Clinician’s Ear: Learning to Listen

Clinician’s Ear: Learning to Listen


MARCIA DAY CHILDRESS:
Good afternoon. I’d like to welcome you
to the Medical Center Hour, this spring 2017 series
of Medical Center Hour Programs. This is the first. I’m Marcia Day Childress
from the Center for Biomedical
Ethics and Humanities here at the School of Medicine. And I’m delighted to see
all of you here today. I’d like to welcome
you on a day that feels frankly like maybe the
first day of spring outside. I’m sure that’s a tease,
but it’s nice to have it, nonetheless. Our program today is
called Clinicians Ear– Learning to Listen. This is also the Jesse Stuart
Richardson Memorial Lecture created at UVA
School of Medicine in 1999, which remembers
Mrs. Richardson, who’s untimely death nearly
20 years ago was a result of tragic
adverse events in her care at this hospital. Her long career
as a schoolteacher prompted her family to invest
funds in medical education so that upcoming generations
of health professionals at UVA might know better how
to care for patients, how to give cure that has
the patient at its heart, and how to explain and
explore without fear of medical mistakes
when they occur. This afternoon,
as every year, we welcome to our lecture
Mrs. Richardson’s son, Dr. Don Richardson. This year also, we are
delighted to welcome Mrs. Richardson’s
granddaughter, Donna, and her
great-granddaughter, Rachel. And Rachel also happens to
have moved into the health professions also as a nurse. Welcome to all of you. We acknowledge today
with this lecture both the Richardson family’s
loss, and their generous gift, and their ongoing
collaboration with us. These annual lectures constitute
an evolving conversation on a couple of themes that
have considerable currency. One theme, medical error
and patient safety, has been addressed several times
in recent years at this lecture by leading experts. Another theme right
from the start has been attention to the
patient, indeed, attention to the patient as the
doctors or nurses teacher. And this year’s lecture,
Clinician’s Ear, is about that kind of attention
because listening is, arguably, at the heart of what transpires
between patient and clinician. Amid today’s data deluge,
checklists, business buzzwords, and the demanding pace
of clinical practice, are we still listening
to the patient? And how do we listen? At the bedside,
or in the clinic? So that we hear
what is important and so that the patient feels
heard, and known, and truly cared for. And how do we listen to
one another, and ourselves, and learn more about
the potential healing nature of both our words and
our our attentive silence? We’re really proud today to
welcome the 2017 Richardson lecturer Dr. John Coulehan,
emeritus professor of medicine and former director
of the Center for Medical Humanities
Compassionate Care and Bioethics at the State
University of New York at Stony Brook. A longtime practitioner
and teacher of internal medicine, Dr.
Coulehan, who’s known as Jack, is co-author of a respected
text of the medical interview. But he’s also a poet
who recently published his sixth book of poems– The Wound Dresser. There are copies of this
outside the auditorium provided by UVA bookstore. These are available for
sale, and Jack would also be happy to sign books. That book just
came out last fall. We’d like to welcome Jack. And considering that
we have someone so accomplished as a listener
and a thoughtful teacher of attended doctoring
and a wordsmith, I’d say we’re all ears. [LAUGHTER] JOHN L COULEHAN:
Thank you, Marcia. I’m delighted to
be here, and I’m particularly honored to
be giving the Richardson Lecture today. The theme, as Marcia mentioned,
of listening to patients, paying attention to
what you’re doing, listening to your
colleagues, to your heart, in a sense reflecting
on the practice that you are
engaged in is really what I want to discuss today. I have to step over here. When we first think of
listening and medicine, the first thought that
came to my mind, of course, is the stethoscope. Quo And the stethoscope
for 200 years– and I should mention that
Rene Laennec invented the stethoscope in 1817. So this is the 200th
anniversary of the stethoscope. And here he is. Evidently, he has a
stethoscope in his left hand, but he’s using the old technique
rather than the new technology by listening directly
to the patient’s chest. [HEART BEATING] Now those of you who are
experienced clinical ears out there, can you
identify that– [HEART BEATING] –heart sound? That’s a diastolic rumble– very difficult, at least it
was very difficult for me as a student. In this case, I was planning
