Aren't Doctors Taught To Listen?

by Marybeth Lambe MD FAAFP

“You need a good bedside manner with doctors or you will get nowhere.” ― William S. Burroughs

"Primum non nocere" sounds like something out of the Hippocratic oath; instead, this is another example of how truth gets in the way of a good opening sentence. In the Oath, it is said more beautifully. To do for patients, "I will keep them from harm and injustice."

One of the main ways we providers can keep from wounding is to be seekers of truth. Taking a false or incomplete history, and then acting on such an incomplete history causes much harm. Patients have a right to expect competent history taking. But this doesn't make it actually happen.

Medical providers are as varied as any other humans. Many of us have had the privilege to meet wonderful caretakers & it is unfair that the difficult ones tend to stick in our memories. All of us have been cared for as patients; some of us, like myself, also work as physicians. In such work, provider partners have been great instructors & patients stoically teach too. That's good because I am a slow learner. There is one item I have, lately, come to grasp better. I cannot become brilliant, nay, even clever, as many fellow doctors I have known. I have seen some wise MD's surmise someone's condition in a flash, but I have not that ability. Plain physicians like me have recourse to a more workhorse means instead. Sometimes I am surprised how rarely it is endorsed. Perhaps everyone hopes they too possess that rare gift of genius. Alas, this means they must be missing that term "Rare." I rely on listening to history but it is a lesson long in learning. If you are brilliant, please understand, maybe you don't need great history taking. If you are mentally encumbered like me, & already use great history taking, congratulations! I just know being a doctor is no guarantee of intelligence.

When you go to a car mechanic, you hope that mechanic will listen pretty carefully to your summary of worries. Even if your description sounds deranged or is nonsensical, full of sound effects, is incomplete, or unreliable. "The car brakes feel slippery & it heaves to the right!" The engine goes Woo, Pop, Pop, & my husband says to tell you the idle is off, the left tire bumps wrong & something smells bad when I push the accelerator too hard…."

You are well aware this sounds stupid, hopeless even, but believe the car mechanic will nod wisely save rolling his eyes for later. What matters is that later the car you get back has a good chance of being better. If not, you will try a different garage.

Doctors are in the same service line of work yet we forgive them their terrible listening skills & failure to heed a word of what he says. I WORK as a doctor &--as a fellow human—have had many occasions to be a patient too.

I have heard many grievous tales of how poorly we doctors listen or rather don't listen in the least. How we do harm with the arrogance of turning our ears of from a history offered. How we do not give patients the dignity their story deserves. We often act like teenagers, practically plugging our ears when the person across us is speaking. Might as well BE that adolescent shouting back: "I can't hear a word you are saying! Ha Ha. Not a word!"

It goes beyond strange in so many ways. Physicians set up visits that are far too short for most human problems. Even a new patient gets a 10-15 minute appointment in which to ask only their most pressing complaint. I also have sat there, panicked, sorting out how to speak quickly, in shorthand and choosing only my worst problem of the day.

Doctors are often running behind, they are expected to hurl you up the table for an exam in that same compressed time. This makes providers anxious even if it's their own fault. The physician's solution for their poor choice in the appointment time limit is to sacrifice actually taking—or hearing --a real history. They often, in case you haven't noticed often run of time where normally one would expect a clear logical discussion of how they arrived at a conclusion. Sometimes sacrificed too are portions of what we might feel are reasonable concerns—contributing family and social history, other large current worries, likely impediments, and a lucid plan, well outlined.

To be fair, a history does not always have to be a straight storyline: What started, what was next, what followed. Sometimes the order of questions skitters in the way a detective leaps all over a story. If worried, or to be complete, a provider might also bossily take over some of the inquiry but should also leave large portions of the time where the patient feels unpressured & can tell the tale in his own way.

If you tell me you have chest pain I might, instead—start out with my biggest fear for you—how can I know this is—or is not—a heart attack, a blood plot, pneumonia, a fracture, collapsed lung? I might start with questions that help prove or disprove those diagnoses that put you at greatest risk which is why you would hear queries such as

"Can you describe the pain, what makes the pain better, worse? How long does it last? Does it radiate into your jaw, arm, neck? Do you cough, cough blood, have fever, feel short of breath, have associated palpitations, nausea, vomiting, lightheadedness, weakness, injury, anxiety, past heart problems, family heart problems, clotting issues…"

But suppose we kept going, all was negative. Now, a bit less OCD you aren't about to keel over, I might shut up & let you get a word in sideways. You are probably a smart person & have thought a bit. I ask you—at last—an open-ended question. "Tell me more, what do you think?"

