Lack of listening is the core care problem in American health care

Next in a series.

There is and will be a need for many more primary care physicians (PCPs).

Why?

There is a shortage now and it will be exacerbated in the coming years for at least three reasons. The population is growing, the population is aging and there will be more individuals with health care coverage as a result of the Affordable Care Act (“Obamacare”).

I believe that the need will be much greater than the estimate of 52,000 in 2025 as proposed recently in the Annals of Family Medicine. The authors did not address this fourth and particularly important reason driving a need for more PCPs.  If PCPs actually cared for only a reasonable number of patients, perhaps 500 to 1000 rather than today’s common 2500+,  such that they no longer were seeing 24-25 or more patients per day in their offices, then the need for more PCPs would be much greater. With fewer patients seen per day, the PCP can then spend the time needed to listen, to prevent, to coordinate and to think — four key activities that they often are not able to do effectively today. This drives a need for substantially more PCPs.

The need is not to graduate more total medical students but to make primary care desirable as a medical professional career. This means overcoming the current non-sustainable business model so that graduates once again will select primary care.

Here is an example of the value of a primary care physician being able to take the time needed to thoroughly listen to a patient and assess the situation.

The PCP saw a lady one day that he had known for many years. She was always very enthusiastic and very articulate. One day she came in for a routine visit. The PCP noticed that her speech patterns were slightly different than he remembered from the past. No one who did not know her well nor anyone who had only a brief conversation would have recognized her speech as changed. She was unaware and felt fine. The changes were subtle but they were clearly changed in his mind. The rest of the history was unremarkable. He did a neurologic exam which was also unremarkable. But he was certain that something was amiss. So he ordered an MRI of her brain. Her insurer refused because she had no specific indications with an otherwise normal history and examination. He had to call multiple times and explain his rationale; finally the insurer relented. The MRI showed a primary brain lymphoma — treatable, probably curable.

The message is simple. The PCP knew his patient well and because he had the benefit of an extended visit time he was able to notice the subtle changes in her speech pattern. His skill combined with a long history with his patient and adequate time made all the difference and probably saved her life.

Compare that experience to the following story sent me recently:

My mother’s “real world” story is mostly about a cardiologist but touches on the very problem you describe about PCPs in a brief but pointed way.

I took my mother to the cardiologist this week. He spent a good amount of time with her, mostly listening, trying to figure out her medical issue. Once he thought he’d hit upon what was causing the problem and the solution (which happily, did not involve a drug or surgery but behavior modification), he said he’d call her internist who she has been seeing for many many years to tell him about the discussion.

My mother waved her hand dismissively and said, “He doesn’t know me.” The cardiologist looked surprised and a little confused but I understood. My mother was saying that her internist had not spent time listening to her and getting to know her unique situation like this cardiologist had done.

My usually non-compliant and defiant mother called me the morning after her appointment to report she had done what he recommended and would continue to do so. His unhurried gentle questioning, sympathetic listening and obvious desire to figure out how to help her is what made my mother trust him. I felt that my mother had actually consulted with a physician — a healer.

There is both a good and a not so good side to this story. The good is obviously that the cardiologist listened to her and then developed a plan of action — with her and her daughter — that she could accept and follow. The not so good or even most unfortunate is that she felt her PCP that she had visited for many years didn’t really know her — because he did not listen.

When doctors do not have enough time to really listen the result is that they do not listen. A study from 1984 of primary care physicians observed throughout patient visits revealed that the doctor interrupted the patient within 18 seconds on average. Relating to this article, Suzanne Koven commented, “in only 17 (23%) of the visits was the patient provided the opportunity to complete his or her opening statement of concerns. In 51 (69%) of the visits the physician interrupted the patient’s statement and directed questions toward a specific concern; in only 1 of these 51 visits was the patient afforded the opportunity to complete the opening statement.”

This is not only remarkable but a sad commentary on the short visit and the lack of attention by physicians to actually listening to the patient.

