The art of listening

"The psychiatrist listens to everything I say patiently. His treatment helps me a lot. I am feeling better now. But still I don't feel like I have poured my heart out till I sit with you and speak to you..." said a 45 year old woman in one of my clinics. She lost her son in a road traffic crash 3 years ago. She is suffering from a severe extended grief and the past 3 years have been very stormy. Recently, a psychiatrist has started visiting our clinic two days a month. This lady consulted him last month and since that visit, she has had a dramatic improvement in her symptoms and her mood. I ascribed her feeling of satisfaction when she had a conversation with me to our long stating clinician-patient relationship and the trust that has built over the years. Yesterday, I realized there could be more to it than that. An elderly man who came to the clinic yesterday for his diabetic foot ulcer dressing, commented to our nurse on his way out of the clinic, "there is something different about how this doctor listens to me talk. I have never seen any doctor who listens like this". This comment and the comment of the woman got me thinking about the art of listening in a clinical encounter. 

Flash back 20 years, I remember our everyday evening clinics in Dr. K.P. Misra's cardiology OP. I was in third year medical college and started attending Sir's clinics in the evenings. "You must unlearn the method of history taking they teach you in college" Sir told us. In medical college they give us a template for history taking and we just need to go systematically from one history to another till we fill out that template. History of present illness, past medical history, personal history, family history, that would be the list of things we ask. We would ask, note it down in our records, and then when the professor comes to teach the clinical class, just repeat everything that was said in that order. Sir taught us to do it differently. In Sir's clinic you put down pen and paper and sit in front of the patient, maintain full eye contact and have a conversation. You don't interrupt the narration of the patient as they explain their symptoms and their problems in great detail. You listen with full attention. Then once the narration is over, you go to the table and sit and compose the entire story in the standard template format from your memory. Sir would say, "history taking is an art. It must flow like a story. A good history will lead to a good diagnosis..." Having done this style of history taking day in and day out almost every day from 3rd year of medical school till almost 5 years after finishing MBBS, it became an ingrained practice. Even today, I listen to the full story and then I tell the patient that I want to write everything down so that I can recollect during the next visit, take some time to pen down the story in the history taking format, and then only proceed with the clinical encounter. I did not know if this was what the elderly man was referring to. 

I have been reflecting on the art of listening. I have found myself listening to conversations in different ways:

1. Listening to reply - In some conversations, I listen purely to prepare a reply. I have noticed that when I do this, I am keenly focussed on the key words and points and even before the person completes what they are saying, I am already composing a reply in my mind. 

2. Listening followed by reaction - Some conversations are emotionally charged and in the heat of the emotion, sometimes I have found myself reacting immediately as I am listening to what is being said. I have had angry, happy, embarrassed, defensive reactions to things that patients have said. 

3. Listening to analyse and interpret - Most clinical encounters happen in this style. As I am listening to the history, I am committing it to the memory, and I am piecing the information together to make sense of what is happening in the patient's body. I often find myself reading between lines, sensing the subtle message in the said word and the meaning of what was not said. A patient gave a solemn commitment to practice regular physical exercise every day, but his body language and his facial expression was disengaged. I was analysing this and interpreting all this and making note of these in my case notes. This type of listening is strategic and very useful in the clinical encounter. 

4. Listening in the here and now - This is the greatest and most human kind of listening. This is the kind of listening without any agenda, strategy, without judgment, with empathy and keen attention. At the end of this kind of a listening, I have often found that I cannot reproduce the words of the patient exactly as they told me. I cannot make clear diagnosis without further processing the information. I often don't say anything in response, neither do I react to what the patient says. But I feel the emotions that the patient expresses and am with them at the moment as they speak. This does not happen often. But when it happens, it creates a deep impact on the patient. It is therapeutic. 

I think this fourth type of listening, in the here and now, is the reason why the woman with extended grief finds solace in having a conversation with me. It must be the same reason the elderly man commented that there was something different in the way I listened to him. I try to listen to patients in the here and now, but am unable to do that frequently. Listening to the patient in the here and now takes a lot of time and focus. I need to work more towards gaining that and expanding these great moments of pure human connection. Listening is an art, and one of the most important attributes of a good clinician is the art of listening.