When Patients and Doctors Don’t Hear Each Other
David Page, MD MFA
In a traditional clinic encounter the patient’s frightened, intimate first person voice becomes transmuted through jargon and evidence into the doctor’s omniscient third person point of view. The physician’s ‘authored’ interpretation of the history she’s hearing is subject to flaws in mishearing, misinterpretation and misunderstanding. These snafus may be amplified by either party.
That’s a lot of near misses for the least complicated aspect of what doctors refer to as ‘working up the patient’.
As a patient your unfettered narrative is often cluttered by your doctor’s experience, expectations, and prejudices. Doctors assume they are always right. A majority of the time your physician will be accurate when she assigns diagnostic meaning to your tale. Multiple readings of your story are not permitted. At least, not right now. Your doctor is on a quest, an important journey of discovery. She’s slugging through a laundry list of diagnoses in an effort to single out the significance of your symptoms. She’s searching through her mental files to identify your disease.
After all, that’s why you came to her.
Yet, as you toss out your deepest fears about what might be causing your pelvic pain or the blood from your nipple, you become aware that much of what you’re saying is having little or no effect on your doctor. Why? Doesn’t diagnosis depend on what you say? The easy answer is yes. And no.
This raises the question: what is a medical history?
Really, why the confusion about something as elementary as you telling your story about how you feel? As a patient you must keep what I’m about to tell you clearly in your sights as you interact with your doctor. This advice reduces the possibility that you will misinterpret your doctor’s intentions. It also opens the door to improved communication and caring. A lot of patient-physician interactions fail because neither the doctor nor the patient is sensitive to the nature of the other’s focus.
Here’s your pearl: your doctor is creating an objective medical history; you are relating your subjective illness narrative.
Could doctors learn a lesson from literary deconstruction theory? We might well accept as progress that a medical history in the service of making a diagnosis differs from the patient’s illness narrative. Doctors should know what they’re after. Excessive exposure to the emotional underbelly of the patient’s story might well hamper the physician’s understanding of the disease. The threat of misdiagnosis and of offering the wrong treatment hangs in the balance between information gathering and interpretation.
Empathy may be the last thing on your doctor’s mind.
Multiple readings of the medical history are not permitted for practical reasons. Diagnostic clues may become submerged beneath the raw surface of a fear of dying or mutilation. Often while the doctor is seeking key clues to diagnosis, the patient is serving up a lumpy gruel of symptomatology, of what’s really bothering her, and her admission of her dread of lethal illness.
Meanwhile, the doctor searches her mind for links, for connections between shortness of breath and bloody sputum, layering in the importance of the smoking history, often unconsciously labeling the patient irresponsible. Physicians’ unspoken periodic annoyance with the unwashed masses remains embedded and unacknowledged in medical care today; numerous reports have documented the inadequacy of care received by African Americans and other minority groups. The bright illumination of cultural sensitivity medical schools defend often experiences an ethical ‘brown out’ in the clinic and ER.
The logical way to resolve the various demands on the medical history and the patient’s illness narrative is to cultivate the notion of individual history, and thus the patient's own truth: a story that only emerges over time. In this way, whether or not a patient’s record is assembled in the outpatient setting or as a complex hospital chart, the entire medical record could be viewed as the history of that patient’s illness. Not only would the chief complaint, the history of the present illness, and other aspects of the history and physical examination be cordoned off in separate tabbed compartments, but the disease would be intermingled with the patient’s illness narrative as various caretakers write in their observations of the patient-in-evolution.
The introduction of such things as the patient’s greatest fears – of course, somebody would have to actually talk to the patient and ask them what was bothering them – into the progress notes would dilute the technological burden of the chart. “Sarah is afraid of smothering in the MRI machine,” annotated by a nurse or doctor would humanize the diagnostic interventions and medications listed with scientific authority in separate sections of the medical record.
Empathy requires a close reading of the patient.
This tight focalization requires a hand-held lens and high magnification obtained by sitting close to the patient. It requires one to listen. And it takes time. It cannot and should not be attempted all at once. Patients must be, well, patient. Hospital care is constructed around waiting. Waiting for your doctor to make rounds, waiting for breakfast, waiting to have a test, waiting for the results of that test, waiting for your doctor’s interpretation of the results of the test and the decision: what to do next?
And through it all the best doctors return to the bedside if only for a quick word of encouragement. Eventually, descending from the Mount Olympus of detachment and sitting on the bed sharing the story as it gets retold, together patient and doctor seek patterns and possibilities. In this fashion a clinical truth emerges over time, a verisimilitude that rises up from the backside of terror as much as the facts of the case.
You have to be listening to get it. You have to believe there is something valuable beyond data points and the word scramble of medspeak. It is where meaning lives, an exhalation of pent-up breath often missed by physicians.
Were I to select potential medical students, I’d take the ones who wanted it most, craved the caring life. If only medical school dean's believed what they say about caring versus a 4.0 GPA. If only we could measure the capacity to hurt, to experience pain in others. Is there some bipolar magnetic opposition between intelligence and empathy? Can you buy both in the doctor marketplace?
And when it all fails and death strolls the hospital’s corridors, doctors frequently scatter like pigeons.
So how do we shrink the narrative distance between physician and patient? Can empathy be taught? Do we each need to suffer before we can sense another’s pain? Is there a ganglion in the brain that patients possess that helps them sense empathy like a sweet alluring aroma in their doctor?
To reach a patient’s pain we must be willing to compress the emotional distance between our words and the patient’s heart. We must listen to the rhythm of the patient’s fear, the profluence of adjectives, the hesitation, the silences. We must learn to wait through them in order to hear the panic.
We have no scanner to detect a patient’s horror.