I always admire doctors who can write books criticizing their own profession, including any shortcomings they may have as practitioners, in an effort to improve patient care. In their new book, When Doctors Don’t Listen, Brigham and Women’s Hospital emergency room physicians Leana Wen and Joshua Kosowsky reveal what patients have long suspected: Doctors often tune out a patient’s story when seeking a diagnosis and simply clue in on specific symptoms, which may lead them to over-test and over-treat.
When patients utter the words “chest pain,” doctors may kick into immediate action, giving patients an aspirin to chew, an EKG to monitor their heart’s electrical activity, blood tests, and X-rays, and possibly keeping them overnight in the hospital to confirm or rule out a heart attack.
All too often, patients with muscle strains or heartburn are admitted to the Brigham and elsewhere for a two-day heart work-up — despite having no initial signs of a heart attack. That’s because doctors were following a standard diagnostic protocol for evaluating chest pain — instead of listening to their patients to determine whether something more common was likely to blame.
Today’s doctors, Wen and Kosowsky contend, have failed to practice the art of listening to gain a context in which to place a patient’s symptoms. Wen, who is completing her residency training, admitted that she, at first, stuck to this form of cookbook medicine — ticking off a checklist of symptoms in her head as a patient spoke — in an effort to become an efficient doctor.
Kosowsky, vice chair and clinical director of Brigham’s emergency medical department, called it a “failure in the way doctors are being trained to think,” a result of too much reliance on high-tech imaging tests and blood tests to measure biomarkers that weren’t around a generation ago.
“It’s about finding a balance,” he said in an interview. “Neither Leana nor I would say to throw all guidelines out the window, and doctors are well intentioned when they follow these protocols,” Kosowsky said, “but they’ve taken on an oversized role.”
In an era that’s ushering in medical checklists to help doctors and nurses avoid transmitting infections or leaving instruments in a patient during surgery, both Wen and Kosowsky told me that while such lists might be fine for improving safety, they shouldn’t be used when making a diagnosis.
How can you get your doctor to become a better listener? Here’s what the authors recommend.
1. Tell a good story. Start at the beginning and proceed chronologically, highlighting the most important parts in five minutes or less, if possible. Don’t use medical jargon that you may have heard on a TV show such as “Grey’s Anatomy.” Doctors have specific definitions for terms such as “radiating” or “palpitations” that may differ from what you’re actually experiencing. If your doctor tries to interrupt your tale with questions, take a breath and ask to continue before the questioning.
2. Always provide context. What was happening in your life when the symptoms started? If they’ve recently gotten worse, explain what you think may have exacerbated them. This will help your doctor to think beyond the set diagnostic protocol and see you more as an individual.
3. Describe symptoms as specifically as possible during a physical exam. If you feel the pain in only one spot, make that known. Let your doctor know if it’s sharp or dull, intermittent or constant. Pain scores doctors traditionally use — 1 to 10 with 1 being mild and 10 akin to the worst torture — can often be misleading because a patient’s definition of a 10 may be very different from a doctor’s.
4. Get a differential diagnosis. Doctors should have more than one diagnosis in mind initially to make sure that all bases are covered. Usually, a doctor will strongly suspect one particular condition while considering a few others. For example, you might be told you likely have a migraine but that if the pain doesn’t abate at all over the next week, you might need a brain scan to rule out a tumor. “Be wary if your doctor seems to focus on one particular disease to rule out,” write Wen and Kosowsky.
5. Ask for the reasons behind every medical test. Your doctor should be able to explain what the test is looking for, how likely you are to have that diagnosis, and whether your treatment plan will change based on that diagnosis. Every test, even a simple blood draw, has risks, according to Wen, so they all should be done for a reason.