Listen to Your Patient, They are Trying to Tell you What is Wrong with Them

David Reilly explains how you can totally concentrate on your encounter with your patient. This series aims to support and encourage you towards developing the therapeutic effect you have as a person and concentrate on the ingredients common to most all of your medical related encounters. So far, you have considered some reasons for doing this.¹ The main ingredients are human. There will always be relationships, even if only fleeting. So let us begin. And let us begin with the key ingredient you can influence - you.

Do you know the difference between music on in the background and listening to that music? The transition is clear between the two states - even though to an onlooker there is nothing to see. How do you make that transition? How does it feel when you do it? Try putting on some music and repeatedly taking yourself "into" and "out of" the music. Study and think about this internal change, because whatever this natural ability is it may be crucial for good human contact and so good consulting. It can even be the difference between a good outcome, no outcome, and a bad outcome. It can be the difference between a healing relationship and a complaint. Or perhaps you can think of this transition in relation to a meeting, or a movie, or a poem, or a wonderful conversation, or drawing, or singing, or playing an instrument, or sports. Try to find an example from your own life of the movement between these two states and study it carefully. How do you achieve this "listening," what blocks it, what helps it? How could you access it consciously?

These ordinary abilities are so natural we can fail to notice them. Take the "we must have lunch" syndrome (a variant of the "Oh, how lovely to see you" syndrome). When you begin to talk to someone, say at some sort of medical function, or a party, how long is it before you know if they are really interested? It's extremely quick - in the blink of an eye? Behind those head nods, smiles, and well contacted eyes you know they/you are not really interested - there will be no lunch. And that's without communication skills training or that course in psychology. You have this skill already.

How do you make the room disappear?

And other puzzles for your consultations

Do you know how you:

Activate yourself?
Read an activated context?
Preactivate yourself?
Create creative conditions?
Approach in neutral?
Enter a creative mode?
Use both your brains?
Know what to do when you don't know what to do?
Activate your compassion?
Choose your attitudes?

These innate abilities are heightened when a person's welfare or life is at stake - or they fear that it is. For us that next patient is potentially just another case, for that "case" it is their meeting, and their bullshit detectors are fully tuned - on you. Charm will not fool this alarm system - our "gut feelings."

The consultation begins before the consultation begins. Have you ever been a patient or been around one of your own loved one's medical encounters? These experiences are among your best teachers. Was it good? "Why was I referred, what will they find, will I appear stupid, will the wait for the appointment allow things to get worse?" You check and double check the appointment card on the mantelpiece, the transport to get there, who will come with you, if anyone. Then it's the night before. What will I wear? What will I say? Will it be a doctor I've never met?

You get the point - the context is powerful and preloaded, the stakes are up - and the opening seconds can make it or break it. Get this right and build the opening well and there can be such forgiving leeway in what then occurs that you will be surprised. Even if you are not in a heightened state it is best to assume the patient is - they usually are.

Preparing yourself is important. If you can, try and get the physical environment as right as possible. Do something to move you from the previous experience to the one you are about to have. This could be some sort of signal to yourself - perhaps just holding the case sheet of the next patient and reading the last letter (if it is a very thick case sheet of a patient with chronic problems try and read at least the most recent letter and the original referral letter). If you are really rushed (and you often will be), at minimum take a good deep breath and remind yourself of the importance to the next patient of what you are about to do. It can help you to go and get the patient. Just the few seconds walking towards the waiting area can be used to focus yourself, and seeing the patient for a second before and as they react to you can be helpful.

So here we are, barely beyond the opening seconds, the beginning of the therapeutic alliance or the beginning of its end. And sometimes not a word has yet been spoken. If we could change only one thing that might help, it would be helping the carer get out of the "background music mode." Truly be present and much else follows naturally. Imagine a dance, the type where you will move together. Your partner is already in rhythm; you approach; perhaps it takes a moment, could be an awkward moment as you try to match and move with them. Once you have got some connection there is a chance you can influence, even lead you both, if appropriate, to a different pace. This is another way of thinking of the medical concept you will come across of "concordance" - good mutual agreement between the doctor and patient. Remember that when you really come into someone's presence the feelings you begin to feel are important - sometimes that awkwardness or sadness or stilted conversation is letting you know how they are inside. The less of you and the more of them is a good start point. Once you get to know and understand someone it becomes easier to judge if they would benefit from more of you and less of their own stuff. The key point is relationship. Establish trust and safety and respect. Don't let yourself use time as an excuse here. How long does it take at that party before you know how you feel about the way a person is approaching you? Fast, isn't it?

