Next in a series.
Years ago while in oncology training, I was on night duty when a patient of one of my colleagues was having severe penile pain. He had received a new investigational chemotherapy and it turned out to have an unexpected property of damaging the lining of the bladder and urethra. It gave him a strong uncontrollable urge to urinate yet each time the burning was excruciating. Oral pain killers were of no help and Pyridium, used for the burning of a typical urinary tract infection, was ineffective.
Eventually I found an anesthetic gel to squeeze into his urethra which offered some relief — enough that he could sleep. My job for the evening was done. But I learned that this pain had a much deeper meaning for the patient. He had developed a close rapport with a long-time evening shift nurse. She told me that in college his classmate girlfriend became pregnant; she had borne the child but he had abandoned them. Now nearly a decade later, married to another woman and with two children, he had developed testicular cancer. That diagnosis plus tonight’s pain was, he believed, God’s punishment and he was wracked with guilt. His physician had never learned this because he had only focused on the cancer itself. It was the nurse who sat quietly and nonjudgmentally with the patient in the evenings and learned of his inner turmoil.
So it is necessary to look within to find the root cause of discomfort. The disease may well be a random event but it may just as well be a manifestation of an underlying issue or, as with this patient, a new reminder of an old guilt. Treating the disease, even successfully, will not heal the underlying issue and it will ultimately remanifest itself as a recurrence or as a new symptom complex.
Deep nonjudgmental listening is the essential first step in healing. From there begins the therapeutic exchange. The nurse listened but did not judge and as a result that patient was able to open his heart to her.
Patient satisfaction surveys completed after hospitalizations are quite consistent. The patients may not love the food or parking arrangements but they are deeply troubled that their doctor or nurse “didn’t listen to me.” Studies have shown that doctors tend to interrupt patients within seconds — not minutes — of them beginning to explain their illness. This is incredibly frustrating to the patient and of course it means that the real narrative is lost.
I was once referred to an otolaryngologist. I knew what I wanted to tell him but it was obvious that he had already developed a diagnosis in his own mind within well less than a minute of my arrival. I decided to politely insist that he hear me out — which he did but I could sense it was with reluctance. He then did his exam and announced his original diagnosis was correct. It was only a few weeks later when his prescription was not creating any improvement that he finally began to listen — somewhat. He now listened more carefully and considered another diagnosis — one that was fairly obvious if he had just listened the first time — and hence I finally got into the proper treatment plan. A second point to this story, probably contrary to most patients beliefs: We doctors are not listened to any more than you are.
A medical school professor and general internist learned the value of deep listening early in his training. As a resident in the primary care clinic, he had a patient who was always ending up in the hospital. She did not seem to have any serious underlying diseases and he thought he was giving her good medical care. Still she bounced into the hospital frequently.
But at one clinic visit his attending faculty physician stepped in. She quickly developed a close rapport with the patient, delved deeply and learned that the woman was in need of someone to listen to her life’s issues. No one was doing so and her admissions to the hospital were her way of crying out for some help, some understanding. Armed with this new insight, the resident would meet with the patient regularly and just listen in an empathetic and nonjudgmental manner. Sometimes for 30 minutes, occasionally for more. She would pour out her heart to him.
Later in practice in a community hospital and then at the university he continued to care for her, mostly listening carefully in a nonjudgmental manner over a period of about twenty years. There were no more hospitalizations. Then came managed care. Her insurance mandated that she go elsewhere for primary care — the university overheads were too much for the managed care operator to tolerate. It was only less than a year before she was once again back in the hospital, not once but many times. The insurer had saved some money on primary care but had paid a dear price in hospitalization bills. Penny wise and pound foolish on the insurer’s part but more importantly a lady that could be helped easily with some humane attention was no longer benefiting.
Tolstoy wrote these three questions:
What is the most important time?
Now, no other time matters.
Who is the most important person?
The one you are with.
What is the most important thing to do?
To do good for that person.
It is the physician who focuses on the patient and not just the disease and who constantly respects the answers to these three questions who can aspire to be a healer.
Stephen 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.