The Listening Problem 

Noah Taeckens 

IDMD 101 Short Paper 

10/10/23 

“Why Doctors Don’t Listen to Patients” is a short article written by Qing Yang, a doctor who graduated from Yale’s School of Medicine, and Kevin Parker, a public policy administrator, as part of a local newspaper outlet in Springfield, Illinois called “Special To The State Journal-Register.” The article discusses the importance of listening when practicing medicine and why that skill has fallen out of favor with physicians in recent years. Yang and Parker start off by stating that in the modern age of medicine and technology, listening has taken a back seat due to time constraints. The authors claim that an average primary care physician sees about 20-30 patients a day for usually only 15-30 minutes with little time in between visits to return calls, chart information, and write prescriptions. As a result, physicians are overwhelmed and constantly running behind schedule. In order to make up time, physicians in all disciplines including specialties, become overly reliant on the decision-tree model to ask rapid-fire questions and generate a quick diagnosis. This is problematic because it makes the patient feel as if their thoughts are not valued and could cause the physician to ignore issues within the biopsychosocial model, such as the effects of grief. The article ends with Yang emphasizing the need for physicians to actively work to clear the listening hurdle and resist the urge to forgo real and meaningful face-to-face interactions. While failure to listen may seem trivial, Yang and Parker shed light on why that is not true. Patients are more than their disease, and thus failure to treat them as complete human beings, with emotions ranging beyond their chief complaint, results in worse outcomes. As the Hippocratic Oath states, “There is an art to medicine as well as a science.” 

The “art” of medicine is perhaps best expressed by the biopsychosocial model. George Engel first suggested the concept in a lengthy paper in 1977 and since then its ideas have permeated the worlds of medical literature and philosophy, including as a focal point in Jacob Stegenga’s “Care and Cure.” The biopsychosocial model states that a person’s biological, psychological, and sociological health are all distinct, yet interconnected, meaning that they can affect one another. Based on that idea of interconnectivity, the model calls for physicians to examine their patients in a more holistic manner. Instead of purely examining biological issues, physicians need to ask open-ended questions and obtain qualitative information to gauge how their patient is doing psychologically and socially. This is necessary because a patient’s psychological and sociological health can have a strong impact on their biological health and vice versa. In essence, the biopsychosocial model implores physicians to examine the whole person behind the patient. In order to successfully examine the whole person, a physician must listen to that individual. This is where conflict arises, and it’s not necessarily all the physician’s fault. As Yang and Parker point out, the medical training system is deeply flawed: “medical training still emphasizes asking questions more than listening for answers. Even the asking has shifted to diagnostic tests and the search for “data,” rather than direct conversations with patients.” While we have been blessed to live in a golden age of medical testing where almost any condition can be discovered based on lab results, data only tells the biological side of the story. Data can tell a physician that a patient’s calorie intake is too low. However, data cannot tell that the low-calorie intake is a result of heartbreaking grief that a patient is shouldering by hyper-controlling the one thing in their life they can still control: food. In this situation, overreliance on data and the biological model may lead the physician to simply tell their patient to eat more, missing the evidence of the beginning of an eating disorder that requires therapy. 

An extension of this overreliance on the biological model that poses new roadblocks to listening is the decision tree; a decision-making flowchart used by physicians to quickly come up with a logical diagnosis. While the tree sounds good in theory, it often causes physicians to miss the rarer cases, or situations that don’t fit cleanly into a box. This happens for two main reasons: the desire for efficiency and stereotypes. Yang and Parker touch on efficiency by stating, that physicians often do not evaluate their patients on a biopsychosocial level because they are too busy getting through “guidelines, algorithms, and checklists” and thus there is “little room for open discussion.” Additionally, the authors claim that stereotypes and biases are unfortunately, and often accidentally, used by some physicians in the “helpful skill of pattern recognition” which can increase the “risk of drawing conclusions too early” based on preconceived notions. When one combines the effects of stereotyping with the push for an efficient decision tree model, the effect on patients is devastating. Instead of walking into an environment centered around the patient, patients are walking into an environment centered around time, all the while providers scrutinize them based on their appearance and their race among other things. When the patient finally gets to the exam room, the provider may already have a diagnosis cemented, before the patient has even had a chance to speak. Not only is this offensive and hostile to the patient, but more importantly, it is the wrong approach, even from a purely scientific perspective. While rushing and stereotyping may work for the regular fall flu case, it will potentially cause the provider to miss the lurking meningitis case, a mistake that could have fatal consequences. 

