Listen to the Patient

Psychosocial Medicine: Thought-provoking essay
Jeremy A. Ginoza, R1 Spring 2010

Listen to the patient—he is telling you the diagnosis.
—Sir William Osler

I would sit and listen because I had to, really. I was simply an observer, along for the ride, literally. When I was a boy, I often accompanied my father, a well-loved Christian pastor, on his frequent visits to the sick and elderly in their homes. He was a minister in the United Methodist tradition, which I would come to learn as characterized by its openness and emphasis on living one’s faith in a practical way in the world.
My father, I remember, would warmly greet and reconnect with each person we visited, whether sick or well, with such ease and lightness of heart, as if we were all sitting on a porch on a Sunday afternoon together, sipping cool tea or lemonade. Then my father and I would both listen, as each person would tell us of their lives, physical or emotional struggles they had, and how they might be coping. We would listen, laugh, and empathize (my father with words, myself with respectful silence and perhaps some thoughtful facial expressions). My father would often offer a blessing of prayer, and we would wish the person well. I came away with a sense for how people could find everyday joys despite physical limitations and other tough obstacles, and how a simple visit like this could remarkably lift up and brighten someone’s day. At an early age, I also saw how much I could learn by following the advice found in an old proverb, keep your mouth shut and your ears open.
During my sophomore year in college, as my hopes and aspirations began to solidify, I settled on studying medicine. It was, I felt, the ideal career in which I could reach my fullest potential for both my skills in science and mathematics and my compassion for people. It was the final gesture of decision after years of shaking my head (at least privately) to queries of so many people as to whether I was going to follow in my father’s footsteps. I had inherited his personable demeanor and his rich, deep voice, after all.
I looked back on those experiences with my father and saw possibly the roots of my drive to study medicine. Hearing about someone’s ailments, and his or her daily struggle to cope, I wanted to do more than empathize and offer hope and prayer. I want very much to offer them the best opportunity for healing that today’s medicine can offer. What is more, though, as I reflect now on my early medical training, is that I don’t want to let go of what I learned early on from my father—a show of deep respect, humility, and care for the spiritual dimension of the person. Care in one dimension is not enough for me, and I believe this is why I find myself frustrated at times now in treating patients, much as I may have felt a bit helpless as a young boy, wondering what to say, even though I knew my place was to simply be, and to listen. Now that I am caring for patients as a resident, my foremost challenge is to develop skill at caring for the whole person, body, mind and spirit, within the time boundaries of a busy practice, and to have the wisdom to know when this is even possible.
An electronic health record offers many tools for supporting and guiding efficient patient care. One task I am pursuing now is to create an electronic template for interactions with patients that I am scheduled to see in our clinic, based on presenting complaints, including a checklist for a pertinent history and physical. I have found that the very process of doing this makes for some high-yield learning, and is helping to build the mental framework I will need to organize my thoughts and prioritize my time during the course of a busy clinic schedule.
Practice guidelines in the form of checklists and flowcharts are part of a growing trend which presents a lot to debate and consider. Sir William Osler said that the “practice of medicine is an art based on science,” and it’s worth asking if some of the art is lost in medicine when we apply standardized formulas and algorithms to a unique individual. The value of a tool is all in how it’s used, and if a chart tool could be utilized to be both thorough and time-efficient, creating space to address a patient’s multidimensional needs, then this supports a doctor’s and a patient’s bottom line.
Jazz musicians are well-recognized for their improvisational ability, to let the music flow through them with passion and freedom. A good jazz piece, though, begins with a structure, a formal composition, even, from which the improvisation emerges and then takes off. Otherwise, what you have is simply a jam session, and patient care is much more than a series of jam sessions in the pursuit of health. The art of the interaction is to have just enough structure, just enough spontaneity.
Music is great for bringing us back to listening. That, after all, is where the interaction must begin, to properly build the process of counseling and negotiating, all informed by the body of scientific evidence and reasonable standards. How to keep all this tapping to a brisk, yet unhurried, rhythm is my hopeful aspiration as I strive to be a physician worth his salt, and, when I start moving my lips, one worth listening to as well.