“Wait. When did you say you started that medication?”
“Two weeks ago.”
“And when did you say you started having those symptoms?”
“Uh … about … uh … let me think … it was … two weeks ago.”
This kind of circumstance is my holy grail. It is my ultimate moment where I connect the dots. It has happened several times recently where patients have had chronic symptoms and have related to me that they have been taking medications started by other physicians within the time frame of those symptoms. One of my rules of thumb (I don't know how the thumb always gets involved) is, when in doubt, blame the medication. And, yes, stopping the medication in these circumstances fixed the problems the patient was having. It doesn't always work that way, but it often does when you listen enough.
I recently had a diabetic patient come to me embarrassed with his poor control.
“Why have you been having such a hard time lately controlling your diabetes?” I asked.
“Well,” he said, looking down at his hands as he spoke, “I just haven't been taking my medications over the past month. It's hard for me to take them.”
“And why is it hard for you to take them?” I pressed.
He shuffled in his chair. Looked up at me, and then said, “I can't swallow pills. The metformin. They are so big. I just have a hard time getting them down. So I just gave up taking my pills.”
I looked at him and smiled. ”You do realize that you can cut those pills into halves and quarters?”
He looked down. Obviously not.
“Okay,” I said, “Let's come up with a plan that doesn't require you to swallow big pills all the time. I know that it's not easy when you have a strong gag reflex and you have to take big pills. Let's find something that works well for you.”
He smiled broadly and seemed to relax. I actually listened to him. I took the time to find out why he wasn't taking his medication instead of judging his suboptimal diabetic control like he expected me to do.
That's what people want. They want to be listened to so that they are understood. It's not just being heard that is important; it is being heard and appreciated that is the key. Everyone has a story to tell, and everyone has a reason to be in the place they are in at the moment they interact with you. It's your job as a clinician to figure out what got them there and what exactly they are looking to accomplish at this moment. My patient really did want to control his diabetes, but was very much prevented from doing so by his inability to swallow large pills. He believed (falsely) that this was a complete roadblock to good diabetic control and had given himself up to amputations, dialysis, and other inevitable complications of poor diabetic control. All I needed to do was to listen a little and his myth was dispelled.
One of the big unfortunate things about the medical system is that it turns listening into a rarity. ”You are the only doctor who has ever listened to me,” I often get told. Really? That's like being told that I am the only chef who has ever cooked food for someone. Isn't listening the essence of care? How could so many people go through our system feeling like they never get listened to? Yet they do. It is incredibly sad. It causes a huge amount of pain. It probably kills a fair number of people.
But if we are rewarding doctors for spending less time with people, what do we expect? If we are making computer time more profitable than patient time, ICD more important than bowel sounds, Medicare compliance more important than the emotional state of the person in the room with you, then it's hard to blame clinicians for ignoring patients. They are just doing what they are told.
Our system needs to be better than that. The reason I can spend time with people is because I don't have to worry about the codes I can generate from each visit. I don't have to worry about Medicare audits, or meaningful use, or MACRA. I just focus on the person in the room with me. I'm lucky that way. I'm lucky that I raised my middle finger to the system that required me to spend so much time documenting that I could no longer give care. I'm lucky that I walked away from a system that made profits for me when my patients had pain or illness, and hurt me when they were healthy. Yep. I am lucky. Pure luck.
But in any situation, even in one where profits are paramount, listening is always best. When we listen we can understand. When we listen we can solve. When we listen we can make good plans of action. Without listening we are left to become box-checkers, form-fillers, and data entry monkeys. We don't want that, and I'm pretty sure our patients don't want that.
After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.