The lack of physician listening is a problem that is only getting worse because of the extensive use of technology and online health visits replacing in-person sit-downs. Technology, while helpful, has exacerbated the problems posed by the overreliance on the biological model and the decision tree model. However, the patient-physician relationship and listening itself are not doomed. In understanding why the biological model is flawed and how physicians need to go beyond using a decision tree, we can avoid the pitfalls of these issues. In other terms, awareness is the solution, and not just for the doctor. Patients have agency and can take charge of their own care. If patients are made aware of the dangers of failure on the physician’s behalf to listen, and refusal to evaluate based on the biopsychosocial model, then they will feel more empowered to speak up when necessary. It is through communication and development of the patient-physician relationship that the medical world will learn to listen again and in doing so will better itself to the benefit of the patients. 

Sources: 

Miles, Steven H. The Hippocratic Oath and the Ethics of Medicine. Oxford ; New York :Oxford University Press, 2004. 

Stegenga, Jacob. Care and Cure: An Introduction to Philosophy of Medicine. University of Chicago Press, 2018. 

Yang, Qing, and Kevin Parker. “Why doctors don’t listen to patients.” The State Journal-Register, 22 November 2022, https://www.sj-r.com/story/lifestyle/health-fitness/2022/11/21/why-doctors-dont-listen-to-patients/69658485007/. Accessed 10 October 2023. 

Noah Taeckens- Empathy Exams Presentation Paper 

9/28/2023 

This week we only had one reading, Empathy Exams, by Leslie Jamison. Jamison discusses the importance of empathy in the medical world, and what can happen when there is a lack of it. She compares her personal experiences to those that her fictional but very realistic character, Stephanie Phillips has as part of Jamison’s work as a patient actor. The narrative starts off with an explanation of Stephanie’s ailment, which is her unexplained seizures. Stephanie’s convulsions are actually caused by the impact of the loss of her brother; however, Jamison has been told not to reveal this to the medical students evaluating her. The medical students who get closer to the root cause of the seizures are the ones who display more empathy and as Jamison explains this means going beyond saying “that must be hard for you” and emotionally connecting with the patient. Jamison then switches gears and begins to tell her own story about how she struggled with the complexity of her emotions when dealing with a pregnancy, subsequent abortion, and heart surgery all within a couple of months of each other. Jamison felt guilt for having the abortion, fear of not understanding its effects on her upcoming ablation, and constant worry that she was either not having enough emotions or having too much. This level of emotional weight made it hard for Jamison to communicate with her doctors about her needs both as a patient and as a human. Jamison related this to Stephanie’s experience as both of them had a difficult time identifying what was the root cause of their emotional distress. The one-time Jamison tried to express herself, she was shut down by Dr. M, who was too busy trying to check off boxes to notice how worried and stressed Jamison really was. This further reinforced the harmful idea that Jamison was making a big deal out of nothing. Despite the difficulties, Jamison got the abortion and after a couple of physician miscues, was able to have successful heart surgery. As the piece comes to a close, Jamison makes a critical point that empathy is not as simple as projecting someone’s situation onto yourself as she had done with her brother who has Bell’s Palsy. What empathy is exactly is left up to interpretation. The narrative ends with passionate paragraphs that emphasize the constant questioning, lack of control, and pure exhaustion that many patients face in today’s medical system without the help of empathy. 