to have a plural [INAUDIBLE]. [HEAT BEATING] But I got another rumble. So that is to show you
that you can’t always depend on your clinical ear. But I think the more
contemporary problem– even though the stethoscope
is now an icon of medicine, and the stethoscope over
the neck is almost an emoji for medical practice– a more important and I
think much more difficult clinical skill is
listening to the patient. And although I want to begin
by saying that I acknowledge the fact that many,
many physicians have excellent clinical
ears in that respect and hopefully most of us
in this room do as well, we have to admit that there’s
a problem today, a problem that is widespread, causes a
lot of dissatisfaction, a lot of incorrect, misleading
diagnoses and treatment. And that is– and I
think medical error– and I think that is our
inability to listen carefully to our patients. So today, I want to talk
about three components of the clinical ear in a sense. The first– and I think it
will take the longest part of our time together– is listening to the patient. The second will be listening
to your own heart– in other words,
reflective practice. And the third will be
words that you speak– the healing words,
the aural component of the therapeutic process. First, we’ll talk about
listening to the patient. And there’s many, probably
hundreds of aphorisms of Osler. And you can see it there and
listening to your patient. He is telling you the diagnoses. I want to go back a
little, maybe 30 years, before Osler’s time to the 1870s
when this man, Anton Chekhov, was a medical student
at the Russia State University in Moscow. And when he was a student,
he had a preceptor on his hospital clerkship. It was a community hospital
that he went out from Moscow to work in, and his preceptor
wrote an evaluation, as preceptors still do today. And you can see here’s is
part of the evaluation. He did everything with
attention and a manifest love what he was doing,
especially toward patients. He listened quietly to them,
never raising his voice however tired he was, and even
if the patient was talking about things
irrelevant to the illness. Let’s fast forward to an
American, William Carlos Williams, who, as you
know, was a general practitioner/pediatrician
in Patterson, New Jersey for almost 50
years, while at the same time he was creating in essence
a body of poetry it is one of the most
prominent poetry collections of the 20th
century in the United States, as well as writing novels
and other works in addition. He wrote an autobiography
toward the end of his life. And these are a couple of
quotes when he is talking about his medical practice. “In a flash, the
details of the case would begin to
formulate themselves, and the patient would
shape up into a person who called for attention.” And this one I really love– “The physician enjoys
a wonderful opportunity to witness the words being born. We have in the
words very parents.” On the other hand, we have a
dichotomy in medicine today. I think most of us would
agree with Oliver Sacks, that the first act of medicine
is to listen to personal story. In our hearts, I
think this is embedded in the sense in our vocation
to become physicians. But on the other hand,
we have this model that is really widespread
of characterized I think in its most extreme
form by Dr. Gregory House, who not only doesn’t
listen to patients, he doesn’t listen
to his colleagues. He doesn’t listen to anybody nor
trust anybody except himself. And there is a kind of
detachment and lack of trust that has creeped in
to our profession. And I want to talk about
that a little bit today. I ran a narrative
medicine elective for fourth year medical
students for many years. And one of the
things they had to do was to keep a clinical
journal for at least 30 days– or at least 30 entries. They didn’t have to
be consecutive days. And in our classes,
they would actually have to complete this before
the formal course began. And in our classes, we
would discuss excerpts from these journals. So I’m going to present a
number of these excerpts related to listening to
you this afternoon. Here’s a student
on family medicine. “This was my worst
rotation by far. My preceptor in the
family health center was a big disappoint. She talks a good talk but wait
till you see her in action. She never listens.” Another one from oncology– “I was totally unimpressed
with the attendee’s handling of the situation. I felt that his
approach lacked empathy. He didn’t listen
to family members who just found out that
their mother had little time to live.” Here’s another student–
a fourth year student who is really making a
