The Exile of Listening

How many of the 20,000 breaths we take in a single day are we aware of? Yet if our ability to breathe is restricted or impaired, the absence of breath stops us in our tracks. What was once a silent, subconscious rhythm is propelled to the foreground, relegating everything else to a distant background.

Listening suffers the same fate as breathing: we often aren’t aware of its presence until it’s gone. However, unlike breathing whose absence is experienced with an immediate and unavoidable force, the absence of listening has a more insidious effect. We may feel isolated, excluded, unappreciated. Perhaps we feel tired and irritable. Our work may feel futile and meaningless. We know we feel badly, but we often don’t realize why.

The problem with the absence of listening is that it’s like lowering the oxygen content of the environment in minute increments: we may not feel short of breath at all. We feel exhausted. We develop headaches or nausea. Much like high altitude sickness, if we don’t know what we’re experiencing is due to the thinning air, we may think something is wrong with us. Only when we look around and notice that everyone else feels the same way do we realize that perhaps the problem isn’t just with us. Could there be something wrong with our environment?

Yet, when it comes to listening — or the absence thereof — when we look around us and see everyone is suffering from the effects of its absence, why do we fail to ascribe even partial responsibility for this to the systems we inhabit? Even if we see the connection, the onus of addressing the problem often falls upon the individual.

In a well-meaning document distributed to primary care physicians to assist with physician burnout at a prior practice, we were advised to meditate more, be more mindful, spend time with family, and pick up a hobby. At the time, we were struggling with a chaotic work environment due to staff turnover and were trying to address the causes of this with our administrators, who were not hearing us. I felt as though we were in a sinking boat, and instead of being given the tools to patch the hole in the hull, we were bailing the water out with a cup–and were being told that our burnout was due to not bailing the water out mindfully enough. Resiliency can no more replace our need to be heard than it can our need to breathe. This is what happens when genuine listening has been exiled from our institutions: good intentions, absent listening, magnifies problems instead of ameliorating them.

So what does the absence of listening look like? And why is it so pernicious? To answer this, let’s take a step into an exam room and observe a typical encounter, on a typical day. Come, let’s listen in:

A young woman sits on the pale blue chair in the exam room. Her wrist has been hurting, so she scheduled this appointment with the first available clinician, as her primary care physician couldn’t see her until the following month. On the floor next to her there’s a baby in a car seat; the woman is holding the handle firmly, rocking it back and forth. The baby spits her pacifier into her lap and looks at her mother, the beginnings of a dissatisfied wail gathering on her face. The woman returns the pacifier to its rightful place, and the baby’s face immediately relaxes. “Be good for mommy,” the woman pleads, “this won’t take long.”

She’s still rocking the car seat as the doctor enters. He nods at her; his gaze barely meets hers as he mumbles his name and heads straight to the computer screen which is facing the door, out of her view. She’s not sure whether she’s supposed to just start talking. He’s so focused on her chart–she doesn’t want to interrupt.

“So, you’re here for wrist pain?” He’s still looking at the computer as he says this. “And I see this is your first time coming in for this.” This is a statement, not a question.

He turns his head toward her and glances at her wrists. “Left or right?”

“Right,” she replies.

“And you’re right-handed?”

“Yes.”

“Ok, and how long has this been going on for?” He’s typing as he asks this.

She feels pressed to answer quickly, but she’s not sure why. There’s a faint sense of being back in high school. She hated high school. Middle school, too. She’d dread being called on. It was as though her name, if uttered by a teacher, sent the answers flying out of her head. Tests were alright, but she was always marked down on class participation.

She notices a throbbing in her chest; her tongue feels heavy and tingly. “Um, two weeks,” she blurts.

As soon as she says this, she knows she made a mistake. Was it 2 weeks? It had started right after her mother had come to visit. That was closer to 6 weeks ago. She opens her mouth to correct her answer, but the doctor has already moved on:

“What are you taking for it, and how frequently?”

She hadn’t really kept track. He’s going to think she’s irresponsible. Or stupid. She knows better! She’s so careful and methodical when it’s about the baby. When the baby hadn’t been gaining weight as expected, she presented the pediatrician with spreadsheets documenting each feeding, bowel movement, and weight. “You want a job here?!” he had asked.

“He’s going to think I’m an idiot,” she thinks. She makes up an answer to sound precise.

There are a couple more questions like this before the doctor rolls toward her on his swivel chair to examine her wrist. He presses it in various places, swiftly moving his touch systematically, directing her to move her hand in one way, in another. It hurts a little as he does this, but not enough for her to say anything. Next, he holds her wrist with one hand and with the other, holds her hand, as though in a handshake. The softness of his hand surprises her. She looks at his face. He’s young. He reminds her of a boy who always sat at the back of the class in her honors classes. He never spoke up in class, either. She had always wanted to talk to him, but the time never seemed right.

The doctor twists her hand, and she flinches.

“It’s just a mild wrist sprain,” he tells her as he rolls back to the computer. “Wear a splint for 2 weeks, day and night, and take ibuprofen 600mg every eight hours with food because it can cause stomach upset; stop it if that happens and call the office; call the office for another appointment if you’re not better in 2 weeks or if it gets worse; this will all be written in your after-visit summary which you pick up when you check out.” He’s clicking and typing as he says this, then swirls back around, “Any questions?”

He’s looking at her now. Is she supposed to say something? The throbbing in her chest is now louder than her thoughts. She knows she has questions. Why aren’t the words coming out?

