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Listening As Medicine

Robert Kornfeld, DPM writes about the lost art of listening in medicine and claims that this loss is having a negative effect on outcomes.

July 18, 2023

As doctors, we spend years in rigorous training atmospheres where we must learn, imbibe, and apply all the information we are taught. Our minds are trained to evaluate symptoms, choose the most appropriate lab work or imaging studies to confirm our suspicions and then apply a treatment protocol to help our patients. On the surface, it makes a lot of sense. After all, aren’t we there to figure out what’s going on and then treat it?

Well, yes…and no. One of the blessings, and at the same time one of the problems inherent in medical training of any type, is that we are in clinic and hospital settings designed to expose us to the most amount of pathology so we can have a well-rounded and thorough education in our specialty. We are taught to listen to the chief complaint, get a history of the symptoms, come up with a differential diagnosis and we then concoct a diagnostic and treatment approach for this patient. The system has a responsibility to expose us to as much pathology as possible so when we finish training and enter into private practice, we are prepared for anything we may encounter. And on the surface, that is good.

However, what we are often not prepared for is the reality of treating our own patients in our own private office setting. There is an added level of intimacy in a private office as opposed to a hospital or clinic setting. And yet, we tend to approach things the same way. Think quickly, evaluate what you believe to be going on (there is a tendency to jump to a diagnostic conclusion before the patient can get a word in) and proceed. What is often missed is the human connection. The patient on the other side of our examining fingers is often nervous, frightened, stressed, skeptical and frustrated with whatever it is that is going on. And then we come into the room, blow through the exam quickly, give a quick explanation and leave the patient unsure of what is going on. And more importantly, we may unintentionally leave them feeling disconnected from us, the very people who are there to help and reassure them.

 

There is an added level of intimacy in a private office as opposed to a hospital or clinic setting. And yet, we tend to approach things the same way. Click To Tweet

 

If there is one thing I hear most often from my patients, it is that the last doctor (or doctors – many of my patients have seen numerous doctors for the presenting problem) “didn’t even listen to me”. We must remember that our patients are living their story. And they want to share that story with us. And when they are given that opportunity, two things happen: 1) they form a bond with us that leads to greater trust and compliance and 2) they may reveal more information that completely changes the direction of our work up and differential diagnosis.

 

"We must remember that our patients are living their story."

 

Our current system of insurance-dependency does make it harder to change this unfortunate dynamic. Head buried in a computer compiling information for EHR that will stand up to an audit certainly changes the level of intimacy that can be achieved. It isn’t easy to listen and type at the same time. All the while, ICD10 codes and CPT codes are taking up disc space in your mind and you are not really paying attention.

I admit that I walked away from insurance-dependency 23 years ago. In direct care settings with a much lower volume of patients, you can actually sit in front of your patient without having one foot out the door running to the next patient. What I have been able to nurture first and foremost is my relationship with my patients before I have evaluated their “story” for clues. I never touch my computer during an encounter. I sit, with full attention and eye contact, and I ask them to share what brought them into the office. In this type of setting, you can bet that your patients will have a lot to say. First, about their disappointments with their previous doctors and then an often-long-winded tale about why they are there and all about the history of their symptoms.

All through this part of the encounter, I may jot down a few notes (I have learned to commit most of what I hear to memory) but I maintain eye contact, so they know I am present, attentive and most of all that I am listening. Listening! This is the magic ingredient for a potent doctor-patient relationship. Listening not only invites a full understanding of what is going on, it truly starts the healing process.

 

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Ask any patient who loves their doctor why they love him/her and most will tell you that “my doctor really listens to me”. So many times, as I am listening to a patient tell me about their experience with chronic foot or ankle pain that has forced them to give up the lifestyle they so desperately miss, I will say something like “That has to be so hard for you” and their body language immediately changes. They feel safe! And I cannot think of a better way to jumpstart the healing process than to have a patient who feels safe, heard, and acknowledged.

Attentive listening is the missing ingredient in today’s fast-paced medical system. Many important clues are missed. Too many assumptions are made. Keeping an eye out for things that are uncommon is rare because it is too time consuming. And sadly, mistakes are made and diagnoses are missed.

We have come to rely on technology way too much. We have lost the human element of “doctoring” our patients. We have lost the ability to listen, patiently, while our patients build trust with us as they share what they need to share. This is something I know every DPC and DSC practitioner can relate to. We all find a deepening of our doctor-patient relationships because not only do we have the time to listen, but we actually do listen.

 

"Listening! This is the magic ingredient for a potent doctor-patient relationship."

 

I admit I do not know what to tell doctors who are still in the system running very high-volume practices about listening skills. I have been away from the system for too long to make any recommendation. And please understand, I am not here to criticize any of you. But I have been a patient many times and have experienced the very same thing – I have not been listened to. And I hear it every single day from my patients who express gratitude to me for really being attentive and listening to them.

In summary, I will assert that listening is the first prescription that must be filled. Once that “dose” is given, we have a much better chance of healing our patients.

All opinions published on SomeDocs-Mag are the author’s and do not reflect the official position of SoMeDocs, its staff, editors. SoMeDocs is a magazine built with the safety of free expression and diverse perspectives in mind. For more information, or to submit your own opinion, please see our submission guidelines or email opmed@doximity.com. Do you have a compelling personal story you’d like to see published on SoMeDocs? Find out what we’re looking for here and submit your writing, or send us a pitch.

All opinions published on SomeDocs-Mag are the author’s and do not reflect the official position of SoMeDocs, its staff, editors. SoMeDocs is a magazine built with the safety of free expression and diverse perspectives in mind. Do you have a compelling personal story you’d like to see published on SoMeDocs? Submit your own article now here.

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One Response

  1. Spot on, Robert. Two ears, one mouth.

    I left my first job because I couldn’t do this adequately for my patients. I now feel fortunate to work within a team-based care model (still insurance, still plenty of headaches) that allows me to be a doctor.

    Like you, I never touch or look at the computer in front of a patient. This makes their perception of the time I spend with them a lot longer than it sometimes actually is.

    Perhaps I’m fortunate because the only other dermatology game in town is a blood sucking for profit PE-owned venture. Many of my patients express relief and gratitude given what they did not experience with their first dermatologist.

    Thank you for sharing this and congrats on 23 years of staying true to yourself and taking great care of your patients.

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