confession here saying that “I have found my
ability to listen to patients has gotten worse. At the beginning
of the third year, I allowed patients to speak
uninterrupted for as long as they wanted. But with more experience
under my belt, I sometimes find myself
distracted by my own thoughts while listening to
a patient’s story.” Now, what are the barriers? What are the difficulties? We agree that the
first line of medicine is listening to the
patient’s story. And unless we’re Dr. House, we
don’t strongly object to that, but we often don’t do it. And so what are the
barriers that we encounter? And I’ve clustered them
in three groups here. One is the mental traffic jam. We are preoccupied. We’re trying to multitask. We are constantly aware
of time constraints. We’re thinking
about what we need to say next, ask next, do next. And so we can’t listen. The second is what I call
a lack of motivation, although that might be
a little too strong. And it’s the issue that
we’ve categorized data into objective data
and subjective data. And no matter how we subscribe
to the biopsychosocial model and to all the different
aspects that we learned as we start the first few
years of medical school, we tend to gradually
drift toward the belief that objective data, which
we define as the things that machines and lab
tests produce for us, is more important than what
the patient says or feels. And so consequently, we don’t
pay as much attention to that. The third group is what
I call emotional baggage. And that’s the internal
baggage that we carry with us– our anxiety, our frustration,
our anger, disgust, and feelings that we have and
that are perfectly natural but that interrupt
our ability to listen. With regard to the first
issue, multitasking and mental traffic jam, I
decided since this is a medical school
and a medical lecture, I had to produce some
kind of chart for you. And so this is taken from
a neuroscience article, and it’s just talking about
the components of attention, what it involves, what our
ability to fixate our attention involves. And I won’t try to describe it
all because I’ve got mixed up and it’ll be
embarrassing for me. But the bottom line
is that attention is a very complex neurological
resource that we have. And there are hundreds
of articles, studies that show that attempts
to multitask invariably decrease performance on
all the tasks involved. And even though that hasn’t
gotten through to our culture yet, it’s certainly true. And so the issue
of multitasking, of being distracted is
a very significant one. One of the other
aspects of distraction has to do with time. And you hear this all the time
from students, from residents, from your colleagues– there just isn’t enough time. And I’m reminded
of an article that just came out in the Annals
of Internal Medicine. And if any of you are interns,
you might have seen it not more than a month or two
months ago, which was a study across many,
many practices of family medicine, primary care,
internal medicine, orthopedics, and one other specialty. Basically, it was
a time usage study, and they showed that only
29% of the office time, on the average, is spent
in direct patient care. Whereas 50-some percent
is spent fooling around with the electronic
medical record, and other types of paperwork, and so forth. And of course, that’s
a real problem and one that we can’t really
address today. But I do like to
look at listening as having at least two components. I tell students, if
you’re worried about time, think of listening as
having a vertical component and a horizontal component. The vertical component
is now, in this moment, I am listening deeply
to what is being said. I’m listening. I’m here. I’m connected. The horizontal
component has to do with the concept
of reconstructing the patient’s story over time. And of course, there
is a valid, I think, objection that we have less
time to gather that whole story and put it together in
a coherent narrative. I’ll say two things about that. One, is that that’s no excuse
for not listening deeply in the vertical dimension. And the other thing is
that what time we have we don’t often use efficiently. And I’m sure most of you are
familiar with the very famous study by Beckman and Frankel in
1984 that less than a quarter of patients who come
to see their doctor are able to even finish
their initial statement before the doctor
interrupts them. And that interruption
comes in about 18 seconds after they start talking. Marvel and his coworkers
reproduced that study in exactly the same
methodology 15 years later. And this is during
the 15-year period when medical interviewing,
et cetera, et cetera became very big in medical schools. And they found essentially
