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.

4 Responses to “The Art of Listening: When the Inner Voice Whispers”

  1. 1 johndykersmddykerscom March 1, 2021 at 1:05 pm

    Thorough and insightful. Sharing with patients is so much more comfortable than 60 years ago. I loved the new relationship and embraced it as adding depth to Dr/Pt and a real degree of comfort, especially considering the litigiousness of our society and profession. Thank you for expressing this so well
    I invite you to share “The Price Of Eggs Is Down”.

  2. 2 johndykersmddykerscom March 1, 2021 at 1:06 pm

    PS. Telling someone not to worry is about as useful as worrying.

  3. 3 James Sedwick March 2, 2021 at 10:35 am

    Here’s a specific patient worry: Given the mix of recommendations, pro and con, about statins for primary prevention for people in their mid-seventies and older, how do you approach this patient concern? Thank you.

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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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