by James Martin, MD
Listen to patients and they will tell you what is wrong with them. This simple thought was put forward by Dr. William Osler, the well-known physician and professor at Johns Hopkins University School of Medicine at the turn of the 20th century.
His assertion may seem self-evident, but it profoundly reminds us of an essential component to delivering the best possible medical care, especially in family medicine. Dr. Osler’s concept, however, is put into practice only sporadically throughout our profession in recent years. Nonetheless, listening to patients to learn about their backgrounds and details of their lives – instead of merely discussing their physical ills – can still provide telling information that leads to more ef-fective diagnoses.
What Patients Want
Research from the past decade indicates that, while patients have a variety of expectations and needs concerning the health-care system, the majority overwhelmingly desire personal attention. They want to be heard and understood. They want a physician who knows them as well as their medical condition. This kind of familiarity can come only by establishing a continuous, long-term relationship that allows the doctor to understand the patients’ values, preferences, and backgrounds.
It is imperative to learn about more than an individual’s physical condition, because understanding the context of a patient’s life provides clues for diagnosis. We know that family life influences a person’s overall health. Lifestyle habits, personal choices, and the way that a family views illness or disability can impact a patient psychologically and physically.
One’s home life, level of job stress, personal views, religious beliefs, degree of job satisfaction, and quality of friend-ships are examples of social issues that should become part of an ongoing dialogue between patients and their doctors. For example, if a patient feels as though his or her job is on the line, the likelihood increases that this person could ex-perience a severe infection or a life-changing event, such as a heart attack.
If a doctor knows his patient well, someone suffering from high blood pressure may feel comfortable enough to reveal that the elevated blood pressure could be due to his or her marital problems. At this point, the treatment approach could take a very different turn. In instances like this, where root causes are easily pinpointed, patients may be spared not only the suffering and frustration of a misdiagnosis, but doctors also save time that may be reserved for other patients.
Of course, this sort of information typically would emerge only in conversations that are not strictly related to one’s physical condition. Such a discussion also would be likely to require much more time than the typical office visit would allow. So how can a doctor learn such personal details about a patient if he or she is seeing 30 to 40 patients a day?
Technology / Closer Ties
Technology may provide a way. Since much patient interaction is based on “yes/no” questions, e-mail communication can be a valuable tool for giving doctors the capacity to spend extra time with individuals who may require it. Instead of arranging office visits, a doctor and his staff could address the yes/no questions with certain patients via e-communication, which is reimbursable.
Group visits also can provide an avenue for efficiency. Groups of patients who may suffer from the same ailment, such as diabetes or asthma, could gather with a doctor and a facilitator to receive treatment instructions. Again, several potential appointments could be handled at once, freeing the doctor to spend additional time learning about patients who may represent more complex diagnoses.
Ideally, what doctors need is the opportunity to spend 30 to 45 minutes with a patient, if necessary, and not feel pressured to rush everybody else through the doors. For a physician without deep knowledge of his patients, a man who comes in for a physical and mentions that his stomach is bothering him may represent a 10-minute visit.
For a doctor with a deep knowledge of his patients, however, the same scenario could have a completely different result. That doctor may know that the patient’s father and uncle died of pancreatic cancer. The 10-minute visit then becomes much longer. A physician who shares a solid relationship with patients will extend such visits because doing so is part of his or her understanding.
Spending time to get to know a patient can provide insight into the patient’s condition that otherwise would be unavailable. This knowledge can lead to more precise diagnoses, as well as greater efficiency when doctors can use their familiarity with a patient to more quickly identify the reasons behind various conditions. As Dr. Osler suggested a century ago, listening can be a very powerful diagnostic tool.
Dr. Martin, director of the CHRISTUS Santa Rosa Family Medicine Residency Program and vice president for medical affairs at CHRISTUS Santa Rosa Health Care, has practiced family medicine for more than 30 years. He also spearheaded development of the system’s highly rated family health center.
