The Art of Listening

The patient, a middle-aged woman, says that 15 years ago she found a small mass in her breast and drove herself to the doctor to have it checked out. The diagnosis was cancer.

Two Tufts medical students in the room proceed to ask the woman a series of routine questions—how she’s doing now, if she has had any further medical issues. It takes John Mazzullo, an assistant clinical professor, veteran of 31 years in the trenches at Tufts Medical Center and a volunteer instructor in the patient-interview course for first-year students, to pick up on a seemingly minor detail in the story and inquire, “Are you saying you drove alone to see the doctor? Who was your support group when you learned you had cancer?”

It quickly comes out that the woman is divorced and lives alone, her family far removed in California. Her isolation and loneliness had been implicit in her story, lurking there in the background, but unspoken. “That was a pregnant detail. It was really sad to hear, but this information opened up an insight into the patient,” Mazzullo says later. “As doctors, we always need to be concerned about how the person with disease handles the disease.”

There’s more than altruism at work here. Research has shown that the more finely tuned a doctor’s appraisal and understanding of a patient, the better the outcomes for that patient. Accordingly, Mazzullo tries to teach his students how to listen with what he calls “a third ear” for the unspoken messages in what their patients have to say.

The process is about leaning forward in your chair, experts say. It’s about eye contact and nodding, giving encouraging responses, drawing the patient out. It’s about paying attention. It’s about expressing empathy—and it’s nothing new.

It all goes back to Johns Hopkins Hospital co-founder Sir William Osler’s admonition to doctors in the waning years of the 19th century to “care more particularly for the individual patient than for the special features of the disease.” Francis Weld Peabody famously echoed the theme in his oft-quoted remark to the graduating medical students at Harvard in the fall of 1926: “The secret of the care of the patient is in caring for the patient.”

A generation or two went by at midcentury, and something big got lost in the shuffle. Mazzullo, who graduated from Columbia Medical School in 1969, remembers being handed a brochure and sent up on the wards—without guidance or words of advice—to see his first patients.

“It was terrible,” he says. Nor was this an isolated case. Asked to describe any lessons he might have received at Tufts concerning how to conduct the doctor-patient interview, Leo Shapiro, M67, a psychiatrist who volunteers as an alumni instructor in the patient-interview course, gives a quick, rueful laugh: “None that I can remember. I just stumbled along and gradually got better at it.”

Caring for the Patient

These days, Tufts is determined not to leave this essential professional skill to chance. During their first week of school, all medical students encounter patients on the wards who have volunteered themselves as interview subjects. They are immersed in a situation that has many students groping for words initially, but connecting with patients gets easier and more rewarding with practice. Instructors are a mix of alumni volunteers, faculty (both active and retired), upper-level students, social workers and nurses.

The potential payoff for the well-done patient interview is huge. Disgruntled patients—those who feel their questions and concerns have been brushed aside or altogether ignored—are common in modern medicine, even in cases where physicians may be highly skilled technically.

The failure to connect is about more than hurt feelings. “Inattention to the person of the patient, to the patient’s characteristics and concerns, leads to inadequate clinical data-gathering, non-adherence and poor outcomes,” a group of experts from seven U.S. and Canadian medical centers write in the Annals of Internal Medicine in a 2001 article titled “‘Tell Me About Yourself’: The Patient-Centered Interview.”

“Growing evidence suggests,” the authors note, “that physicians who focus on the patient as well as the disease obtain more accurate and thorough historical data, increase patient adherence and satisfaction and set the stage for more effective patient-physician relationships.”

In other words, the more we know about our patients, the better for everyone. The authors of the article go so far as to rank patience and curiosity among the most useful tools a doctor can lift from his or her medical bag—meaning, they explain, “curiosity to ask questions such as ‘Tell me about yourself,’ and patience to wait for the answer.”

Tricks of the Trade

Interviewing a person you’ve never met before is like trying to tap dance or play the cello without tutoring and extensive practice. It’s not something that anyone can do very well by instinct alone.

Ian Murphy, M17, learned just how hard it can be to do this seemingly easy thing. “I’m an extrovert, and I thought I’d be good at interviewing people,” says Murphy, who is president of his class. “My first patient was an 85-year-old man with bladder cancer. I found myself showing the man a lot of empathy, but shying away from gathering any medical information. There were questions I was afraid to ask. Afterward, my instructor, Evan Barnathan, M14, pointed out that I shouldn’t have neglected the medical history side of things. He told me, ‘You need to balance acting as a physician and as a person when you do the interview.’”

Murphy took the advice to heart. “I got better,” he observes. “I transitioned from being a friend to a patient to being a physician and a friend to a patient.” By coincidence, Murphy had two nearly identical patients to interview at the beginning and end of the course; he thinks of these two cases as “bookends” for his learning curve.

When everything is going well in a patient interview, the relationship in the room is dynamic. Murphy’s growing confidence enabled him to be more direct and at ease during his scheduled interviews, and as he relaxed more into his role, his patients grew more comfortable and began to volunteer additional details about their lives. The results were mutually satisfying and productive.

Nothing about this evolution was accidental. The Tufts course, scheduled on Thursdays from the end of August through the middle of November, is structured to focus first-year students’ attention through theory, reflection, discussion, practice, presentation and group critique.

Those Awkward Silences

A given week may concentrate on gathering a meaningful medical or social or sexual history from a new patient, with all the stammering and misdirection and silence that each topic may entail. (On this last point, Daniel Luther, M14, a small group facilitator for the course, says, “Experiencing the awkward silence, and learning what to do with it, is part of the process.”)

