by Vikas Saini
October 17, 2016
(STAT) – Ten years ago, a woman with a heart murmur who experienced a bout of dizziness saw me for a second opinion. Another cardiologist had told her she needed open heart surgery to replace a valve in her heart. The idea of surgery terrified her, in part because she believed she would lose her job if she took time off from work. She knew she needed a new valve at some point, but hoped to put it off until she retired in eight years.
Her cardiac ultrasound looked horrible and, based on that alone, qualified her for surgery. But the more I listened to her story, the more it didn’t add up. Her dizziness had been fleeting, likely from a virus. She was extremely active, exercising vigorously several times a week with absolutely no symptoms. Her pulse wasn’t worrisome, nor was sound of her heart murmur through the stethoscope. I asked her to do a treadmill exercise test, which she passed with flying colors.
So I ignored the ultrasound results and listened to what my patient and her body were telling me. When I said it would be perfectly reasonable for her to wait on surgery and check in with me every six months, she overwhelmed me with her gratitude and relief, like I had commuted a death sentence. This year, 10 years later, she finally had her valve replaced.
In medical school, doctors-in-training are taught that 85 percent of a diagnosis comes from a careful history, and another small portion comes from the physical exam. But these days we are so busy testing that it’s easy to miss the subtle — and sometimes not so subtle — indicators of a patient’s health. It’s certainly quicker to order the test, get some numbers, and then treat the numbers instead of the patient.
The doctor-patient visit is becoming a commodified transaction rather than a collaboration. Clinical life feels more and more like sprinting on a hamster wheel, chasing unproven metrics to get graded on “quality.” It’s no wonder that burnout is exploding among physicians across the country.
The idea that more is better has many Americans going from doctor to doctor to doctor, getting test after test, and becoming increasingly anxious about our health while increasing the cost of health care.
We’ve been told that a big problem with health care is inefficiency and waste. (It is.) We’ve been told that old fashioned doctoring results in huge variations of care. (It does.) We’ve been told that constant electronic nudging will make doctors better. (Maybe.) Doctors are being told they must make their productivity numbers to keep their jobs and prove they are efficient. (Sad but true.)
Pioneering cardiologist and Nobel Peace Prize winner Dr. Bernard Lown has said that the usual rules of efficiency are inverted in medicine. The more time a physician spends with patients, the more efficient he or she becomes. Listening costs next to nothing, and so is infinitely more cost-effective than drugs and devices. Listening promotes healing and causes no harm. In fact, it’s the bedrock of a genuine trusting relationship — something everyone wants from their doctors and nurses. In the tone of voice, in the subtlety of the pattern of pain, in getting the sequence of events right — that’s how a correct diagnosis is made and the person emerges from the patient. If all health care providers listened better, we would save billions of dollars and transform the system. So why don’t we have the time we need to listen?
Because clinicians have been put on a treadmill driven by the pitiless demands of a false concept of efficiency. Money has replaced quality care as the measure of health care. The idolatry of the market is driving a race among hospitals, insurers, and manufacturers to get bigger and bigger.
To fix health care, we need a genuine democratic dialog. To start that, our society needs a massive dose of listening to understand what really matters to patients and communities.
This week, close to a thousand doctors, nurses, and patient activists are making extra efforts to highlight the lost art of listening as part of Right Care Action Week, which is sponsored by the organization I run, the Lown Institute. In order to listen to Americans talk about their own health and the health care they receive, they will set up listening booths on busy streets, participate in health care “story slams,” and call patients to ask what worries them most.
If listening matters in the exam room, it matters even more in our society.
In the early 1960s, a decade into the civil rights movement, students went to Mississippi to organize partly because it was the most difficult place in which they could imagine being successful. When they arrived, they met with scores of leaders in the churches and NAACP chapters. They solicited ideas from ordinary local people like sharecroppers and farm laborers. It was through this months-long process of intensive listening that the students learned what people wanted from the civil rights movement: “What we want is to be able to vote.” The next phase of the movement was born, and together they made history.
We face a similar moment today in our efforts to fix health care. To make a difference, we must first identify what matters most to patients, health care providers, and communities. To do this, we must all learn to ask open-minded questions and listen carefully. That’s why doctors, nurses, students, patients, and community leaders are listening hard across the country this week. It’s the necessary prelude to action.