Sometimes the trick is knowing when to keep quiet
From the January-February ACP Observer, copyright © 2006 by the American College of Physicians.
By Janet Colwell
Georgia L. Newman, FACP, had been treating one patient for hypertension, hypercholesterolemia and other problems for months with limited success. Then during a routine physical the man revealed to her that he was an alcoholic, and the pieces began to fall into place.
"I had been treating him for depression," said Dr. Newman, 60, a geriatrician and general internist in a three-physician practice in Oberlin, Ohio. "Now I know that his alcoholism underlies a lot of his hard-to-treat medical conditions."
Unfortunately, such information often fails to surface in the typical 15-minute office visit. Doctors who spend extra time can find themselves hopelessly behind schedule while those who stay on track must resort to assembly line efficiency.
Dr. Newman, who has been in practice for more than 30 years, doesn't profess to have the answer to that dilemma, but she does try to maintain a balance. Her mantra: Listen carefully and try to learn one new thing about each patient at every visit.
She now knows, for instance, that one patient launched her own business, that another struggles with compulsive gambling and another stormed Omaha Beach on D-Day. Those details have deepened her relationship with patients at a time when medical interactions, she said, seem increasingly under scrutiny by insurers and attorneys.
'We end up finding out interesting things about patients by reading their obituaries.'
—Georgia L. Newman, FACP
"Doctors are burning out and quitting in frustration, and it's partly because patients are becoming clinical goals they have to achieve," she observed. "We end up finding out interesting things about patients by reading their obituaries."
A balancing act
A classic study published in the November 1984 issue of Annals of Internal Medicine found that physicians on average interrupt patients 18 seconds into an interview. A follow-up study in the Jan. 20, 1999, issue of the Journal of the American Medical Association found that the average time to interruption had increased only slightly to 23 seconds.
Dr. Newman said she constantly reminds herself to "shut up" and let patients talk. That gives her clues to problems, such as depression or anxiety, which often lurk beneath the surface of patients' complaints or symptoms.
But making sure patients receive appropriate tests and screening leaves little time for relaxed conversation. And focusing on the patient interview to the exclusion of all else can have disastrous consequences, as Dr. Newman found when she took over the care of several patients from a relocating physician in the early 1980s. The older physician, known for making house calls by motorcycle, was beloved by patients--but his colleagues saw a darker side to his bedside manner.
"After his departure, we discovered that he hadn't been doing any preventive care. Women he saw every three months hadn't had mammograms in 10 years, if at all," said Dr. Newman, who had to tell two unsuspecting patients that they had advanced cancers. Patients with then-uncontrolled diabetes and hypertension "still tell me how much they miss him."
Still, spending too much time talking or listening is rare. On the contrary, Dr. Newman said, training programs can be so intense that they can instill outright hostility toward patients, something many doctors struggle to shake off in practice.
"You are brutalized in training," said Dr. Newman, who graduated from Harvard Medical School in 1971 and completed a hematology-oncology fellowship at Boston's Peter Bent Brigham Hospital. "You come out hating patients because every patient is a personal affront on your life. It's just more work that you have to do when you're exhausted."
Practicing in small communities has gradually helped repair that damaged connection to patients. After completing her fellowship, she and her husband opened a joint general practice in his hometown of Mechanicsburg, Ohio, population 1,700. She later moved to Oberlin, which has about 10,000 residents when the college is in session. She found that patients in a small town were grateful for her help and even "stopped me on the street to thank me for moving there."
She also saw a wider range of illnesses in practice than she had encountered in training, and experienced the satisfaction of clinical success with problems like headaches.
"When I have a patient returning again and again who isn't getting better, instead of getting frustrated, I tell myself that I have another chance to figure out what's wrong," she said. "I've discovered spousal abuse, severe sleep apnea, awful living conditions, a lot of depression."
She's also learned that people rarely say what they really need in the first few minutes of a visit. To encourage patients to open up, she sits physically below them on a stool near the exam table so, psychologically, patients feel in control of the conversation. She keeps the tone friendly but saves personal chitchat until after she's taken a detailed history and discussed the reason for their visit.
She also asks them to fill out a form in the waiting room and list issues they'd like to discuss during the visit.
"If they say they can't sleep or feel stressed," she said, "that gives me a heads up that other things might be happening in their lives." In the case of the alcoholic patient, for example, Dr. Newman picked up on the fact that the man hadn't filled out the CAGE questionnaire portion of his intake form. She found out that he had stopped drinking after experiencing a blackout—and she recommended that he get help through a support group.
Taking the time to figure out what's really wrong can mean as little as a few extra minutes, she said, but it's the difference between knowing patients as people and seeing them as numbers on a chart. And that is a key part of career satisfaction.
"Listening actively to the narrative, diagnosing, explaining the diagnosis and partnering with the patient is really what we do," observed Dr. Newman. "How best to help is an intellectual and emotional puzzle to be constantly re-solved."
Internist Archives Quick Links
Reviews of the World's Top Medical Journals—FREE to ACP Members!
ACP JournalWiseSM is mobile optimized with optional email alerts! Get access to reviews from over 120 of the world’s top medical journals alerting you to the highest quality, most clinically relevant new articles based on your preferred areas of specialty. ACP Members register your FREE account now!
New CME Option: Internal Medicine 2014 Recordings
New CME Package
Includes 75 of the most popular sessions in internal medicine and the subspecialties. Stream the sessions, answer brief quizzes and earn CME credit. See details.