the same results. If you want to
argue, the doctors waited another five
seconds before they interrupted the patient. So that raises the
issue of even if we have a smaller amount
of time, we seem to be not using it efficiently. We seem to be interrupting
and destroying the flow. The second issue
is the detachment that is implied by our
devaluation of subjective data. Here’s a fourth year
student who says she was labeled a pain
seeking drug addict simply due to the stereotype associated
with right sided endocarditis. But no one seemed to notice how
terrified she was of needles. I was the only one
left to listen to her, and I felt powerless in my
protest, patronized for getting to attached to the patient. And this reminds me of
a story that some of you may know by Ernest
Hemingway called “Indian Camp,” where the
doctor is camping on the lake. And he’s called to see an
Native American woman who is in severe pain. She’s having a very,
very difficult labor. And he rows across to her
camp to attend to this, and his son was with him. His son is Nick Adams. And his son says,
daddy, she’s screaming. What can we do about her pain? And his response is her
screams are not important. I don’t hear them. I don’t hear them because
they’re not important. They’re subjective. He’s interested in the objective
features of, in this case, performing an
emergency c-section. This deaf ear, or unresponsive
voice, leads to problems. It leads to an
inadequate diagnosis, inadequate treatment, and
medical care, which again, is a theme of this lecture– the latrogenic harm. But sometimes we don’t
also look at the other side of the story, which is the
clinician herself or himself. She’s actually harmed by
closing off this ability to connect with patients,
and to listen, to understand by becoming more
detached as a person and more dissatisfied
with their work and eventually succumbing to
burnout, which, again, as you probably know, is becoming more
and more prevalent in medicine. So what do we listen to
with the clinical ear? Well, we listen to
their words, but we also listen to aspects of language
that surround the words and create the actual language– the rate and the
rhythm of speech, the pauses and hesitations
that patients have, the way they articulate
the words, the volume, or the pitch, or the tone. And also we listen
to the silence. I want to just read
you a couple of poems. And these poems are in
the patient’s voice. And although there’s words– you can hear words– they’re stories that
many doctors wouldn’t listen to or be interested
in but I think tell us a lot of very important
data about the patient. This one has to do with a man
is having a cardiac calf because of an episode of
unstable angina. and This is in his voice. It’s called “Heart Blockages.” “Those white ragged lines are
what’s left of my vessels– damaged legs and old
spurs a jostled bareback on that black bull
of a heart, my heart, whose flanks on
the overhead screen are heaving and faltering. I watch my arteries taper,
twist, crimp to a thread, in a blockage so tight it’s a
wonder the front of my heart hasn’t died. I remember the rodeo
in Willcox, Arizona where leaning on a jeep behind
the bleachers I dipped snuff like a cowboy and
bragged I could ride all night through the
gap in those black mountains.” Here’s a man who is remembering
his potency, his ability to project himself,
his competence, his imagery of himself as
a man, and reflecting on that as he looks down the
line toward his future. This is something
that we necessarily want to know about our patient. Here’s another poem. It’s a woman who’s talking
about her medications. “In an open box beside my
chair sit vials of poison and the jar of cream I
use to smear my scalp. My son comes in to check me out,
afraid that I’ll forget to take the poison, but I won’t forget. For heart, I take
a white one once. For bowels, a scarlet
ball at night. And when I think
too much in bed, I take a lavender and green. To keep my heart
from beating fast, the poison pill
that binds me up. For blood, high
blood, I take a brown. For blood, high blood,
a red and white. For blood, low blood,
I take a brown. To make the prostate– actually, I’ve got the wrong
gender here on my picture. I apologize. I didn’t think of that when
I picked out the picture. Anyhow imagine– to
make the prostate work, I take an elephant
tablet twice a week. My son brings my
seven refills in and asks if I would
like to some air. It’s warm, he says,
let’s get some rays. That boy sees poison
in my eyes, the poison working through my skin. He wants to hold my
hand, but he’s afraid. That makes two of us. For heart, I take