Perhaps this pain began after a new job as it did for one patient I met. His new job had long hours & he no longer could exercise. Gradually he put on weight. No one asked. Looking back, he noticed he had put on 35 pounds & slowly heartburn became more bothersome. This was really bad at night.No one asked. Someone told him Apple Cider Vinegar would help. Every morning he drank a few teaspoons. Two months ago he decided that, if a little vinegar had a benefit, he would switch to a lot of vinegar believing finally that should help at last. He wished someone had asked. He wasn't getting any better & so began drinking a LOT of vinegar. His chest hurt even more so he ate more too... Whatever your own tale is, be sure it is heard.

Because this was a story a patient told me recently. Unfortunately, he had tried to tell it to three other providers. Nobody got to the part with the vinegar. The first doctor gave him antibiotics and told him he must have bronchitis. The next, at an urgent care told him it was muscular and gave him a muscle relaxant, suggested physical therapy. The third told him he was anxious & should seek a psychiatrist.

By the time I saw him, the burning indigestion was keeping him awake at night & when he bent over he got acid backwash which burned into his nose & throat leaving him coughing. He was weary but still working long hours. Because of this, he had taken to drinking 6-8 cups of coffee & resurrected an old cigarette habit. He found the nicotine helped keep him alert at work. He was so worried about losing his job from exhaustion.

He had other problems by then. The 2 cups of vinegar hadn't started his problem. The weight gain arrived when his calorie count no longer matched his activity. His chest pain was from bad heartburn & his reflux actually sloshed up into his sinuses & lungs which fooled people into thinking he had lung and sinus infections. The vinegar—at that big dose—just didn't help matters.

What was depressing, besides how hard this fellow kept trying—was that nobody listened to what this man could have told. Nobody heard. No one helped.

And, it isn't just handing this fellow an acid blocker, I don't mean that. It means also hearing him the whole way. How to help about the crazy long work hours, lack of sleep aside from heartburn ruining quality. It's helping the man find quality and joy and—yes, exercise and health—but how? It's looking for preventative issues in the midst of urgent problems. There are much more dramatic examples. This was the easiest one.

I met a woman who complained of episodes of feeling faint and dizzy. These episodes had been going on for 2 years. She had been admitted to a hospital for them twice, seen these specialists: Heart, ENT, Neurology, Gut, Pulmonary, Internal Medicine, Sleep, Gynecology and had brain MRI, Brain vascular imaging, heart echo, heart vascular, lumbar and cervical imaging, breathing tests, endoscopy of upper and lower gut. Her cost to date was 17, 000 dollars. I can't imagine what the insurance must have paid. She was 48 years old. One specialist told her she had vertigo & had her go to vertigo therapy which gave her spinning vertigo so she stopped.

No one asked, but it all started when her mom in the patient's home country far away. The patient's sisters lived there had told her she was a bad daughter for not being there when the mom died.

The patient became anxious. The dizzy spells only occurred in large crowds like Costco or when her church was very full. If she left these crowded locations, symptoms vanished.

All other symptoms matched Panic disorder w/ claustrophobia. She worked on her grief & sorrow in therapy & her "dizziness" subsided. Actually just considering it as a cause helped. She had been so sad, she had also been eating poorly; better protein & fluids probably also benefited her. Nothing ever seems to have one cause or one solution. 

What Are The Lessons Found Here?

1.  A provider's history taking skills mature with time. Both provider and patient need to comprehend that a coherent history is critical, especially when a serious problem is under evaluation.

2.  Neither party should be afraid to connect & revisit the details of that history. Both sides can ask each other "What can I do or say to make this clearer, make myself more understandable?" And also both to say "This part I don't fathom yet."

3.  Patients & providers should question 15 minutes timeframes if either felt rushed. In some instances, these appointment lengths are irresponsible.

