well…. some patients are stupider than you think they are. The problem is the doctor (or really, anyone who deals with a customer-facing technical subject) has to gauge this and adjust their explanation level rapidly — and they always face the risk of either coming off as patronizing or as intimidating. I’m sure it’s a fine line to walk.

      Really what we need is the equivalent of this. (It’s a dream I have dreamed many times before)

      Re: Rule #7. Our current doctor uses that RelayHealth thingy for maintaining contact with patients. He’s also very cool about getting cell phone calls at off hours. (I very apologetically called him on Saturday night one time because our toddler had bumped his head and.. well.. the lump was a fair bit bigger than we were used to when he got an egg. I felt terrible, and left a message. He called back about 45 minutes later, obviously having been out at a club or something, and was apologetic to me for not answering right away!) This is incredibly helpful to us in navigating when it is necessary to make an in office visit and when it’s not. He’s great.

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