Deep and Active Listening

My philosophy and approach to patient care can be summed up as, “Listen to the patient”.

As the daughter of a pediatrician and the granddaughter of a general practitioner, this is a lesson I learned as child from a father and grandfather who were beloved clinicians and superb diagnosticians. It was evident to me, years before I even considered going to medical school that the essence of good doctoring was to listen attentively and respectfully to the concerns of the patient.

In medical school, I, again, was fortunate to have great role models as teachers who emphasized the importance of taking an excellent history, and how this was the most critical part of the doctor/patient encounter. As I trained to become a psychiatrist, my understanding of what it means to really listen to patients became more sophisticated. From Dr. Paul McHugh, my former chairman in Psychiatry, I learned the importance of a comprehensive understanding of the patient as the crucial vehicle with which to formulate a case and craft a comprehensive and effective treatment plan.

My favorite quotation from Sir William Osler is his observation that it’s more important to know what sort of patient has the disease than what sort of disease a patient has. It’s a remarkable insight, from a remarkable clinician, and reflects his nuanced understanding that every patient is an individual with temperament, personality, and life history characteristics that shape the patient’s response to illness, disease, stress, and challenge, as well the way that illness, disease, and stress manifest themselves in the patient.

Listen to your patient

Yet, in many ways, it’s only now, after many years of clinical work, that I can fully appreciate the full measure of what it means to “listen to the patient.” As a psychiatrist, I’ve learned that patients sometimes voice their most significant underlying worry in the last minutes of an encounter, especially if it is something that is distressing, or embarrassing to them. It’s critical for the clinician to develop an approach to listening that is empathic and non-judgmental, and to pay attention both to what the patient says and how he/she says it. It’s a deep listening, noticing small cues, giving patients the space and time to speak, without jumping to quick conclusions that can short-change communication and curtail transfer of important information.

What I’ve learned as a clinician is that deep, attentive listening to patient is critical to three crucial arenas of patient care. First, it is essential for developing a rapport between doctor and patient and establishing a therapeutic relationship. Each patient encounter begins with the doctor as a stranger to the patient, yet we want our patients to trust us, to divulge their stories, their worries, and their foibles to us so that we can help them. It’s only through a trusting therapeutic relationship that patients will be open about their problems and honestly confide their concerns.

Second, deep listening is essential for accurate diagnosis of the patient’s problem. Often the initial chief complaint may suggest a particular problem, yet probing carefully and listening to the patient will direct the physician to a different, but more accurate understanding of the patient’s problem.

Finally, it’s essential for establishing a framework for therapeutics and treatment. As physicians we have to persuade patients to undergo treatments that can be uncomfortable, or complex, or that challenge their current understandings of themselves, or that don’t yield immediate results. Our patients must feel that we have really listened to them and understand both their problem and their concerns about the proposed remedy to their problem. Only then, will patients trust us to undergo the treatments and protocols that we propose and to bear with us when things don’t go as smoothly or as easily or as quickly as they would wish.

Active listening

What I’m describing is an active form of listening. The clinician can’t be a passive receptacle for gathering information from the patient. Rather, the clinician is always thinking, assessing, reflecting about what the patient is saying while simultaneously paying close attention to the manner of delivery and emotional response. It often requires the clinician to pay attention to his/her own internal reactions to the patient’s presentation because those “gut responses” can cue the clinician to notice incongruities or clues indicative of ambivalence or doubt which need to be addressed.

The challenge of deep listening

This type of deep and active listening to patients is never easy to do under the best of circumstances. It’s harder to do today than ever before as we grapple with pressures to see more patients in less time, and as we deal with challenges of documentation in an electronic record which also needs our physical and mental focus.

Modeling deep and active listening

I try to model and demonstrate this type of listening when I work with medical students and residents. I try to model for them the kind of deep listening that enables patients to feel comfortable with their doctor, and which leads to a fuller understanding of each case. A highlight of my week is always the medical student psychiatry clerkship case conference. In this weekly seminar, a clerkship student presents a patient’s history of a patient currently hospitalized on one of our inpatient units. Following this presentation I’ll interview the patient in front of the group of clerkship students for 20 minutes and then lead a discussion with the students about the patient after the patient leaves. I look forward to this session every week.

It’s a wonderful opportunity for students to see representative patients from different clinical services and broaden their knowledge about a wider range of psychiatric disorders, their clinical manifestations, and approaches to treatment. This seminar provides an opportunity to discuss important, and often more subtle points of interviewing patients and establishing a therapeutic connection with patients.

Even more, through the live interview, I aim to generate their enthusiasm and curiosity with me in wanting to understand the patient and his/her problem.

A favorite line of mine is teaching students that there is no patient who is not interesting to listen to, and that in listening well, we ourselves can learn from every patient. It is my fervent hope these intensive teaching sessions will resonate with the students for a long time to come and will help to instill in them a strong and lively sense of interest in every patient they will encounter in their careers, and the kind of interest that leads to active and effective listening.