Monday, March 17, 2014

The Lost Art of Listening

(I wrote this piece for a local medical journal, I thought I'd share it here too)

The teacher who sticks rigidly to a text book and rarely entertains deviation from the lesson plan isn’t the one that inspires students.  The stalwart disciplinarian who refuses to hear questions rarely gains the favor of subordinates.  We want to inspire others to take responsibility for themselves, and that inspiration comes mostly from understanding and intuition.  Paula Denton wrote a piece for the Virginia Journal of Education called The Power of Listening.  It was written for teachers, but its lessons are easy to apply to my clinic: 

“To be known and understood is a basic human need. When we fulfill that need for students (or patients), they feel a sense of belonging and significance… “

Which brings me to my practice of massage therapy.  Patients love feeling physically better and having their needs anticipated, but above everything else, they want to be listened to. That is often what brought them to me in the first place. 

In his insightful TED talk, Abraham Verghese MD., Professor of Medicine and Senior Associate Chair for the Theory and Practice of Medicine at Stanford University, talks about the most frequent complaint he hears about doctors, 
it is amazing how often you hear, "(S)he never touched me!" or, ". . . never laid a hand on me!" or "never looked at me" or "never listened" or "was too busy looking at the computer screen.""
His main point is that when doctors spend time trying to create a virtual model of the patient, they forget to see the actual person sitting in the room.  Although that doesn’t happen in my field, the opposite problem occurs regularly.  Patients are brought into a room without a proper interview and given a generic massage routine which addresses none of their specific complaints.

As with many complementary and alternative therapies, massage therapists spend the majority of their time with a patient one-on-one.  We are in a wonderful position to help people, and have the time necessary to listen carefully.  People often seek alternative health practices simply because they want to be treated this way.  When I see a patient for the first time, the interview and intake procedure can take 20 minutes or longer, because I listen to everything they have to say about their pain and ask all the necessary questions to understand their goals.  Time to express their complaints with my undivided attention gets nearly as many positive comments as the massage gets.

Listening isn’t easy.  

There is a misconception that if you sit quietly while someone speaks, you have met all the requirements for listening.  

Being present, with open ears, is just the beginning.  

When someone speaks to us they are trying to tell us many things.  Besides the basic message in the words themselves, there is subtext in why they chose the words they use, the expressions both in the face and the tone of voice, and body posture.  Most of these messages are lost on the active listener.  Really listening to someone for more than a few minutes is much more challenging than it sounds.  Most of the time, in conversation our brain is busy anticipating the next chance to speak.  When with a patient, we want simple clear answers to tick boxes either on a chart or in our minds.  Our own thoughts, agenda, point of view, and expectations can seep in and drown out hearing the whole message.  

In a busy environment--with computer whirring, charts with empty spaces, missed calls and texts, anticipation of several more appointments today--focusing on the task of eye-contact and evaluation of words as they are being actively spoken can seem next to impossible.  To combat this there is no computer in my treatment room, there is also no phone, and virtually no other distractions from the patient.  I don’t even write down much of what is said until after the interview is over, just quick notes to keep track.  Even with all these modifications, I still have to actively quiet my mind to avoid categorizing problems prematurely.  My scope is fairly small, and even so, a missed detail can be the difference between an effective intervention, and a null result.

More importantly, I don’t want to be another example in a long line of, “I saw so-and-so and he didn’t even listen to me.”  Most of my patients have these stories in common.  It is not unusual for a primary care physician to send a patient home having never touched them and barely talked to them, usually recommending large doses of ibuprofen or naproxen, if anything is recommended at all.  If they come back, they are sent to a physical therapist who doesn’t touch them or listen to them before sending them off to do painful exercises with an assistant who urges them to ignore the pain and stick with it.  When results from this are less than stellar, should anyone be surprised?

Anti-inflammatory medicine may have been the right call, the exercises may have been exactly the right ones, but the patient didn’t feel satisfied with encounter with his/her clinician, so compliance is minimal.  It is human nature to take the advice of someone we like or respect.  A 2010 Harvard Medical School study showed that about 20 percent of first-time prescriptions are never filled.  That number drops even lower when we look at advice given without a written script.  OTC medicines aren’t taken seriously and take home exercises, in my experience, are very rarely done properly. 

It is admittedly easier to get patients to stick to a massage regiment. Despite the expense, massage is pleasant, feels significant and specific when done properly, and gets quick short-term results. During that time, if I can convince them to dust off the PT’s orders, or follow the regiment their doctor recommended, the results only improve.

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