We are constantly told we need to listen to our patients. “Be a good listener.” “You’re not listening!” “Were you even listening to me?!” However, we can listen to the patient, examine them, and make an assessment and plan that is top notch and still the patient may leave feeling like they were not heard. This is because it is not about listening per se, but being present with the patient. Being present is about attention.
Being present means being free from distraction, both internal and external. To make this happen, minimize any notifications that may interrupt the encounter. The moment you are distracted, and your attention leaves the patient and moves on to something else, it takes a while to bring your attention back.
This increases your cognitive load, and the distraction is revealed to the patient through nonverbal cues. To think that distraction will not occur is unrealistic. Better listeners tend to recognize distraction sooner and they do so because they care more, both about listening and the perception of inattention, so they are sooner to course correct.
There are also other distractions that can occur during a patient encounter, like having to answer a call from another physician or an emergent issue. The patient deserves to know what superseded their visit (no privacy violations!) and when you restart the encounter, apologize, and verbalize that they have your full attention again. They need to know that they are the most important person to you in that moment. You need to give them your full attention and make sure that they also have the perception that they have your attention.
You cannot fake paying attention, but you may be giving off signals that you are not paying attention when you really are (see blog post on nonverbal cues).
Rather than focusing on listening better to others, we can start with ourselves and our attention. We need to think of ourselves like our phones or laptops, with browser tabs open, mulling over issues at work and home, drawing our attention, distracting us from the person in front of us.
To be able to give our patients the attention they deserve, we need to close those browser windows. It helps to be mindful of this by having a ritual before each patient encounter to remind us to be present. A simple one would be to take a deep breath and have a sip of water (I always forget to drink!). This will help to center us and make sure that we are present in the moment.
Listening is not only about attention. There is also…the listening. As physicians, we are listening for the practical information to determine the diagnosis and treatment plan, but we also need to be listening for emotions. This will come in the form of nonverbal cues, which parts of the story are causing emotional distress, which may not take us closer to the conclusion of the visit, but also needs to be addressed if we are genuinely interested in taking care of the whole patient.
Often the emotional issues are the ones that can be sticking points in a visit if we feel like we have arrived at what may have been an elusive diagnosis, but the patient is still unsatisfied or feels like the visit was incomplete. In that regard, getting these issues out in the open can lead to a more efficient and satisfying visit for everyone.
Giving a patient an opportunity to tell their story uninterrupted can be therapeutic in and of itself, and can go a long way towards building that rapport and trust. We are taught that physicians interrupt too quickly and too often. It can make it seem like we do not have time for them or we are not interested in what they have to say because we know better, so it needs to be explained.
Interruption can be the sign of an attentive listener, like a book editor, so interruption is acceptable if it is done respectfully and to facilitate the telling of the story. It is also necessary because while we need to respect the time of the patient in front of us, we also need to respect those in the waiting room and those waiting for appointments.
Interruption is useful if there is a lot of repetition, if they are tangential in their history, or answer a question in a way that does not get the information you may need. This can indicate that the speaker is having some difficulty telling the story. Similarly, if the history telling is not making progress, this also indicates that some facilitation is necessary.
Listening and acknowledging all their issues does not necessitate addressing them as well. When there are many issues, the visit can either be expanded indefinitely or truncated, scheduling the patient for follow-up to address other needs. Sometimes there is not enough time to give each issue the attention it deserves, the attention the patient deserves. Patients will usually respond well, if you explain it as such.
This message must be delivered with respect, care, and concern. It all comes back to attention. “Mr. O’Flannery, I’m so glad we were able to get to the bottom of your sinus headaches and we were able to troubleshoot your CPAP machine, but the dizziness you are describing sounds too complicated to be squeezed into today’s visit. It sounds like something that deserves its own visit so we can give it the attention it deserves. I’ll walk you out to make sure you can be scheduled expeditiously.”
Be present, pay attention, listen for emotions, not just facts, and interrupt to facilitate the telling of the story. Oh, and do not forget to examine the patient, make an assessment and plan, document, and stay on time. And do that 20x a day every day. I understand. I am in the same boat. It helps to practice these listening skills in a social setting so they come more naturally in a professional one.
There has been one unforeseen negative aspect; I am more keenly aware of when others are not present with me.
My sensitivities notwithstanding, this focus on listening and being present has made my patient interactions more efficient and more fulfilling and this skill has spilled into other aspects of my life in a very positive way. While I am not always as present as I should be, my awareness allows me to keep improving.
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