The class approach is multifaceted. First comes an expert’s lecture or demonstration on some aspect of effective interviewing. Then, while organized in groups of four or five students—with two generally acting as designated interviewers, one as a scribe to document what is said and others as intent observers—the group moves with their instructor to conduct a pair of interviews that have been arranged for them. Later, students critique the interviews they’ve just seen and take turns presenting the day’s cases to each other in nutshell form. Finally, the instructors meet for an hour to review any issues that may have arisen during the day’s far-flung excursions.

Some volunteer patients are in one of the Tufts-affiliated hospitals, such as Tufts Medical Center or St. Elizabeth’s or the Lahey Clinic; other subjects, not necessarily sick or debilitated, reside in a network of Jewish Community Housing for the Elderly (JCHE) sites in the Boston area. Here, students get to see patients in their home environments.

Reflecting on her experience in the course, Anita Mathews, M17, was touched by the JCHE residents’ willingness to tolerate a bevy of wide-eyed students popping into their rooms. “As first-year medical students, we didn’t have much to offer them,” she points out, “but they were kind enough to let us practice and sharpen our skills.”

Mathews acquired more than expertise. She says that while improving her own interview techniques, she gained a deeper appreciation—a newfound measure of sympathy, really—for the patients’ plight. “I realized how frustrating it can be to be a patient,” she observes. “As a doctor, you go in and you’re formulating plans for how to deal with the case, but as a patient, you have probably been waiting; you may be in discomfort, and you don’t know what to expect.”

The Language of Caring

Language barriers can often hinder a good connection, as Amy Lee, M02, knows well. She is a part-time faculty member who has helped teach students about the role of the interpreter in the patient-interview course since 2005. “One thing we do in our course is prepare doctors to care for a more diverse population, and that’s important,” she says. “Our students think it’s going to be easy [to deal with language and culture barriers], and then they go try to do it.”

Lee notes that many JCHE residents claim Russian or Chinese as their native tongue and have a limited command of English—a harbinger, to some degree, of the students’ likely future patient populations. “When doctors have language barriers, they tend to cut things short,” she notes, “and that means they’re missing out on key information. We know that patients with language barriers have poor health outcomes. There are many factors, of course, but this is one of the biggest.”

Making the effort to reach such patients is all the more important. Lee stresses eye contact with the patient—“that’s critical,” she says—and keeping the terms of the language used directed toward the patient. It’s better to ask, “How are you today?” than to employ the cooler, more abstract phrasing, “What do you think the problem is?” Proximity to the patient matters a great deal, too. A triangular seating arrangement is best, says Lee, thereby allowing both the physician and the interpreter to keep their eyes fixed on the patient, fostering a kindred mood.

All this lavishing of attention on an individual patient may sound impractical to a doctor pressed for time. But many experts contend that if done right, the process doesn’t have to take long. The authors of the Annals of Internal Medicine article write that a properly trained physician can obtain “a useful sketch” of a new patient in less than a minute. “In fact,” they add, “studies show that contrary to intuition, permitting patients to state all of their concerns without interruption does not add substantially to the length of the interview.”

To the welter of complications that can hinder good, trusting relationships between doctor and patient—language, gender, age, race and economic status, to name a few—limited mental acuity may seem especially tough to overcome. But the psychiatrist Shapiro, who has worked with mentally disabled patients for many years, says that’s really not the way it is, except in extreme cases. He routinely takes students to visit his patients at Tufts Medical Center and shows them just how similar the process of interaction can and should be. (All interviewed patients give their approval beforehand.)

“These patients are really not that different from anybody else,” he says. “They are not incoherent or demented, and they can usually give a pretty good account of their condition. These are just people who may have had some difficulties.”

Shapiro works to get his students more comfortable with the patients’ feelings—and their own. At the start, he says, students commonly worry about upsetting the patients and being too intrusive with their questions. Gradually, he gets them to shed their anxiety. Students are taught to ask, “Have you been suicidal?” or “Have you been hearing voices?” or “What’s it like having a mental illness?”

Shapiro, who has been volunteering in the Tufts patient-interview program for nearly two decades, and even co-taught it with his son Max Shapiro, M09, during his son’s last year of medical school, says he enjoys sharing “whatever knowledge I’ve accumulated over the years” with the doctors-to-be. “I try to teach them about being caring and practicing medicine from the heart as well as from the head,” he stresses. After all, Shapiro adds with a laugh, “these students are the same people who may one day be caring for me.”

Instructors generally play the role of quiet observers in the room, perhaps jotting a few notes while students conduct their interviews. Then, at interview’s end, they may step forward and highlight a detail or two that the beginners have overlooked. Anita Mathews, M17, remembers her instructor, John Mazzullo, listening to one such case. “We talked to this one woman patient for 20 minutes or so,” she relates. “Then, at the end, Dr. Mazzullo elicited that she was adopted—a major fact in the woman’s medical history that we had missed.

“With another patient, he determined, after we had concluded our interview, that the man had been homeless. Dr. Mazzullo told us to ask more direct questions. You don’t have to lose your composure, he said; there are ways to ask difficult questions in a sensitive way. He would tell us, ‘No one gave me this guidance when I was a young doctor.’ I got the sense that he was trying to pour into us this knowledge that he had fought for.”

This article first appeared in the Spring 2014 issue of Tufts Medicine magazine.

Bruce Morgan, the editor of this magazine, can be reached at bruce.morgan@tufts.edu.