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.