Please Hear What I'm Not Saying: The Art of Listening in the Clinical Encounter

Abstract

“Not every patient can be saved, but his illness may be eased by the way the doctor responds to him.” —Anatolle Broyard Near the end of Anne Fadiman's book, The Spirit Catches You and You Fall Down,1 a tragic account of two cultures at odds with each other, the author tells the story of a Hmong patient who was being referred to a specialist for further treatment and, instead of inquiring about the physician's skill or credentials, he asked, “Do you know someone who would care for me and love me?”1p275–6 It is an honest question that bears asking, and yet within its naked simplicity lies the deepest complexity. It is not the type of question one responds to quickly or without reservation, but it is one that deserves a thoughtful answer. It would not be incorrect to assume that beneath our own culture's fiercely held value of independence lies the very same question, for when all is said and done, isn't this what every person desires? Unfortunately, the trajectory of medicine's increasingly one-sided focus on science and technology over the humanities has created an ever-widening gap between physicians and patients, resulting in decreased trust and confidence in a relationship that needs and depends on it the most. “The price for a technologically sophisticated medicine,” says physician Rita Charon, MD, “seems to be impersonal, calculating treatment from revolving sets of specialists who, because they are consumed with the scientific elements in health care, seem divided from the ordinary human experiences that surround pain, suffering, and dying … Patients long for doctors who comprehend what they go through and who, as a result, stay the course with them through their illnesses. A medicine practiced without a genuine and obligating awareness of what patients go through may fulfill its technical goals, but it is an empty medicine, or, at best, half a medicine ….” 2p6 Given these upsetting developments, the physician still remains a symbol of hope in a patient's search for relief from pain and suffering. The singularity of the clinician-patient relationship is what sets it apart, for it is the primary conduit by which all else follows. Characterized by a level of physical and emotional intimacy not found outside of the romantic relationship, the clinician-patient relationship connects the experience of illness with narrative meaning powerful enough to affect a patient's course of treatment and quality of life far beyond what one would imagine, oftentimes standing at the center of our most taxing bioethical dilemmas.