I'm Listening, but I Can't Hear You

WHEN GARY BONNER faced the discouraging prospect of surgery to remove a brain tumor, he decided he had to think and—in several ways—act like a surgeon.

“I knew it was crucial that my doctors really listen and respond to me—and surgeons, in particular, aren’t known for their great communication skills,” says the retired California state parole agent and longtime San Diegan. “Their first instinct is to cut you to cure you, and I was determined I wasn’t going to have conventional brain surgery.”

In each of his many meetings with doctors, Bonner dressed in a coat and tie, wore a beeper and had his wife accompany him to take notes the way a nurse would. “It was very important the doctors saw me as a full and complete and busy person,” he says. “I made certain the doctors knew I had a son, and I always talked about my enjoyment of kayaking and tai chi, so they knew how important it was for me to retain my balance skills.”

Bonner wanted—and eventually underwent a successful, noninvasive gamma knife procedure, wherein a patient wears a helmet-like device that shoots highly focused beams of radiation into the brain to destroy a tumor but spare healthy tissue. “I’m convinced that if I hadn’t taken the steps I did to have the doctors really listen to me,” he says, “I could have been urged into complicated and very risky brain surgery.”

DR. DAVID EASTER, a professor of surgery at the University of California, San Diego Medical School and a cancer surgeon at UCSD Medical Center, doesn’t believe a patient should have to work so hard to get a surgeon to really listen to him. He says it’s the surgeon’s first responsibility to establish and foster good communications with patients.

“It’s a mixed message we usually send,” says Easter. Surgeons certainly want the best for their patients, but too often they present themselves as noncompassionate —brusque, all business and overly fluent in textbook-speak. With surgeons, Easter says, the left-brain traits of logic and analysis trump the right-brain characteristics of emotion and instinct.

Still, he believes a capable surgeon can also be a compassionate one. Surgical expertise doesn’t have to exclude empathy, Easter says. And as director of the UCSD medical residency program, he works to ensure that tomorrow’s surgeons embody that philosophy. He teaches that compassion is good medicine and, not incidentally, also good economic sense.

Much more is at stake than establishing warm, fuzzy feelings with patients, says Easter. Poor communication skills lead to missed diagnoses, wasted time, unnecessary repeat visits, hard feelings by patients and their families—and malpractice suits. “Doctors who communicate well with their patients can be an important remedy for the public’s dissatisfaction with today’s healthcare system,” he says.

In the past few years, Easter has teamed with Dr. Wayne Beach, a communications professor at San Diego State University who is also an adjunct professor in the department of surgery at UCSD School of Medicine. The two have designed an intense communications mentoring program for surgical residents to hone their right-brain talents to blend with their left-brain knowledge.

In studies conducted by Easter and Beach, several doctors were separately videotaped during a first visit with a cancer patient. This is a stress-charged situation, and Easter and Beach wanted to identify and label what they call patient-initiated actions, or “empathic opportunities,” that should be recognized and acted upon by the physician. These opportunities are times when a patient—ever so delicately—is essentially asking a doctor for understanding or support.

Using a conversational analysis technique, measurements were made of patients’ speech inflections, pregnant pauses and such subtleties as posture, facial gestures and eye-gaze patterns. “Across the board, we found that missed opportunities occurred 70 percent of the time,” Easter says. An example of a missed opportunity occurs in this short scenario:

A cancer patient, head tilted and eyes darting off, says to a surgeon, “Hopefully, I caught mine early enough.” The doctor responds, “Well, that’s the thing,” and launches into a description of how cancer survival is better if certain treatment procedures are enacted. The surgeon is actually giving the patient good news, Beach points out, but left hanging is any reassurance the patient was tactfully pursuing. A more empathetic response from the surgeon would be “It seems that we have caught the cancer early, and your condition is very good,” and then discuss treatment options.

Providing such comfort needn’t involve an unrealistic assessment about a patient’s condition,” Beach says. “Such [comments] may aid in minimizing inherent uncertainties associated with cancer biopsies, and facilitate the creation of a partnership for managing ongoing preventive care, diagnosis and treatment.”

“OKAY” IS A PARTICULARLY NASTY FOUR-LETTER WORD for Easter. “Doctors use that as a catchphrase,” he says. “But it’s a point of disconnect. It shuts a conversation down and leaves the patient wondering whose agenda it is.” For their part, surgeons do indeed have an agenda— which invariably involves tight time restraints—and as Beach says, they don’t often see themselves as psychotherapists, dissecting the nuances of any particular patient remark. Yet this is the age of what’s known as “patient-centered care,” and the communications professor says medical training must include specific practices for listening and reacting to what a patient is trying to say.

Beach says doctors need to realize patients are usually circuitous. “Patients often don’t have the right words, and they’ll indirectly hint at their problems,” he says. “We’re all taught to respect authority figures, and patients tend to be submissive with a doctor. For most, it’s difficult to talk to a doctor.”

Yes, a patient—say, a car mechanic—who complains about back problems is concerned about his pain, Beach says, but he’s likely also worried about his financial future if he loses his job because of the condition. Instead of responding to a patient who says she’s concerned about her headaches with “How frequently do you have them?” a doctor would do well to instead ask “Why are you concerned?”

“When she replies, ‘Because it might be a tumor,’” Beach says, “the doctor can reply, ‘I’m sorry you have to go through this discomfort, but we’re going to work together to solve the problem.’ ”

The use of “just a few simple empathetic expressions allows a patient to tell his story, and allows the doctor to get through his medical agenda more quickly,” says Easter. Beach and Easter say patients can assist their physicians in being better, more attentive communicators. “I” statements work best, they say.

“Saying to a doctor, ‘You just don’t understand’ puts some conflict into the situation,” Easter says. You get much better results with ‘I feel like you’re not listening to me, Doctor.’ ” Doctors do care about their patients. Sometimes, they just need some instruction to show it.

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