The Art of Listening: When the Inner Voice Whispers

“I worry, so you don’t have to”, is how I explain to patients when something about their story or physical exam makes me consider that they may have something serious going on.

The worst thing you can do is give false reassurance without serious consideration. And the next worst thing you can do is be an alarmist and needlessly frighten your patient. Finding and explaining the balance between those two extremes is a big part of the art of medicine.

A few times in my career I have struggled with doubt or worry after a patient visit. Did I miss anything, did I order the right test? We all have those moments, but we have personal limits as to how much of such doubt we can handle in the long run.

During my training and early career in Sweden there was more tolerance for physician fallability. Doctors have not been sitting on any pedestals for a couple of generations there. Here, the climate is different: We may not be revered like we were in the past, but if we make errors in judgement, the personal consequences for us can be devastating.

The way to navigate this treacherous territory is first of all to not travel alone. Everything we do is for our patient, so we must maintain a partnership. We are the experts, but we should not make decisions that aren’t shared. I keep coming back to the notion that today’s doctors are guides.

I try to gauge my patient’s degree of worry and match my choice of words and actions to some degree to that. If a patient mentions a symptom and then trivializes it, I often cloak my concern with the words “I worry, so you don’t have to”. That works better than “I don’t want to scare you, but you could have a brain tumor”. The way I say it, I suggest to the patient that my recommendation is a safety measure and I quietly suggest that I just might be worried for nothing. My use of the word worry shows a degree of emotional involvement, partnership and guide responsibility.

If a patient seems overly worried, we must be very careful not to brush off their concern. It is easy to seem callous and to make the patient think we aren’t listening. I may ask point blank what their biggest fear is if I can’t tell and if they name one, I say it back to them and talk about how that condition usually does or does not present. If there is a test that could rule out the life threatening condition they worry about, what’s the point in not ordering it?

In the busy flow of any clinic day, I try not to ignore that little inner voice, that clinical instinct, which tells me something could be dreadfully wrong. If it appears after the visit is over, or after I have already formulated a plan, there is nothing wrong with correcting your course. Those few times when I have said “I’ve been thinking about your symptoms, and maybe we should just have you go to the emergency room and get that scan done so neither one of us has to worry tonight”, nobody has faulted me for changing my mind.

How I Write

When I worked at MedNow, Dewey Richards’ walk-in family practice in Orono, a part time transcriptionist worked in the break room.

She would sit down in front of her old fashioned computer monitor, put a doctor’s micro cassette in her player, the ear phones in her ears and start typing. The screen in front of her was completely empty except for the cursor in the upper left corner. When each office note was finished, she would print it and start again with a completely blank screen.

Most word processors today are full of icons with formatting options. The only time I use that kind of writing platform is when I actually do some formatting, like a pamphlet or layout of a completed book manuscript.

I write on my iPad because it lets me work anywhere, and I prefer a blank screen in front of me as I choose the right words to express my thoughts. Just like I prefer to write in the early morning, when life has fewer distractions, I find the big white space of my favorite writing app helps me open my mind and be inspired. I don’t usually start with a topic already in my head until I see the empty screen in front of me.

The free program I use for creating blog posts and personal correspondence is called Simplenote. It was created by WordPress, which is the backbone of probably the majority of websites, from A Country Doctor Writes to The New York Times.

Simplenote synchs seamlessly between all my devices every time I close a document, so I can open what I created on my iPad minutes later on my iPhone or my MacBook.

This way of writing is as close to a blank page in a typewriter that you can get. I have heard some people are intimidated by sitting down in front of a blank page. I find it inviting and inspiring, because it suggests that anything is possible.

For blog posts, I copy the finished piece and paste it in WordPress, where I can insert graphics, italicize or make text bold, insert links or indents for quotes.

For book chapters, I paste my text into Scrivener, which synchs (although they spell it ‘syncs’) with Dropbox across devices. This is a writing program that lets you create, format and organize chapters. The last step is then to convert the whole project to a Pages, pdf or (if necessary – ugh) Word document.

As I now finish writing this post on my white iPad screen, my eyes also take in the whiteness of the new snow on the trees and the red cedar fence of the horse pasture outside my bedroom window. It is a silent, sunny Sunday morning.

Time to feed the horses.


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

BOOKS BY HANS DUVEFELT, MD

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