Business Review

Executive Summary

Modern medicine’s true healing potential depends on a resource that is being systematically depleted: the time and capacity to truly listen to patients, hear their stories, and learn not only what’s the matter with them but also what matters to them. Some health professionals claim that workload and other factors have compressed medical encounters to a point that genuine conversation with patients is no longer possible or practical. The authors disagree. Their experiences — as a critical-care physician whose own critical illness led her to train physicians in relationship-centered communication (Rana Awdish) and as a health services researcher who has interviewed and observed hundreds of patients, doctors, and nurses (Len Berry) — show that hurried care incurs hidden costs and offers false economy. Not hearing the patient’s voice harms the patient and the clinician, they say. They don’t have the benefit of pooled knowledge, ability to make fully informed mutual decisions, or time to build trust. Health systems that want to avoid those pitfalls need leaders who invest in shaping an organizational culture that values hearing patients’ voices. The authors offer six steps health care organizations might take.

Modern medicine’s true healing potential depends on a resource that is being systematically depleted: the time and capacity to truly listen to patients, hear their stories, and learn not only what’s the matter with them but also what matters to them. Some health professionals claim that workload and other factors have compressed medical encounters to a point that genuine conversation with patients is no longer possible or practical. We disagree.

Our experiences — as a critical-care physician whose own critical illness led her to train physicians in relationship-centered communication (Rana Awdish) and as a health services researcher who has interviewed and observed hundreds of patients, doctors, and nurses (Len Berry) — teach us that hurried care incurs hidden costs and offers false economy. In other words, it might save money in the short term but wastes money over time.

Why Listening Matters

Actively listening to patients conveys respect for their self-knowledge and builds trust. It allows physicians to assume the role of the trusted intermediary who not only provides relevant medical knowledge but also translates it into options in line with patients’ own stated values and priorities. It is only through shared knowledge, transmitted in both directions, that physicians and patients can co-create an authentic, viable care plan.

A doctor’s medical toolbox and supply of best-practice guidelines, ample as they are, do not address a patient’s fears, grief over a diagnosis, practical issues of access to care, or reliability of their social support system. Overlooking these realities is perilous, both for the patient’s well-being and for efficient delivery of care. We believe not only that a clinician should share medical decision making with the patient but also that it must occur in the context of an authentic relationship.

The Costs of Hurried Encounters     

Compressed medicine has real risks. Clinicians become more likely to provide ineffective or undesired treatment and miss pertinent information that would have altered the treatment plan and are often blind to patients’ lack of understanding. All of this serves to diminish the joy of serving patients, thereby contributing to high rates of physician burnout. These consequences have clear human and financial costs.

The medical literature increasingly offers potential solutions to the inefficiencies that rob patients of physicians’ time and attention, including delegating lower-expertise tasks to non-physician team members, improving the design of the electronic health system, and greatly reducing the paperwork bureaucracy that adds little or no value. We can create more space for active listening. Unhurried medical care may be elusive, but it is practical.

Reimagining Roles

Beyond time pressures, the typically unquestioned roles that physicians and patients assume also inhibit relationship-building. In their medical training, physicians often are taught to maintain a clinical distance and an even temperament. They are warned not to get too close to patients, lest they internalize the suffering and shoulder it themselves. The best physicians, we know, reject this advice because it diminishes their humanity and disadvantages their patients, who need more than a highly-qualified body technician, especially when they’re seriously ill.

Insight Center

Patients learn roles, too: adhere to the doctor’s plan, squelch errant thoughts that might sound foolish, don’t ask too many questions, defer to the expert, be “a good patient.” In a new article we co-authored with others, we show that many patients, especially those with serious disease, behave like hostages in the presence of physicians — unwilling to challenge authority, understating their concerns, requesting less than they desire. Most physicians certainly don’t want patients to feel like hostages, but the patients often do. When patients feel like hostages, the ideal of shared decision making is a pipe dream.

It’s no wonder, then, that for patients with serious illness, the emotion they most often cite is “overwhelmed.” The diagnosis, the options, the treatment, the myriad side effects, the change in identity when living with disease — all of it can indeed be overwhelming. In this complex, fraught situation, people need a compassionate guide — a wise, comforting sherpa who knows the mountain, the risks of various routes, the viable contingency plans. The physician-sherpa should be a partner on the journey, not simply a medical operative, extracting formulaic rules and implements from a toolbox. Patients need and deserve much more.

When doctor and patient join forces, the team dynamic dismantles the harmful hierarchy. Both members of the dyad can rely on each other because neither owns all the data that matter. Speaking at a White Coat ceremony for medical students, Dr. Rita Charon, a pioneer in the rising discipline of narrative medicine, stated:

I used to ask new patients a million questions about their health, their symptoms, their diet and exercise, their previous illnesses or surgeries. I don’t do that anymore. I find it more useful to offer my presence to patients and invite them to tell me what they think I should know about their situation.…I sit there in front of the patient, sitting on my hands so as not to write during the patient’s account, the better to grant attention to the story, probably with my mouth open in amazement at the unerring privilege of hearing another put into words — seamlessly, freely, in whatever form is chosen — what I need to know about him or her.

An Organization that Listens and Heals

Not hearing the patient’s voice harms the patient and the clinician. They don’t have the benefit of pooled knowledge, ability to make fully informed mutual decisions, or time to build trust. Health systems that want to avoid those pitfalls need leaders who invest in shaping an organizational culture that values hearing patients’ voices. Here are some steps such organizations might take:

• Share patient stories and related lessons at every meeting. Perhaps one should be a story of success (what we did well for a patient) and another of a failure (where we must improve).
• Offer a communications curriculum to clinical and non-clinical staff. The professional development should be engaging and dynamic so that adult learners seek it out because they view it as worthwhile.
• Encourage and reward clinical curiosity, whereby generous questions are asked to elicit generous patient responses. Emphasize listening for not just what is said, but also how it is communicated. Consider a narrative-medicine component.
• Convene patient advisory boards that meet regularly with practice leaders to convey concerns and make suggestions about improving patients’ experiences.
• Use multiple methods to identify and systematically address impediments in clinicians’ daily work — the “pebbles in the shoes.” Examples include rounds, conducted by senior leaders, with both staff and patients; staff focus groups and anonymous surveys; and CEO feedback meetings with small groups who speak openly about what prevents them from delivering better care.
• Create a balanced scorecard of physician performance that tracks not only productivity but also professional development, team building, safety and quality metrics, timeliness of care or access, communication skills, and care coordination — measures that matter to patients.

A Way Forward

Medicine is constantly evolving as new ways to treat, heal, and even cure emerge. We must continually reflect on the changes, and correct the course as needed. This work cannot happen in a vacuum of forced efficiency. Physicians, patients, and administrators all must maintain and build on what is sacred and soulful in clinical practice. We must listen generously so that we nurture authentic, bidirectional relationships that give clinicians and patients a sense of mutual purpose that no best-practice guideline or algorithm could ever hope to achieve.