“Just listen to your patient; he is telling you the diagnosis.”
This medical maxim is attributed to Sir William Osler (1849–1919), widely considered to be one of the greatest physicians and diagnosticians of all time. Although Osler’s advice might seem impractical in today’s healthcare environment in which clinicians face increasing pressure to deliver care faster and more efficiently, a recent experiment by a New York City physician suggests that letting patients speak about their health problems without interruption can be both practical and beneficial for both parties.
Studies have shown that doctors interrupt or redirect patients within the first 30 seconds after they begin speaking, and two studies found the average time to interruption was 18 and 12 seconds, respectively. Danielle Ofri, MD, a physician at Bellevue Hospital and an associate professor of medicine at the New York University School of Medicine, confessed to having been guilty of such interruptions and redirections in her recent essay in STAT (adapted from her new book, “What Patients Say, What Doctors Hear”). Like many of her peers, she feared her patients would “ramble on ad infinitum” if she didn’t home in on their top priorities quickly. But after reading a study by a group of Swiss researchers who found that when doctors did not interrupt, the average duration of their patients’ monologues was a mere 92 seconds, Ofri decided to do some informal research in her own clinic the next day.
Throughout that day, she asked each patient how she could help her or him, then quietly clicked on a stopwatch to time their responses. She encouraged them to keep talking until they had finished telling her everything they wanted to discuss. Her first two patients, who were basically healthy individuals, spoke uninterrupted for just 37 seconds and 32 seconds, respectively. Her third patient, who had unresolved back pain plus glucose, cholesterol and weight that were creeping up, spoke for two minutes.
But Ofri was understandably worried about what would happen with her next patient, Ms. Garza (not her real name). Garza not only suffered from a wide range of chronic, insoluble pains compounded by anxiety, depression and irritable bowel syndrome, she also had to care for her demanding, elderly mother, who had insomnia and routinely was up and complaining at all hours during the night. “Exactly the type of patient who can drown you with a list of complaints,” Ofri noted. In addition, Garza, who had been a teacher in her native Argentina, had a penchant for offering observations about New York City’s “pretensions of culture” and its lack of sophistication compared to Buenos Aires.
Ofri feared that if she allowed Garza to say everything she wanted to without interruption, “the visit would unfurl like a Borges labyrinth. We’d tumble down a dizzying path of her symptoms that would encompass every organ system of her body, plus a list of her mother’s medical woes and a stinging critique of the Metropolitan Opera’s soulless production of ‘Turandot.’” Nonetheless, Ofri understood that if she excluded “difficult” patients from her experiment that day, her data—informal though it was—would be flawed. So, despite her qualms, she encouraged Garza to keep talking until she had “fully, truly, absolutely come to the end of all that she had to say” while Ofri jotted down the long list of issues. When Garza had finally talked her fill and Ofri clicked off the stopwatch without looking at it, she estimated that between eight and 10 minutes had passed. Later, when she checked the stopwatch, she discovered that even Garza’s lengthy monologue had actually taken just four minutes and seven seconds.
Garza had already had an extensive workup, and all the results were negative. Ofri explained to her that something was going on and that “Medicine is very poor at explaining pain syndromes, but that doesn’t mean we can’t go ahead and start treating your symptoms.” She and Garza spent the remainder of the time reviewing the list of issues. They went through each type of pain, which included shooting pains in Garza’s gums, a painfully sensitive scalp and neck pain that radiated down her spine, and identified treatments that might help, including ice packs, local heat and massage, physical therapy and pain medications. They discussed how antidepressants could be helpful, how seeing a therapist could decrease Garza’s stress, how she might get help in caring for her elderly mother and the critical role of exercise in treating chronic pain. Then they put together a written plan based on those discussions.
Even so, the visit didn’t run overtime by much. Before leaving, Garza said, “Just talking about all this has actually made me feel better.” To Ofri’s surprise, it had made her feel better, too. In fact, it was the first time she had ever felt good after a visit with a patient with chronic pain. “I was actually doing something to help, rather than just rearranging deck chairs,” she explained. “It’s a reminder that doctors sometimes need to zip it up and let the patient talk uninterrupted. Although it may feel like time is being wasted, it could actually make everything much more efficient.”