How not to be a doctor
Interpellant article paru dans le QMJ ce mois, posant avec pertinence les questions relevées lors des débats du cours Visages de patients. Merci à Pierre Chevalier et à son épouse qui nous l'ont transmis.
‘How can I help you?’ I asked. It isn't the way I always open consultations but I was making a teaching video, so I thought I would be conventional for a change. As it turned out, it was a fortunate move. ‘I’m not sure if you really can help me’, the patient answered. ‘I’ve seen lots of specialists, and none of them have managed to help me so far. You see, I keep having these funny turns ...’ Two weeks later, when showing the video to a group of senior house officers, I stopped the recording at this point and asked them to write down the woman's presenting complaint. All ten of them wrote down ‘funny turns.’ They were wrong, of course. The woman's presenting problem was that she wasn't sure if I could really help her. The funny turns were at this point a lesser problem.
There were more shocks in store for the group. I spent almost the entire consultation asking the woman about her experience of other doctors, and what they had got wrong. I listened as dispassionately as I could, without dismissing her catalogue of disappointment or offering any hint that I might do any better myself. In the end I asked her what she thought the doctors ought to have done instead. She told me: a referral for homoeopathy or acupuncture. I asked her which of these she would prefer. She chose the homoeopathy referral, and I said I would arrange this. As she left, I thought she was going to cry with relief.
After I had finished showing the video, one junior doctor erupted. How could I have been so incompetent—not to take a full history, or indeed any history at all? How could I be so irresponsible, by assuming that the other doctors had done their job properly? How could I be certain that her funny turns did not presage some terrible, terminal disease? If I thought the problem was psychosomatic, why didn't I take a decent psychiatric history instead? And how could I possibly direct her, without a clear diagnosis, towards a form of treatment that I probably didn't believe in, and which lacked a thorough evidence base?
A number of other doctors in the group came to my defence. Some had realized that I might have looked at the notes in advance, and that I might be willing to trust local colleagues not to make gross errors of judgement. Others had heard the patient mention that she had gone through the mill of extensive and futile investigations several times over. One or two had noticed how the patient gave indications of an aversion to anything remotely suggesting psychological inquiry. A particularly thoughtful doctor pointed out that no intervention was without its risks; at this stage it would probably cause the patient more risk if I started all over again, instead of just doing what she wanted. Yet their sceptical colleague remained unconvinced. How could I have behaved so ... so ... well, so unlike a doctor? I took the question as a compliment.
Of all professions, doctors are almost invariably the most proficient at not listening. Indeed, a friend of mine sometimes describes my educational work in consultation skills as ‘remedial therapy for selective brain damage’. It is a cruel characterization, but I do not entirely object to it. I am struck again and again by how much medical listening—even the kind that sometimes passes for being ‘patient-centred’—falls desperately short of anything that one might expect from an attentive, untrained friend. Many doctors seem to tune out totally from any words or phrases that do not fit the medical construction of the world. In addition, most appear to be extraordinarily timid about going where the patient wants to lead, for fear that this will break some rule, or upset any other doctor who might hear about it.
When it comes to unexplained symptoms, I often observe doctors fall back on an impoverished list of questions such as ‘are you under any stress?’ rather than displaying any true curiosity about the story itself. There are two other common consultation ploys that bring me out in an allergic reaction. One is the question ‘How did you feel about that?’. It is generally asked as the doctor asking leans forward in a theatrical pose of solicitousness, but with eyes glazed over in weary automatism. The question seems to go with a belief that it will elicit some definitional nugget of truth, accompanied by a sublime catharsis on the part of the patient. It arises, I guess, from some ghastly misreading of Freud's more minor followers, but ninety-nine times out of a hundred, it is emotionally bogus. The other manoeuvre that I find equally offensive is the phrase ‘It sounds as if ...’ (as in ‘it sounds as if you’re very upset ...’). Believe me, if it's so bloody obvious that even a doctor has noticed, it usually isn't worth saying.
Lois Shawver, a Californian therapist and teacher whom I much respect, has come up with a wonderful distinction between ‘listening in order to speak’ and ‘speaking in order to listen.’ In the former, you merely scan the words that patients are saying, looking for opportunities to dive in and tell them what is ‘really’ going on. In the latter, you do the opposite: speaking only in order to give them more opportunities to explain their own view of the world. In a post-modern age where the authority of professional knowledge is gradually waning away, Shawver argues that we will have to learn how to speak less and listen more.
In the same vein, the late Harry Goolishian, one of the founders of narrative approaches to psychiatry, offered the advice: ‘Don't listen to what patients mean, listen to what they say!’ Quite simple really, except that we probably still fail to do this, most of the time.
John Launer
A number of other doctors in the group came to my defence. Some had realized that I might have looked at the notes in advance, and that I might be willing to trust local colleagues not to make gross errors of judgement. Others had heard the patient mention that she had gone through the mill of extensive and futile investigations several times over. One or two had noticed how the patient gave indications of an aversion to anything remotely suggesting psychological inquiry. A particularly thoughtful doctor pointed out that no intervention was without its risks; at this stage it would probably cause the patient more risk if I started all over again, instead of just doing what she wanted. Yet their sceptical colleague remained unconvinced. How could I have behaved so ... so ... well, so unlike a doctor? I took the question as a compliment.
Of all professions, doctors are almost invariably the most proficient at not listening. Indeed, a friend of mine sometimes describes my educational work in consultation skills as ‘remedial therapy for selective brain damage’. It is a cruel characterization, but I do not entirely object to it. I am struck again and again by how much medical listening—even the kind that sometimes passes for being ‘patient-centred’—falls desperately short of anything that one might expect from an attentive, untrained friend. Many doctors seem to tune out totally from any words or phrases that do not fit the medical construction of the world. In addition, most appear to be extraordinarily timid about going where the patient wants to lead, for fear that this will break some rule, or upset any other doctor who might hear about it.
When it comes to unexplained symptoms, I often observe doctors fall back on an impoverished list of questions such as ‘are you under any stress?’ rather than displaying any true curiosity about the story itself. There are two other common consultation ploys that bring me out in an allergic reaction. One is the question ‘How did you feel about that?’. It is generally asked as the doctor asking leans forward in a theatrical pose of solicitousness, but with eyes glazed over in weary automatism. The question seems to go with a belief that it will elicit some definitional nugget of truth, accompanied by a sublime catharsis on the part of the patient. It arises, I guess, from some ghastly misreading of Freud's more minor followers, but ninety-nine times out of a hundred, it is emotionally bogus. The other manoeuvre that I find equally offensive is the phrase ‘It sounds as if ...’ (as in ‘it sounds as if you’re very upset ...’). Believe me, if it's so bloody obvious that even a doctor has noticed, it usually isn't worth saying.
Lois Shawver, a Californian therapist and teacher whom I much respect, has come up with a wonderful distinction between ‘listening in order to speak’ and ‘speaking in order to listen.’ In the former, you merely scan the words that patients are saying, looking for opportunities to dive in and tell them what is ‘really’ going on. In the latter, you do the opposite: speaking only in order to give them more opportunities to explain their own view of the world. In a post-modern age where the authority of professional knowledge is gradually waning away, Shawver argues that we will have to learn how to speak less and listen more.
In the same vein, the late Harry Goolishian, one of the founders of narrative approaches to psychiatry, offered the advice: ‘Don't listen to what patients mean, listen to what they say!’ Quite simple really, except that we probably still fail to do this, most of the time.
John Launer
QJM 2006 99(2):125-126; doi:10.1093/qjmed/hcl003
posted by Carl Vanwelde at 10:01 AM
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