a white one once.” I just want to make
one comment about time as I said before regarding
our inefficiency. Again, there are many clinical
books on doctor-patient interaction that point at–
and I think effectively– that it doesn’t take much time,
that with active listening, with accurate empathic feedback,
focused priority setting, that we can do a
remarkable amount. It’s a skill I think that
we can gain over time, despite the limitations. And I’m not, in any way,
minimizing our limitations, our 56% paperwork, et cetera– those are important problems
that we need address. But we can’t, I think,
ignore our patients while we try to address them. I think a second
area of listening is listening to your own heart. Writers about medicine
have been interested in this for at least 250 years,
and these are just quotes. And they bring up two issues. One is that the
study of medicine hardens the heart,
corrupts the heart– hardens the human
heart by which we live. And opposed to that,
of course, is a quote from Dr. Gregory
House who is not worried about his
heart being hardened and some additional
quotations from my students. “We have never been encouraged
to look at the assumptions and feelings that the physician
brings to the process. I can’t believe how arrogant
the residents and attendees are. If an emotion creeps
into the situation, the attendees deflect it away.” One of the things that has
become somewhat popular in recent years is the
concept of reflection rounds based upon the more generic
concept of reflective practice. How can we, in
this turbulent time in our turbulent
environment, learn to step back and reflect
on what we’re doing? At Stoney grow up in each of
the third year clerkships– we students have
reflection rounds at least twice in which they,
in a small group setting, are able to talk about their
feelings, their conflicts, their difficulties that
they’ve had with patients or with other
members of the team, talking about how
this makes them feel– not just trying to suppress
it or speaking about it in cynical, ironic,
joking ways, but actually talking about it as
genuine human beings one to another about the
difficulties that they’re having. What does it mean? Are we doing this the right way? So reflection rounds
is one aspect. Another aspect is the concept
of narrative medicine, and I’m sure you’re all
familiar with that concept and its prevalence in
the last 20 years or so. But I think sometimes we ignore
one dimension of narrative medicine. We focus on that narrative,
on that horizontal dimension of listening so that
we get the narrative. And we talk about
patient’s narrative or make up our own narrative
without the vertical dimension of talking about making
narrative medicine a habit of the
heart, of reflection, rather than just a habit of
the mind learning how to listen and construct a narrative. So the clinical ear– again, this is one
of those slides that you see after some guy
stands up and talks and tells you a lot unrealistic things. Then he gives you a
table about how you can solve all your problems. Well, this may look
like that, but it isn’t. It’s just my own reflection
on some of these issues, and I think the key word
here is “mindfulness.” And I’m sure you’re
familiar with that term. It’s a very simple concept that
has gained a lot of traction in medicine and hopefully
will gain more traction. The ability to just
get into that space by clearing your minds
with deep breathing or with some other
technique before you walk into a patient’s room. If you throw away, discard
those other concerns and become mindful
of what’s going on at that moment on a more
cognitive level, the concept of time management, which
I think we haven’t really been so good at as
physicians in general. The cult of the objective
can only, I think, be effectively fought by having
good clinical role models who demonstrate the necessity
to integrate the heart and the mind in caring for
patients and who can do it so that residents who are
skeptical about how I can do this– because this
is so terrible, I’ve got so many things to do,
I’m so distracted, et cetera, et cetera, the world hates me– sees that there are role
model physicians who not only are able to do this
but are excellent models of what a good physician should be,
and reflective practice, the idea of reflection
rounds, and of course there’s reflective writing as well. Many techniques are out there Unrealistic? Well, they’re realistic
for many physicians. So I think we should all
approach it with the concept that this is possible. It’s effective. How can I learn to practice
reflective medicine? I have to give you a more