She shakes her head. He types a little more and leaves as briskly as he had entered.

The woman bends over to pick up the car seat and realizes her wrist hurts more than it had when she had come in. He had said something about a splint. How’s she supposed to take care of the baby with a splint? And ibuprofen­. Is that the same as Aleve? Can she take that if she’s breastfeeding? She’ll wait until she sees the pediatrician next week to ask. Anyway, maybe the pain will just go away on its own, she thinks to herself as she lifts the car seat, ignoring the tingling and numbness in her fingers as she does so.

Listening is not a supplement to good medical care–it’s an intrinsic requirement. We do not treat it that way, though. Except for a couple of classes in medical school, we really don’t pay any attention to listening as a skill or a craft. Articles may be written about the importance of listening, but they are invariably relegated to the back pages of journals along with the other “fluff,” which is what we often call anything related to the experiential, philosophical, poetic, or reflective exploration of the practice of medicine. We know listening is important, but clearly not important enough to preserve, protect, or develop. We don’t go to conferences to hone our listening skills. We aren’t tested on listening on our board exams. Our administrators aren’t tracking our listening competency (or theirs) or setting thresholds to meet as they do for other measures. Institutions aren’t including enhanced listening on their lists of quarterly goals. Don’t get me wrong — I do not want listening to be reduced to another metric. But should we ignore listening altogether simply because we can’t distill it to a measurable, definable quantum? Yet that’s precisely what we have done.

It is clear that the doctor in the scenario above isn’t listening. It is also clear that the care his patient is receiving is deficient. Yet, if you were to review the patient’s chart, his care was competent. He made the correct diagnosis. He gave her the right treatment. He counseled her on side effects and gave her precise instructions on when to follow up. The fact that his care plan was not going to be followed by this patient will later be pinned on the patient as not being “compliant” when she shows up to the orthopedist months later with neurological damage to her hand.

This is the paradox that we face every day. The “care” we give looks good, sounds good, measures well, but it doesn’t feel like care at all. Clearly, the doctor in the scenario above didn’t seem too happy or engaged, and the patient left feeling worse than when she had come in. But on the surface, nothing registered as being wrong. We haven’t noticed that what we refer to as “care” has been transformed into a tangible, transactable service, and we don’t pay sufficient attention to the effect this has on us.

Now imagine if the scenario above — the doctor not listening to the patient — is repeated in thousands upon thousands of interactions in a medical institution: interactions between doctors and patients, staff and patients, doctors and staff, administrators and doctors, and so forth. The woman who had checked the patient in hadn’t made eye contact. The doctor had just come out of a meeting with his supervisor, who had told him he wasn’t seeing enough patients quickly enough and his pay would reflect that. The supervisor had tried to explain to her boss how the measures they were using affected staff morale and was told that her job was to implement the rules, not make them. And imagine if that’s the status quo year after year after year.

Would being in such an environment make it more likely for the doctor to listen to their patient or less so? What effect does this have on the patient, the clinician–on all of us? What happens to our ability to bring our best selves into an encounter when that best self has been eroded by systems that are created to foster uniformity and compliance rather than creativity and engagement? The absence of listening creates environments no less harmful to health and well-being than air devoid of oxygen. How have we allowed this to happen? Has it always been like this?

The retired physician who lives across the street from me once told me about his days in practice decades ago: “You knew all your patients, and they knew you. But there wasn’t much you could really do for them. If they were having a heart attack, you would give them morphine for the pain and hold their hand.” He said this almost apologetically.

He marveled at what medicine could now do. How many lives are saved, diagnoses are made, and treatments are available. But in the same breath, he acknowledged that he was glad he didn’t have to practice medicine in this highly regulated corporate medical environment.

“We thought we were doing the right thing,” he mused as he reflected on selling his private practice to the local hospital, as so many other practices had done. He and his colleagues had trusted the hospital system to be better equipped to manage the increasingly complex business of running a practice. And that’s happened: hospitals, then increasingly larger medical delivery systems, were run as businesses. Clinicians became “Providers” of services. Patients became “Clients” or “Consumers” of said services, and the interaction between clinician and patient was transformed from a relationship to a transaction.

He saw all this happen. Some of his children, also doctors, had chosen not to practice medicine in this environment. They knew what real doctoring looked like. They had seen their father do it.

“I’m sorry,” he told me, “I think we ruined it for you.”

I’m sure I tried to reassure him. Perhaps I said that we would likely have done the same, or that we were all on a train that no one could stop, or that it was bound to happen one way or another. But all I could think of was his initial comment:

He had held his patients’ hands as they died? When had I ever done that? And when exactly did that no longer become something we value? When did the ability to develop such a profound relationship with a patient become a relic of a distant past?

I am all for medical advancements. If compelled to choose between a system that can save our life or one that can provide comfort as we die, most of us would choose the former. But why do we have to choose between one system or the other? Are we really incapable of developing systems that can deliver services and also foster kindness and caring? Systems that can save lives and also nurture relationships?

Rupturing the clinician-patient relationship and reconfiguring the relationships of provider, client, and staff to the institution rather than to the human beings within the institution has essentially exiled listening not only from patient exam rooms but from our system as a whole. Just as we, as individuals, require breath to survive, we, as human communities, require listening to thrive. Without intentionally reclaiming spaces where listening can occur, we will remain diminished and oxygen-deprived, trying to survive in a service-producing hierarchy instead of inhabiting — and strengthening — the health-promoting ecosystems we all need and deserve.