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Listening is Good Medicine

Posted By Peter Fifield, Monday, February 8, 2010
Updated: Thursday, June 2, 2011

The National Day of Listening happens every year, the day after Thanksgiving. I know it was a while back but due to both a past blog and a recent patient encounter I began thinking about this concept again. This year during National Day of Listening, I chose to interview my father. He has lived a fulfilling life in his 78 years. When we sat down to kick the "interview” off he, with sincere curiosity, asked "You are not doing this because you think I’m going to die are you”? After I debunked this myth of his, we proceeded. With a digital recorder on the table, we sat and talked over coffee for about two hours. My entire life, I have had a great communicative relationship with my father but something was different this time. This time my sole intent was just to listen, nothing else. I had no intentions, no predispositions, no expectations, just open ears. I learned a lot about my father that day that I had never known before.

For a Behavioral Health Consultant (BHC) in a primary care setting, this happens (in a much abbreviated fashion) on a daily basis. We learn about our patients through listening to them. A recent web article puts communication third on the list of things patients want from their providers (after eye contact and partnership: two other integral parts of communicating). Communication as we all know is bidirectional—both inquisitive and declarative—and as many surveys have pointed out, patients want more in terms of healthcare than just to be told what to do. However, in a world of fifteen minute fee-for-service health care visits this has proven to be quite difficult for the average primary care provider (PCP) to perform. PCP attitudes regarding this high level of communication vary from virtually uninterested to dutiful: I have worked with both.

During the onset of the 20th century, Sir William Olser counseled his Hippocratic brethren to "Listen to your patient, he is telling you the diagnosis”). Why is it that so many patients still complain that "my doctor doesn’t listen to me? Well because they don’t…at least not to all of it. The Happy Hospitalist states quite clearly that doctors do ignore patients, because they have to. PCP’s need to filter what they hear in order to provide accurate, succinct and timely care for their patients. That being the case, where is the middle ground? When over 70% of patient visits in the primary care setting are psychosocial driven—how can the PCP, proffer an environment where patients can express not just their physical but their psychosocial needs? And of course, now fit all of this into a 15 minute slot (including charting). One option is to utilize Motivational Interviewing (MI) skills designed for the primary care setting. Although this approach necessitates some practice, the learning curve is not too steep and the average Joe, can adapt rather quickly. This MI approach requires the strategic use of certain communicative tools, that allow one to express empathy, develop discrepancy, work with patient resistance and support self efficacy (Miller & Rollnick).

For a growing number of primary care offices, the BHC is a viable option to fill this void—we get paid to listen. As Sir William Osler so pithily stated, listen to your patients. The BHC can enhance the PCP’s ability to hear the patient’s needs—not replace it but enhance it. Although it sometimes happens, the concept is not to merely pass off a rambling patient to the BHC because the PCP doesn’t have time and the BHC does. The BHC role is to improve the diagnostic and treatment abilities of the PCP. Two sets of ears, listening from two different and distinct perspectives to the same set of symptoms.

Recently, after an initial 15 minute consultation w/ the PCP and a new patient I was hugged by the patient in the exam room. Upon leaving she said "Thank you so much for just hearing what I had to say, I felt like no one was hearing me, no one”! We all have a story, and I listened to hers. Interestingly enough, at no point during our consultation did she mention any medical indications. She has returned a few more times since for follow up and Hypertension has been removed from the problem list. Now I’m not so naïve to think that all medical ailments can be healed by merely lending an ear, however; patients are the experts on themselves, they just need help interpreting what they know. Listening is a mean to this end which makes it good medicine.

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Randall Reitz says...
Posted Friday, July 8, 2011
Pete, apparently writing is good medicine, too. Reading this post lightened my soul.

In a primary care world where even counselor visits frequently get shortened to 15-20 minutes it is easy to feel overwhelmed by the pressure to provide on-demand pith and profundity. This is compounded by doing most of our work in the audience of physicians and other collaborators.

I distinctly remember when I was brought in for my first patient introduction at Marillac Clinic 10 years ago. We had a wonderful nurse practitioner who served up the perfect softball of a referral and then looked to me to take over the conversation. I got completely tongue-tied because I wanted to solve all the patients' problems with the perfect intervention. Over time, I learned to return to my Counseling 401 skills: warmly greet the patient, listen to her story, summarize the salient points, and offer some version "You came to the right place, we see this all the time here and we have a wonderful team that will help you to get back on your feet."

Listening, then reassuring and connecting. If we take the time to hear our patients, they'll tell us it's what they really want.
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