This lack of listening is the core care problem in American health care today. It is prevalent, pervasive and getting worse, not better. It is the inadequate income per patient (by whatever payment system – fee for service, capitation, etc. — is used) that is driving the lack of listening.

Today the PCP sees too many patients for too little time each. Until the payment system is corrected and, in return, doctors get back to listening, health care will not be true care and certainly not healing. Call this a future combination of shared rights and responsibilities — the doctor earns a decent income in return for offering superior care to a reasonable number of patients. This would be a good balance all around. And although primary care would cost more, the total cost of care would come way down.

My next post in this series will address the “paradox” inherent in today’s American medicine.

Lack of listening is the core care problem in American health careStephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.

email

Comments are moderated before they are published. Please read the comment policy.

  • buzzkillersmith

    It won’t get better. It will get worse, idiotic ideas like the PCMH notwithstanding.

    The solution is obvious and is stated, with no apparent irony, in Dr. S.’s post: Go into cardiology and suchlike, young medstuds.

    Stick a fork in physician-based primary care.

  • Ira Nash

    I agree that listening is essential. I had a recent example with a family member: http://nslijmdblog.com/2014/02/20/just-listen/

    • futuredoc

      Your penultimate sentence in that blog post says it all. “The patient was offering the diagnosis, and his doctor still missed it.” because he was not listening. I remember a mentor in medical school saying something along the lines of “Just listen, your patient will tell you the diagnosis.”

      • rbthe4th2

        The best PCP I had for years (before he left the area) was this way. He told me you’ll tell me the issue.

  • Deceased MD

    And what they are leaving out is what will continue to get worse. Increased morbidity and mortality for pts if the PCP has no time to listen. Simply because anything that is especially complicated (or not ) will get overlooked because no thought will be put into it. Yes there will be good specialists. but how will the pt know how to get to them, especially anything not terribly obvious. There is a positive example of the PCP picking up the brain tumor but no example of the real negative consequences happening right now.

  • Lord Acton

    I am certain that you are right. I am doing direct primary care. I see an average of 7 – 10 patients a day and am available 24/7. I do home visits and inpatient care. I have time to listen to my patients and I am saving the system a boatload of money: less testing, fewer referrals, far fewer ER visits and fewer admissions. I don’t charge the government or the insurers a cent for my services. All this for $55 a month and $20 a visit. And I am a very happy and satisfied family doc. So happy patients, check. Saving the system tons of money, check. Happy doctor, check. Sounds like a solution to much of what ails our health care system.

    • futuredoc

      Agree

  • Bob

    I’m not sure the population is growing in the previous manner but perhaps is from immigration past and present, often not insured. As to aging the actuarial calculations are based on deaths causing a projection problem under projecting length of life, and healthcare is a need not directly related to insurance which only increases demand that ObamaCare pushes through a single entity the PCP who are diagnosticians, most often young physicians looking to become specialists, and work only 40 hour weeks as specialists most often do. This is the path of most people in every field and is not a criticism and is where most patients end up after referrals often to many specialists, if they are lucky enough, as specialists also equate to Senior physicians and nurses as well who are looking to “slow down” or retire. Advanced ER treatments and clinics not requiring massive amounts of physician involvement would bring better and faster results which will come after ObamaCare collapses.

  • Sue Hawes

    As a patient and health care professional, I couldn’t agree more about listening. Truncated visits, cursory exams if they are done at all and endless typing erode listening time. Instead, a quick review of the major symptom and script for a test or drug is what the patient walks out with. Complex health problems are not resolved by a 15 minute appointment. I would like to feel like a person rather than a cog in the wheel in the medical machinery.

  • katerinahurd

    Do you agree that eliminating medical history from the medical school curriculum contributes to the fade out of the art of listening? In addition, do you agree that popular medical shows that glorify medical specialties attenuate the significant role that the art of listening plays in exercising an holistic medical art?

Most Popular