Bernard Lown, MD
That we have a dysfunctional health care system is now widely acknowledged. No longer does one hear that Americans receive the best medical care in the world. Moreover, the US crisis in health is noteworthy for a blatant contradiction. Despite our investing a king’s ransom on health care, one-third of the population is inadequately protected against the unpredictability of illness. The number of uninsured people has reached a staggering 47 million, with an additional 30 million covered merely for catastrophic illness. No other industrial nation comes close to the approximately US$7000 spent by each American annually for medical care.
Mounting health expenditures preoccupy economists and politicians. The escalation is ascribed to an ever-aging population with greater health demands as well as to costly scientific and technological advances. What is largely ignored is the commodification of illness that America’s market-oriented health care system fosters. As is true in business, the underlying intent is maximizing profitability rather than promoting patient well-being. Unnecessary tests and procedures are encouraged. A market-based health system also has significant upfront costs and unavoidable systemic inefficiencies.
Another consequence of the system contributes to its rising costs and malfunction: Market values are the invisible elephant in the doctor’s office. They quench the human dimension in health care and corrupt the doctor-patient relationship. The first casualty is listening. Since listening to a patient consumes much time and is minimally reimbursed, it is most often done in a cursory, hasty manner, leaving the patient frustrated and the doctor uninformed.
My thesis is straightforward: When doctors give short shrift to listening and conversing with patients, health costs mount. More than 80% of the problems that bring someone to a doctor are minor. They derive from the stresses of living. In a majority, the symptoms do not augur a stroke, a lethal heart attack, or cancer. In a bygone age, when an extended family reigned, older relatives counseled simple, commonsensical remedies that decompressed the agitation provoked by unexplained symptoms. Minor illnesses, real or imagined, were healed by the passage of time. This fact, which the ancient Greeks had comprehended, accounted for the dominance of Hippocratic medicine over more than two millennia. Hippocrates promoted the notion that, given time and gentle intervention, the body is self-healing.
Medical care in the United States has grown to be a lucrative business. Multiple vendors, including hospitals, specialty clinics, and pharmaceutical and appliance companies, wage media-hyped campaigns to instill uncertainty about possibly serious illnesses. As a result, people are preoccupied with health issues requiring frequent visits to doctors. The distinguished essayist Norman Cousins joked that Americans expect to live forever until they catch a cold; they then fear dying within the hour.
It takes time even for an experienced doctor to sort out serious from trivial symptoms. However, careful history taking is no longer the norm. Patients commonly complain that “doctors don’t listen.” Generally patients are interrupted after a few sentences.
Chief complaint not always the most important
Without listening, how do doctors reach a diagnosis justifying a course of treatment? Generally, they focus exclusively on the chief complaint. Many years of clinical practice has convinced me that the chief complaint is inadequate to guide an intelligent medical workup. For example, if a patient complains of chest discomfort, it may be due to heart or lung disease, esophageal reflux, peptic ulcer disease, costochondral arthritis, or merely a so-called heartache due to the rough-and-tumble of living. When a patient with such a complaint is past middle age, the time- pressured physician is much less likely to indulge in careful questioning than to order costly cardiac work.
There is another reason against focusing only on the chief complaint. Commonly it is just an admission ticket, a cry for help. A theater critic would be foolhardy to write a commentary about a play merely from the scanty information on the admission ticket. The ticket is mute about plot, characters, staging, or the playwright’s or director’s intent. Yet frequently doctors diagnose, prescribe, and treat merely the chief complaint, this measly admission ticket. I have frequently observed that the chief complaint, though looming large at the outset, is largely ignored by the patient at the end of a visit.
One patient sharpened my insight of the limitations of the chief complaint. He was a middle-aged Orthodox Jew from New York whom I had followed for five years for intractable angina. Various remedies, including a panoply of drugs, a stenting of diseased coronary vessels, and coronary artery bypass surgery, had brought only temporary relief. I wondered why he continued to travel to Boston, for none of my ministrations helped. Each time he resisted my request that his wife accompany him for the semiannual medical visit. Finally, when I threatened to stop seeing him, he permitted her to come. Interviewing her exposed the underlying basis for the intractability of the chest pain. Five years earlier he learned that his son was gay. He went into mourning, sundered all connections, and behaved as though his son had died. After strong pressure from his wife and me, he reconnected with his son. When the two reconciled, the angina ceased.
Some years ago the value of the history in reaching a correct diagnosis was subjected to an objective study. (1) A carefully obtained history contributed 75% of the information necessary to reach a diagnosis. Next was the physical examination, which provided key information in 10% of the patients. All the complex and costly technologies helped in only 5%. This was the same as that contributed by such simple tests as examining a sample of urine and blood. In 5% the patient’s illness remained undiagnosed.
