May/June 2008

the Zen of Science

By MARC RINGEL, MD

Hey Doc:
Shut up and Listen

Marc Ringel, MD

Everything changes, all the time. Case in point: you’ve probably noticed that the layout of the columns in Nexus and the mug shots are a little different. Most importantly for me, the space allotted to my work is less, which is good news in that it raises my pay rate per word. But so has my challenge increased. I’ve loved the opportunity that “Zen of Science” has given me to address the magazine’s sophisticated, engaged readership about important topics at the border between medicine and healing. Among other subjects, I’ve written about dying, diet, childbirth, pain, diabetes, and quantum physics. The challenge is to discuss such important topics in some depth, but using 500 words less.

Which brings me to this installment’s theme (having already expended 125 words). Listening. It’s the tersest strategy for communication. Study after study in the medical literature has shown that, on average, an encounter takes no longer if the doctor starts with an open-ended question, like “Why did you come to my office today?” and then listens to the answer, than if she launches immediately into rapid-fire questions designed to elicit the exact information she thinks she needs to arrive at a diagnosis and treatment plan.

In fact, doctors who take the time to find out what’s really bothering their patients do better, both in outcomes and in patient satisfaction. I’ll conjecture they do better in their own career satisfaction too, because real connection is the best antidote to the burnout that afflicts so many physicians. Spending our days trying to help suffering, needy, unhappy people takes its toll. Compassionate engagement, which begins with listening, is the way to keep our own batteries charged.

Can you guess the average time that passes in a medical visit between when the doctor asks the opening question and when she speaks again, interrupting the patient? Studies show it’s four seconds. That’s right. Four seconds before the physician steps in with a question meant to lead the patient down a decision pathway that hopefully will terminate in a specific diagnosis.

That’s how we’re trained: to gather data from the patient and apply it against scientific templates, iteratively eliciting information and reformulating hypotheses about what’s making him sick, until we settle on a working diagnosis, around which we can plan treatment. Induction and deduction lie at the heart of this scientific methodology.

We just installed a new computer at home. We couldn’t get the firewall to work. So, when the tech guy returned to troubleshoot our system, he brought his laptop and hooked it up to the device. If the firewall had synched with his machine but not with ours, he’d know that the problem was with our computer, not with the firewall, and if it didn’t synch, he’d know that the firewall needed attention. The tech’s maneuvers to diagnose our system’s problem (it was the firewall) were akin to the reasoning doctors use to arrive at medical diagnoses.

The trouble with applying such a logical methodology to any particular patient is that it puts a lot of noise in the doctor’s head, an inner monologue about which bits of data rule which diagnoses in and which ones out, all during the time she’s supposed to be listening to the patient’s story. As a result of medical training, doctors tend to be far worse listeners than the average lay person.

Firewalls and computers send error messages in the form of unambiguous notes on the screen. The more you understand about the operating system and the syntax of its messages, the better you can be at fixing them. Likewise for people. The better you understand them, the more you can help them. The doctor doesn’t have the luxury of consulting a limited repertoire of standard error messages to make a diagnosis. (It would be great, for example, if there were a control panel conveniently located on the flank with a little light labeled “appendix” that would flash in the case of a patient complaining of abdominal pain).

Though appendicitis can be a tricky diagnosis and the stakes for missing a surgical emergency are potentially much higher than for misdiagnosing a computer network problem, I’m very glad, most days, that people aren’t contraptions with indicator lights. Humans are far more complex, varied and interesting than machines are. I can honestly say that every week I learn enough about at least a few people to understand that each one is so unique, I could never have made them up. In the case of patients, the better I understand them the better I can help them. (Perhaps not as well as that computer technician understands Windows because mastering another person’s “operating system” is unrealistic, if not downright impossible.)

I get to know my patients by listening to them. It’s my greatest professional pleasure, and my greatest challenge. I figure listening lies at the heart of good writing too. So, maybe, if I really listen to you, Nexus readers, I’ll understand you better and say in less space what you really need to hear. Please tell me what you feel, believe, know and question. You can reach me through the magazine. Then perhaps I’ll be able to pack that much more into that many fewer column inches. Anyway, I promise to listen.

Marc Ringel has spent the majority of his career as a family doctor working in rural communities, including the last 12 years in Brush, Colorado. He has written extensively, for lay and professional audiences, about rural health, medical informatics and healing. Marc lives in Greeley with his wife and many pets.