positive view of my students, so here’s one. “I observed a physician who
was very kind to his patients but ruthless to his– well, it’s partially positive– but ruthless to his residents. No doubt he was excellent
at what he did and should be congratulated for that. But I do not respect
him as a person. I think his actions
and words constituted psychological abuse. It is refreshing to find that
the majority of physicians I have encountered. I have encountered
genuinely invested in people as human beings.” So in this case,
it’s the majority of physicians she’s praising
and not the individual person. The last thing I’d like to talk
about is our healing voice, and I think we
often ignore that. And I’ll go back to Anton
Chekhov, who I didn’t really introduce earlier because I
assume that you know, aside from being a
practicing physician, was one of the greatest world
masters of the short story and, along with Henry
Gibson and probably August Strindberg the father of
contemporary modern drama. And he practiced medicine. He did a great amount
of public health work, and he did all of this before
dying at the age of 44. He has over 400 published
stories, by the way. But in that same evaluation
by Dr. Chekhov’s preceptor, he said, “The mental state
of a patient interested him particularly, as well
as traditional medicines. He attached great
significance to the effect the doctor had on the
psyche of the patient and on his way of life.” And my own mentor– well, so medical
language can be healing. But it can also harm. One of the big issues today
is that since perhaps we don’t appreciate the
healing power of words, that often inadvertently use
our words to harm patients. And one of my
mentors, Eric Casell, wrote “sticks and stones
can break your bones, but a word could kill you.” And we’re all familiar
with phrases and words that we use in medicine
that are common but that actually harm patients. I’d like to read one
more poem that shows how important words can be. And this is a poem in which the
words that are about to be said could be very harmful
to the patient if said in the wrong way. But also they could
initiate the healing process if said in the right way. And this poem is
called “The Words.” “For the third time this
month, his bronzed face sits with its swaggering lisp
of what he needs me for– the test he read about
Sunday’s Time, a second script for percocet in case the pain
that’s almost gone comes back. Why his appetite is shot,
whether a drink at night would do him good. That body bears the
years with regal grace. His face is Olympian. His face is Olympian– commanding and ageless. The father of the
gods assumes the form of a broker in futures
on his way to the club, that immaculate
sun-drenched chest almost tugs me to his feet to
learn the secret of success. But I hold fast. That newest test won’t
help either of us, nor will the trip to a clinic
in Texas no matter how famous. I want to escape
to the next room, to leave him with his
power, and run from mine. The words that cut to his core– behold the pancreas. He looks at me
with faint unease, rising in the
creases of his eyes. My words will make him mortal. He will die.” When we look at other cultures
and read anthropology and so forth about traditional
medicine and so fourth, we often agree that words can
heal in these other cultures. For example, in
the Navajo culture, the blessing way is a very
important healing ceremony. It’s a seven day
healing ceremony. This is a picture of
a sand painting being made in the ceremonial hogan. And here’s a picture of
the atawe, or medicine man, putting clay mud on the patient. This is a pediatric
patient as you can see. And here is part of it–
the enemy away chant. It’s a little
different ceremony, but I’ll read it for you– this little excerpt. “Today I will walk out. Today everything
unnecessary will leave me. I will be as I was before,
a cold breeze over my body. I will have a light body. I will be happy forever. Nothing will hinder me. In beauty all day
long may I walk. Through the returning
seasons may I walk. On the trail marked
with pollen may I walk. With dew about my
feet may I walk.” And if you’ll visualize a desert
camp, an evening, a bonfire, a community of people and
you imagine the chant. It’s, I think, easy
for you to understand the effect of that
chant on the emotions of the people, the patient. It’s easy to
understand it’s effect on the lympic system
and the neuro hormones and so forth if we want to
translate it into our language. And to say perhaps
these words are healing. And i think this is the idea
that Anatole Broyard had in mind in his essay