So they have had their preparation, and you have had (or failed to have) yours. A long night on call, a long decade in general practice, a too short personal phone call spinning in your mind as you approach the room, trolley, bed. What are you going to have to do to access that music, resist it being background noise? You know how annoying and tiring that noise can be: "get it off" or "give me a break." The only hope is to begin to listen, to become absorbed. Your intention, motivation and attitude are underlying forces here.

Approach your patient in neutral, watching and listening carefully. Don't impose a standard consulting style on your patients, and be ready to read and respond to what is appropriate. The way the person walks in will speak volumes. "Who am I meeting?" can be more critical that "What is the diagnosis?" This is the way I introduce myself: "Hello. As I mentioned in the waiting area, I am David Reilly. Call me David, Dr David, or Dr Reilly - whatever is comfortable for you - how should I address you?" Think back to that party or reception - they ask you to lunch but call you by the wrong or unfamiliar name - how does it feel?

As things develop, you know you are there "when the room disappears" - that state of "being there." You know it when watching a movie and you become engrossed and unaware of the room you are sitting in (as opposed to "this is a coded pattern of light projected on a screen of illusion" sort of mental state). You know "when the room disappears" in a great conversation, in a bad argument, in moments of creativity, in moments of change. It's natural, you have it already. It is one of the hallmarks of a consultation as opposed to a chance or haphazard crossing of paths. Will you bring this ability to enter and create that state to your work? Or, will the patient remain as another diagnosis X, another heart sink, or another old person?

I do not want to lift this human process from the natural thing it is, but I know it sometimes helps to label and reference things to help us to take things seriously. So let me suggest that we are talking about an art. Music needs the technical things to be sound and working right - the scientific bits - but then something more is needed - our artistic self - and that applies as much to participating by listening as by making. Perhaps this is what used to be called the "art of medicine." In our medical art we have to strive to become familiar with our tools - say drugs, surgery, acupuncture needles, communication techniques - but equally important is the creative processes that they serve.

The artist Jane Kelly says, "First create the conditions to create, then create." Knowing how to help access at conscious will a "present" state (listening to the "music" that is your patient) will in turn help make a creative state in yourself. This will help generate a creative state in the patient and so your interaction. Studying and practicing other ways into this mode can be of definite help - such as learning to draw, sing, dance, play music, whatever moves and inspired you. Then use it to cross fertilize your work. But none of these "creative/artistic" modes are necessary. Every meeting with a patient will bring you an opportunity to develop this ability.

A useful scientific analogy for "when the room disappears" comes from the Nobel prize winning work of Sperry, which first described how the right and left cerebral hemispheres tend towards different ways of perceiving, processing, and experiencing things.² Right hemispheric mode (R mode) is characterized by whole pattern, non-verbal, analogic, non-temporal, intuitive processing ("artistic") - like the creative listening state we have discussed here. In contrast, left hemispheric (L mode) is analytical, verbal, reductionist, temporal, logical ("scientific") modes of thought. Our practical L mode contributions are more effective when we are also accessing and using active R mode. Why consult with one hemisphere's hand tied behind your back? Betty Edwards's book Drawing on the Right Side of the Brain can help you practice entering R mode at will.³ Learning a meditative practice is also helpful.

Of course, access of the state we have been exploring is just a beginning. What are you going to do in and with it? Often we do not know what to do. Don't panic. Fortunately, your patients are creative in their own right (an old saying is "listen to your patient, they are trying to tell you what is wrong with them"), and your effective listening and engagement will facilitate their efforts, sometimes with no other role required from you. You can definitely lean on this in the early part of your career, trusting that your active listening means you will be more sensitive to normal cues and signals and natural instinctive responses, while getting on with the technical jobs you have to do. Your struggle to access this real connection with your patient will bring you to understand them and their predicament better, and so will naturally help bring out your empathy, compassion, and other aspects of healing care. Patients rarely feel empowered if they feel the doctor shows no empathy towards them.⁴