Discussion Questions: 

• What is your definition of empathy in regard to medicine? Could this definition change depending on the patient? 
• To what extent is the patient responsible for expressing their internal thoughts and emotions to the physician? 
• Were Dr. M’s actions harmful enough to constitute medical negligence or medical malpractice? 
• Which structure of empathy is most important: sensitivity, nonconformity, even temperedness, or social self-confidence? 
• Can we expect physicians to have empathy for patients that they do not like? 
• How can we emphasize the importance of empathy to already-practicing physicians? 

Our in-class discussion began with deep insights into the meaning of empathy and the responsibilities physicians have when attempting to display empathy. Throughout this part of the discussion, several students emphasized the necessary use of non-verbal communication when displaying empathy. Skills such as listening, and proper body language were highlighted as key elements of successful non-verbal empathy. Additionally, students mentioned that empathy will look different for every person and that authenticity is critical because patients can tell when a physician is disingenuous. Next, the discussion centered around physician responsibility. Overall, the group agreed that a calm demeanor and composure are essential for all physicians to maintain when dealing with patients, as patients can often feel very nervous since they may not fully understand what is going wrong. It is the doctor’s responsibility to help the patient feel comfortable and taken care of. One student brought up how Dr. G was able to read Ms. Jamison and knew that she needed to hear a straightforward explanation delivered in a calm tone. The student then made a great point stating that a critical piece of physician responsibility is the ability to make an inference on how a patient wants information delivered and how their preferences may change depending on the circumstances. In this case, Dr. G was correct to assume Ms. Jamison wanted a relatively emotion-free explanation, but in other cases, she may have wanted someone to feel emotion with her and it’s the physician’s responsibility to gauge that. The group then discussed possible solutions to the lack of empathy in the medical world. Popular ideas that came up included training sessions for older physicians to get them to embrace the biopsychosocial model instead of just the biological model, as well as the need to teach physicians how to decompress and self-reflect. Those last two solutions I thought were particularly interesting because self-care is not emphasized enough for physicians, and the idea that we could help the patients by putting the doctors in a better mental state is something I hadn’t heard or thought of before. Our discussion concluded with a back-and-forth debate about patient responsibility in regard to empathy. The group settled on the idea that while the patient is not responsible for providing any information, they are responsible for recognizing that the doctor can only help them based on the information they choose to disclose. 

Our discussion yielded critical insights into how we could potentially solve the deficiency of empathy in the medical world. Perhaps none of the insights were more powerful than reinforcing the importance of the biopsychosocial model. While the biopsychosocial model was not explicitly brought up often, its fingerprints are found all over our talking points. In particular, it was the group’s approach to physician and patient responsibility that involved the model. The idea of including practices such as self-reflection and decompression for physicians to help them maintain their own mental health, and setting their mental state as something that they have a responsibility to take care of completely embraces the biopsychosocial model. According to the biopsychosocial model, all of the biological, psychological, and sociological factors, both internally and externally, play a role in the patient’s experience. We often just consider the internal factors, however obviously the mental state or even mood of the physician plays a big role in the patient care experience as an external sociological factor and thus is something that falls under the biopsychosocial model. As the group mentioned, the physician’s responsibility to take care of their mental state is a somewhat novel idea but is critical in terms of patient care. Lastly, informing patients about their responsibility to help the doctor by disclosing the information they feel comfortable with is another aspect of the biopsychosocial model because it emphasizes the need for a strong, trusting physician-patient relationship that goes beyond sharing just biological information. It is by examining medicine through the lens of the biopsychosocial model, recognizing the interconnectedness of mental and physical health, and understanding the responsibilities of both the physician and the patient that we can begin to incorporate empathy as a routine part of the patient experience. 

Work Cited 

Jamison, Leslie. Empathy Exams. Minneapolis, Graywolf Press, 2014.