“Doctor, Talk to Me.” He’s was a critic and
writer for The New Yorker who had extensive
prostate cancer and wrote about his care
experience with his doctors. He talks about the paradox
at the heart medicine. Because a doctor, like a writer,
must have a voice of his own, something that conveys
the timbre, the rhythm, the diction, the
music of his humanity and then compensates us for
all the speechless machines. The doctor is a
storyteller, and he can turn our lives into good
or bad stories regardless of the diagnosis. I’ll leave you,
finally, with another of these wonderful slides that
shows the summaries of all these articles, most of which
are quite boring that tell you the different ways that
language and the way we speak that language can
increase patient satisfaction, increase patient
self-efficacy, increase hope, and all the other aspects that
might constitute a healing process. And here’s an example from
one of my medical students that I think is more eloquent
than all those studies. “As we both sat next
to her, Dr. M’s words were comforting and
deliberate, walking the patient through exactly
what would occur. I was trying to recall those
words– the phrasing, the body language that he used. They were words I could
have said as well, but he just constructed
them in such a way that put the patient at great ease. Some day, I say to myself,
I’ll be that smooth.” And finally, to end
on a positive note, these are two excerpts. These are fourth year
students– maybe two months or three months
before graduation. “I never thought I
would say such a thing. I’m going to miss
medical school. It has been such a
wonderful experience for me, although painful at times. It’s a privilege to pursue
a career that you love.” Now this is one that I, as
a poet, appreciate most. “The practice of medicine
is simply poetry in motion. The art of medicine is the
validation of everything that makes the human experience. I learned more about myself
than I ever imagined.” Thank you. [APPLAUSE] MARCIA DAY CHILDRESS:
Thank you so much, Jack. And I think from
listening to you we’ve all gained a great deal. Now is the time in the
program when you all can bring your questions,
your comments, your thoughts into this community. You may address Jack. You may talk with each other. I have a microphone here. And John, would you be
able to run the other mike on the other isle? That would be great. We’d ask that when you ask a
question or make a comment, please identify yourself. So the floor is now yours. BOB SAVELLI: I’m Bob
Savelli in pediatrics. What are your personal
recommendations for delivering bad news
to news the patient? I think you gave
an example of how you can ruin the rest
of a patient’s life by saying the wrong things. What is the process of
getting tuned into the patient and delivering the bad news. Because I think
often physicians are loathe to confront the
patient with the bad news. JOHN L COULEHAN: Well,
I think first of all, honesty is paramount. I think vague or technical
language is inappropriate. And so I would always prepare. First of all, you prepare
for the situation. You’re not talking on the phone. You don’t have a
pager on, et cetera. You’re in a room
preferably with somebody of the patient’s
choice with them if they decide to
have that person. I would tell them
that I have bad news. And I would tell
them right out what that news is in clear, simple,
unambiguous information, language. I would then allow time for
emotions to be expressed. So maybe this is one area
where we’re deficient and that is isolating the
cognitive aspect of this from the affective aspect. You expect emotions and we
encourage emotional responses to them. I would describe, again,
in clear step by step terms what the next step is,
what needs to be done. But not in global words– not in terms of OK, we’ll
do this, we’ll do that, then we’ll consider
therapy and so forth. We’ll take the next step, which
might involve further studies and so forth. I would always
explain to the patient that I’m sticking with
them and that we’re going to work on this together. And I would emphasize my
accessibility by phone– well, nowadays, email. And I would always schedule
a return appointment fairly quickly. Those are some of the things. BOB SAVELLI: Thank you. AUDIENCE: [INAUDIBLE]
in pediatrics. Of Forgive the lighter question. Do you think improv
is a valuable training for physicians to learn
to become good listeners and to be in the moment? JOHN L COULEHAN: I do. I do. I think improv
and whether that’s a formal thing with
standardized patients in being observed and then
reviewing the tapes or reviewing the interaction,