My essential argument is that listening to a patient constrains the doctor from ordering costly tests as a first resort. Current technologies provide an intimate view of internal body organs. None of these imaging techniques, however, can expose the basis for an aching heart. Far worse, they open a veritable Pandora’s box by exposing unsuspected abnormalities. Every healthy person is laden with diverse anomalies. These probably exist since birth and may persist over a lifetime without causing mischief. So common are these that they have earned the medical name “incidentaloma.” But once some potential pathology is identified, doctors feel compelled to explore further. To expose the incidentaloma’s true nature requires a referral to medical specialists and invasive biopsies, thereby adding to discomfort, potential complications, and mounting health costs.
Overmedication and polypharmacy
Curtailing time with the patient and depending on the chief complaint generate additional problems. When the symptoms first presented are unrelated to what is bothering the patient, the medications prescribed will prove ineffective. Other drugs will be added. The ensuing polypharmacy leads to new complaints, which are assaulted with still more drugs.
This was brought home to me in striking fashion by one 85-year-old woman. She had complained of chest discomfort to a neighbor, who offered her some nitroglycerine pills. Because the nitroglycerine proved ineffective, she consulted a cardiologist, who added other anti-anginal medications. Instability and hand shakiness forced her to give up piano playing, the one activity that relieved her chest discomfort. She had become bedridden for over a year due to severe dizziness, for which more drugs were prescribed by a neurologist. When she consulted me, she was despairing and depressed. When asked to account for the chest discomfort, she ascribed it to bereavement and loneliness. Stopping the medications alleviated all her symptoms, enabled a resumption of piano playing, and restored a vivacious sense of humor. Recently she celebrated her hundredth birthday.
Polypharmacy is a formidable health problem in the United States. In 1991 the Harvard Medical Practice Study reported that adverse effects occurred in 4% of hospitalized patients. Of these cases, 14% were fatal. Such a catastrophe is equivalent to three jumbo jets, each with 350 passengers, crashing every two days throughout the course of a year. Harmful drug reactions are a far larger problem in non-hospitalized patients. One out of five patients consulting me for cardiac problems had symptoms traceable to inappropriate drug prescriptions.
The artistry of fostering trust
History taking does far more than provide physicians with clues for a proper diagnosis. Spending time to learn about a patient nurtures trust and thereby lays a foundation for the most quintessential aspect of doctoring. Without trust, instructions are more likely to be ignored, medications not taken, diets not followed. Instead the patient is on the Internet searching for alternative diagnoses and differing remedies, and ends up shopping for specialists. Without trust, the doctor is an intrusive outsider. The sundering of trust can also have more serious consequences: Patient are more likely to feel aggrieved and to file a malpractice suit. The threat of malpractice stokes another witches’ brew by encouraging doctors to practice so-called defensive medicine, which multiplies unnecessary and costly referrals and interventions.
Not spending adequate time with patients scourges health care with yet another problem. In the absence of meaningful discourse, the doctor is compelled to focus on the acute and emergent. Preventive medicine, though the most cost-effective approach to illness, is largely neglected as it is time intensive. Diligent prevention invariably plays second fiddle to heroic cures.
To sum up, the more time invested by the doctor at the outset, the more cost effective is the encounter and the more satisfied is the patient. History taking is by far the critical part of any encounter between doctor and patient.
Of all the science that a physician acquires, of all the skills mastered, listening is by far the most difficult. The seemingly simple act demands the most consummate artistry. Listening demands intense cultivation, similar to that of musical virtuosity. One learns to be attentive to the fluttering eyelid, to the inaudible sigh, to the unshed tear. To ancient Sumerians the word for ear and for wisdom was the same. Proper listening enables one to comprehend the unique narrative of another human being. (2) Even at its scientific best, medicine is dependent on the intimate story. For doctors this is an exhilarating act of discovery; for patients it identifies a healer.
The conclusion is clear-cut. We need to retire many specialists and train a huge cadre ofprimary care physicians. But whatever their doctoring, they need go back to basics. Medicine is ultimately a social discipline. It begins with a unique story from a fellow human being craving help.
*Originally posted (19 February 2009) on ProCor (www.procor.org), a global communication network promoting cardiovascular health in developing countries. ProCor was founded by Dr. Lown in 1997 to encourage knowledge sharing among a global community about preventive strategies.
1. Hampton J. BMJ 1975;2: 486-489.
2. Lown B. “The Lost Art of Healing” Ballantine Books. New York. 1999.