The Art of Listening: Narrative, Hermeneutics and the Electronic Medical Record

Doctors tend to speed read. We are often in a hurry to extract the salient points from the large amount of information we receive every day in the form of journal articles, discharge summaries, imaging and consultation reports – and we often bring the same trait to our verbal history taking in the office or at the bedside.

In the past, before Electronic Medical Records, people argued over how many seconds the average doctor listened before interrupting the patient, but the point was clear – we often prefer to receive information on our terms, when we want it and in the order we want it. In part this is because we often imagine that this is faster than letting the patient speak uninterrupted. In part it is because it helps our pattern recognition, which can be a useful way of making a diagnosis but it may also be a counterproductive way of pigeonholing our patients without trying to see the uniqueness of their condition.

Osler said, “Listen to your patient, he is telling you the diagnosis”. But there is more to listening than making a diagnosis. All communication requires listening. Physicians today are not asked to diagnose patients as often as Osler’s contemporaries were. Our patients come to us looking for relief from anxiety, insomnia, overweight or depression. They sometimes ask our help in obtaining disability benefits instead of diagnosis and treatment. Those situations are not at all like making a diagnosis of myxedema or an infectious disease. In those situations we need to understand what motivates our patients.

The concept of Narrative Medicine has been around for a dozen years. It is not only the patient with a psychological or psychiatric complaint who needs to tell the story that goes with the symptoms. Many patients cannot reduce their experience of any illness to clear-cut, easily catalogued clinical factoids.

In the days of dictated office notes, many of us put the patient’s chart somewhere within reach but then gave all our attention to the patient. We would use eye contact and body language to encourage continued communication and we would listen for the untold parts of the story that unfolded. Not until after the visit was over and the patient gone from the clinic would we reach for the microphone or digital recorder and create our office note, which would summarize both the clinical details and the narrative.

Today, with real-time documentation into medical records built around structured data entry, doctors who used to sit back and listen are leaning over keyboards and mouse pads. Instead of savoring and contemplating their patient’s unique words, doctors are now choosing between adjectives in drop-down menus, as in a reverse paint-by-numbers process.

With fewer nuances and less detail in the digital narrative, there is greater risk that we may never understand what a symptom or disease means to a patient: Hermeneutics, mostly thought of in the context of Bible interpretation or philosophy, is an emerging area of exploration in medicine, just when our electronic clinical notes are starting to look more and more similar from one patient to the next. At the same time the revolution of modern genetics is creating the potential for what some call Precision Medicine, referenced in a recent issue of The New England Journal of Medicine. This is the science that lets doctors know in advance which patient will respond to what treatment. It has even been suggested that one could pick antidepressant medications based on biochemical testing.

It is ironic that the medicine of the future promises to be exquisitely personalized in the biochemical sense, but more and more depersonalized from a humanistic, hermeneutic point of view:

Picking antidepressants based on genetics – instead of listening to the patient? Maybe if we listen more, we might prescribe less.

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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”.


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