or whether it’s literal improv in a small group– I think both are important. One of the things
that I emphasize, and because I am a poet and I
do reflective writing, poetry is not like football
or something. It’s not the most– the pastime that is most
popular in the United States. So I emphasize that there are
many paths to mindfulness. There are many
paths to reflection, and you have to find
the path that fits you. But I think our responsibility
as medical educators is to suggest a few paths
and have a little experience with them to see what does fit. YANA: My name is Yana. I’m a nurse coordinator
in oncology. In comment to the
first question, I think one thing that we
forget is that the patient often already knows the bad news. Maybe you don’t see it
at the superficial level or she hasn’t expressed it
at the superficial level. But often, the bad
news is not so much a surprise as we
fear it will be. JOHN L COULEHAN: I
think that’s true. But I also think
that verbalizing adds a new dimension to that and
that many patients fear that. They may know it, but they
don’t want to hear it. MARCIA DAY CHILDRESS:
Do you think it’s true too from
a conversation like that, that the patient
can then learn some of the ways that they might verbalize this
information to other people who may have been ill or whatever. But that it really
helps them rehearse and know how to say this. JOHN L COULEHAN: I do. And we have to realize that
in this kind of situation– really in any serious
medical interaction, but especially in this
kind of interaction– the patient’s only going to
remember a certain amount, OK? So you do want to
be clear, and you want to use very
understandable language. But at the same time, you can’t
expect that the patient will remember everything you say. And so that’s why I think
it’s important to encourage the patient, not only
to ask questions then, but to emphasize your
availability specifically to answer their
questions and not wait to some
hypothetical return visit but to be available to them
by phone or by other means so that they might feel more
comfortable in returning to that. Because they’re not
going to remember it. JULIE GARDNER: Hi, my
name is Julie Gardner. I’m a medical scribe in the ER. And my question is
how would you suggest that those of us
who can’t actively participate in patient
contact, patient care help to facilitate a
better experience in all of the principles and
ideals that you are just explaining to us? JOHN L COULEHAN:
You don’t actively participate in patient care. JULIE GARDNER: So I
can’t touch the patient. I can actually
interview them myself. So I’m taking notes and writing
up the chart after the fact. JOHN L COULEHAN: You’re
taking notes from? JULIE GARDNER: From the
physician’s interview. So I go into the room
with the physician, and they interview the patient. I take notes, and then I write
up the medical chart after. JOHN L COULEHAN: How do
you think you can do it? JULIE GARDNER: I don’t know. I’ve been doing this
for a few years now, and I’ve noticed that I try to
focus on the patient myself, even though I’m not the
one speaking to them. And I also train people. For instance, I
noticed one person I was training that
was twirling her hair, and I feel like
those actions tend to make the patient think that
you’re a little bored with them or this is very routine. But I was just
wondering what can I do to either alleviate
the physician’s burden or make the patient’s
experience better. JOHN L COULEHAN: Well,
this is new to me, so I’m just speaking here
entirely off the book– not off the book but ad lib. I think it would depend
on how comfortable you are with your physicians. I can imagine you
asking the physician some gentle questions that
had he or she noticed this? Or had you noticed that? Which, I think
would be perfectly appropriate like the
twirling [INAUDIBLE] Because you’re a good
observer and a good listener. So perhaps in a
non-threatening way to point these things
out indirectly. JULIE GARDNER: OK. Thank you. MARCIA DAY CHILDRESS: Thank you. Well, we’re– one
quick question. AUDIENCE: One quick follow-up– I thought that was
a good question. We often forget how to
say welcoming things and behave like we’re welcoming. And your body language can
go far to make the patient and the family feel welcomed. MARCIA DAY CHILDRESS: I’d
like to thank Jack Coulehan and thank all of
you for being here. Please join us next Wednesday. We will have a program
called Doctors as Makers with Dr. Jay Baruch from Brown
University’s Warren Alpert School of Medicine and
please join us then. Again, thanks to Jack Coulehan. [APPLAUSE]

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