Listening to Our Patients

Sir William Osler

Sir William Osler

“Listen to your patient; he is telling you the diagnosis.”–Sir William Osler

I just read Dr. Dawson’s post from December 4, 2013 about his first flu shot and I wanted to make sure that everybody reads his fascinating reflection.

His allergist took a lot of time with him and asked specific, probing questions in a thorough assessment of his medical history. He was meticulous and probably listened very carefully as well.

The point is that physicians need to be meticulous and thorough to help patients because of the very unique lives they’ve led in the world while inhabiting the very complex biological vehicle they’ve inherited across many generations and beyond. They also need to listen very carefully.

It led to my own reflection about a particular teaching exercise that academic physicians engage in regularly, called the Grand Rounds conference. In our psychiatry department, the basic structure is a meticulous and thorough presentation of a patient’s history, a very brief interview of the patient by a senior faculty member in front of an audience of health care professionals from many disciplines all at different levels of training, followed by a review of a topic pertinent to the patient’s diagnosis and treatment in the context of a meticulous and thorough medical literature review, concluding with questions and comments from the audience.

I’ve presented and attended these Grand Rounds for many years and found most of them to be educational, enlightening, sometimes controversial, and occasionally entertaining.

Probably the most striking component of the Grand Rounds is the patient interview, which can usually be only 10 to 15 minutes long because of time constraints. The necessity for brevity often leads to the impression that we’re barely on the threshold of the on-ramp to all the autobahns, long curves, blind alleys, and meandering byways of a person’s life story.

And after the little journey I may not always reach the same conclusions  that my colleague reaches about what the patient has or what the patient is.

I recall a Grand Rounds interview many years ago in which the faculty member finished a hurried series of focused, mostly closed-ended questions (often talking over the patient), by asking what was the most important part of the doctor-patient relationship.

The patient’s deadpan reply, “The most important thing is to listen.”

There was a small but definitely perceptible ripple of nervous laughter that quickly spread across the entire audience and just as quickly died. At the time I wondered what it meant.

Dr. Dawson’s allergist spent nearly 3 hours with him. Can psychiatrists spare that kind of time in today’s fast-paced, managed-care driven clinical environment? Is the Grand Rounds experience a way to foster excellence in our trainees and does it convey what we would like to our patients?

How long and how often must we ask rhetorical questions like that?

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