Catharine Clark-Sayles

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I think that every medical student is given sometime in their training the advice passed down from Sir William Osler “Listen to your patient, they will tell you the diagnosis”. Excellent advice but not actually taught. I was taught to take a history focused on symptoms—what, where, how often, what makes it worse/better and associated symptoms. I was taught to codify that information into a SOAP note:

S—subjective, what the patient tells me.

O—objective, what I observe.

A—assessment, what I think is going on, often a “differential diagnosis” which is a memorized list of the multiple disease processes that can cause a specific symptom or finding.

P—plan, what I will do to further elucidate or treat the symptom or problem

What I was not taught to do was to listen. Although I was frequently told it is important, I was also supposed to condense all of this into a note during a visit that over the years has been shortened from twenty minutes to ten minutes by pressures to generate billings. In the early days of my practice, billings to pay ever increasing rents and salaries. Later to satisfy CFOs and ever increasing demands for documentation—checklists meant to indicate quality of care by counting what could be counted: the numbers of vaccinations, how many women got mammograms, did I counsel everyone (including 70-year-old nuns) to practice safe sex.  Computers lead to templated notes with cut and paste and checkbox lists and expanding algorithms to check for compliance with those checklists

Studies suggest that the average doctor interrupts within eleven seconds of a patient beginning to speak to guide their problems into the accepted channels of thought. I think most of us, even in social situations do not listen completely as we plan out what we are going to say as our turn in the conversation comes. To completely listen is to focus as much on the silences as the words. I must hear as well, the unspoken words conveyed in the pauses, the sighs, the tiny eye-flicks and muscle tensions. Few of us have ever experienced being truly heard in that kind of deliberate focus. It creates a connection between speaker and listener that is different from the distracted listening of a doctor fumbling through a computer screen. Neurophysiologists can explain with the brain changes of oxytocin and dopamine but the experience of being deeply listened to is profound. It has a healing potential of its own.

No one taught me to listen. I learned it slowly over years with the “doorknob complaints” as the person’s real worry manifested as I placed my hand on the doorknob at the end of the visit. With the woman whose headaches, became stomach pain, became palpitations over the course of a year as we moved through each organ system until I asked the important question “When was the last time you felt well and what was happening in your life?”  and she began to shake as the story of her sister’s death from cancer spilled out. Or the man who seemed perpetually angry until I spent fifteen minutes hearing about orphanages and beatings. There were many soldiers who nearly always said somewhere in their story, “I’ve never told anyone this.” I become better with time although the pressures of overhead and electronic records and prior authorization and utilization review and quality checklists are a riptide pulling against The Listen. 

I think if it as singular. More than a skill, more like an integral part of each visit. A mental “L” to add to each SOAP note. I write SLOAP notes which don’t template well but are necessary to understand what each symptom means beyond the list of possible diagnoses. Necessary to understand the suffering unique to each person and to begin the task of finding cures for what can be cured and healing for what can’t.