4.  Patients are smart. They can & should question the logic of a diagnosis whenever they wish. At the car shop, if the brakes still fail as we drive away from the mechanic's, we come back w/ the car immediately. Isn't human health as valid & valued?

5.   If insurance companies are driving the appointment time limit then patients & providers should join together & rebel as a united front.

6.  Providers can never be so arrogant NOT to ask: a) "Is there anything else I should be asking you?" b)  "Does what I am suggesting make sense to you?" OR "Are you comfortable with why I think this is what is going on with you today?"

7.  Patients cannot be afraid to say. a) "This doesn't make sense." b) "I would like a second appointment for more time to discuss." OR c) "May I have a second opinion?" Not to disrespect but just in case.

8.  Both patients & providers long for everything explained by one single diagnosis. But often, multiple forces are at play, & it can be hard to hold out for that truth. Having the stamina to stay the course, to witness multiple contributing threads is harder; like a tale with many subplots. Yet it brings one to honest solutions too. So hold on, even if your history feels entangled. Don't succumb to the seduction of the quick summary just because it is what feels easy. Patient & provider must encourage each other here. Better to decipher correctly at the first go around than to add more mayhem that others will later then have to decode on top of everything else. Simplicity is sweet as a sound answer but sinister when sham and it subjects the patient

9.  Providers are in this because we have curiosity, compassion, courage, analytical skills, & endurance. Maybe it's time we start having the mettle to demonstrate these traits.

10.  The exam room should be a safe place. It is the provider's job to make it so—does the patient feel the freedom to speak anything, point out any part of the trail missed, and request the provider ask further. The patient owns the story; they are the expert on themselves. We can't forget the respect owed that this engenders. The room is safe, we providers have no right to try & wrestle for power, to shame, to ask questions that are not really questions but are passive aggressive landmines. I have seen providers "Ask" questions such as "Why are you fat?" when that patient came in with strep throat.

11.  I am not the sharpest blade in the block, but anyone—even me—is trainable. Most of us had history-taking hammered into us by wise teachers. I know I was schooled on this by instructors far more astute than me. If I could learn to attend to another's story, anyone can.

In case a professor is reading this, yes, it is true, though I can take a history, I still must absorb the history then find a smarter doctor to help me solve the case. I am not trying to imply intelligence here, merely that we do not do patients a disservice with poor listening in the first step. My point is an accurately recorded narration alone helps people. Think of it. You try calling in a specialist w/o a true & complete tale to relate. Talk about harming someone…What good would I do if what I transmitted a false saga to the genius specialist I would be betraying the patient, & wasting not only the patient's care but my own & the specialist's time. That's cruel all the way around.

12. There will come a day, even in a provider's life, when you will be sitting in an exam room, wearing a hopeless little paper gown. Clutching the gown in embarrassment, as it slides, down your shoulder, or creeping up your leg in spite of your every effort to look tidy & relaxed. In the middle of your articulate summary explaining briefly yet efficiently, your recent bout of arrhythmia, you will notice the provider is just staring at the keyboard. Actually that he hasn't given you more than 10 seconds of eye contact nor seemed to hear one of ten words you've spoken. As a matter of fact, wait, isn't that his email he's checking? Doesn't he realize you are a doctor too, a senior partner? Too late now, he's getting up & you have only been halfway through your erudite review regarding breathlessness, your high lipids, & how your heart beat funny just the other day… But this damn provider's hand is on the doorknob—say, that's rude—and no EKG today even?! Suppose you are having early angina symptoms? Is this guy too stupid to listen to your ROS?! What's he saying now? "Great to meet you & how about come back in a year? I think your knee looks fine. But take about 10 pounds off, wouldn't hurt you. You aren't getting any younger. Bye now."

Yes, the symmetry of irony. But better, far sweeter, is that we treat all w/o resorting to thoughts of how we would like to be treated. We just do what is right because we know how to do the job. It's that simple. We do no harm. We aim for the care we are capable of right from the beginning, as we should. Aim for a level that the car mechanic wouldn't scoff at were he to review us, as he may. Have some decency, compassion. Do what is right simply because it is. Listen, ask, hear. Ask the patient if we are listening well enough. Hear THAT answer too.