Bernard Lown, MD
In the United States geriatrics is a neglected field. The reasons are not hard to find. Doctoring the elderly is intellectually taxing and extraordinarily time consuming. The elderly never present with a single problem. Their complaints are numerous due to co-morbidities involving different organ systems. In addition to addressing multiple symptoms, the doctor needs to sort out whether the patient’s ailments relate to a polypharmacy of drugs. If this were not taxing enough , obtaining a careful history is waylaid by the infirmities of old age. Patients are forgetful, are easily distracted from the key issues, and meander to the unrelated. Further, a doctor has to decipher whether the complaints are a consequence of the psychological stresses of daily living or augur some serious malady, while a depressed mood can magnify a commonplace disorder till it becomes a life-threatening condition.
Our population is skewing to the oldest. Those 85 and over are increasing by around 165 percent annually, far more than any other age group. The elderly account for much of the ever-mounting health care expenditures. One would surmise therefore that geriatricians would be intensely recruited and highly recompensed. The very opposite is true. They are an endangered species and the lowest paid among medical specialists. The reason for such perversity is straightforward: Market medicine, the system undergirding American health care, is oriented toward maximizing profits for investors. A far larger return can be extracted from intervening with tests and technology than from human interactions. The topsy-turvy economics of health care thus tilts toward procedures. The highest remuneration goes to specialists who are essentially technologists focused on particular organ systems. Over the past several decades, the far more profitable technological procedures have been replacing time-consuming history taking and listening to patients.
The essential thesis of this essay is that listening to patients is the bedrock of a sound health care system. It is especially important in caring for the older patient. My great teacher and cardiology mentor at the Peter Bent Brigham Hospital (now Brigham and Women’s Hospital) in Boston, Dr. S.A. Levine, taught me that listening is the quintessential art of clinical medicine.(1) It is the most difficult of all the skills in the physician’s repertoire. Even after five decades as a clinician I have not quite mastered that elusive art.
The Art of Communicating
The complexity of listening stems from the very inadequacy of language. Words are imperfect communication tools. They are freighted with different meanings depending on a host of factors. These include age and station in life, class, schooling, race, gender, and ethnic background as well as many others. In fact, language is both our prison and our major pathway for self-liberation. Facile and inexact, words rarely capture the deeper intent of what we yearn to share. Each of us has sensed the frustration of trying to communicate an unusually charged event. We constantly witness the breach between experiencing something meaningful and attempting to share it with others. Try as we may, we fail to impart the frisson of aesthetic rapture of first viewing Brunelleschi’s Dome or Botticelli’s Primavera, or listening to a perfect rendition of Schubert’s Trout piano quintet, or viewing a great artistic performance. We soon learn that the emotional and spiritual innards of our being are beyond the bland coloration of words. Yet, being human is defined by the very operation of our minds, largely shaped by moods, feelings, and sentiments.
To circumvent the limitations of language, evolution has endowed us with an additional venue to shape the meaning of words. We each possess a powerful nonverbal repertoire based on body language and facial expressions. Communication is thereby finely tuned with tonalities that words lack. This instantaneous messaging system operates across cultures and is even evident in infants and toddlers.
A conversation involves, besides words, complex subliminal tuning constantly adjusting to a host of signals. This may involve a tiny narrowing of gaze, a stare or diversion of eyes, a drooping of lip, a shrug of shoulders, a tightening or unfolding of hands, a shuffling of feet or uncrossing of limbs. The cues are numerous. Information guru Richard Wurman has written, “We make adjustments, simplify, repeat, and move between various levels of complexity based on continuous feedback. A quarter inch nod of a chin, the lowering or raising of eyes, strange guttural noises that say uh huh, uh huh, blinks, shrugs, turns of the head, loss of eye contact, making of eye contact — a symphony of signals occurs during even the briefest of conversation.”(2)
A Personal Journey
Neither medical school nor residency training taught me the art of communicating with patients. Dr. Levine sensitized my awareness of the rewards of a carefully taken history and a meticulously performed physical examination. However, my greatest teachers have been patients. Over many years, they helped me develop these skills, which multiplied like barnacles sticking to a vessel’s hull long in the water.
I began my career craving to be a medical scientist. After a ten-year-long apprenticeship with Levine, I shifted gears, aspiring instead to become a competent practitioner. By age fifty I was convinced that I had reached the top as a clinician, certain of having mastered both the art as well as the science. A good deal of that arrogance disappeared when I reached seventy. I could not deceive myself that I was keeping abreast with the torrent of scientific advances. Increasingly I was falling behind in knowledge of new drugs and procedures. Yet, the older I became, the more patients were clinging to me. Referrals, instead of diminishing, were increasing, and they were largely from a global clientele. The patients I had followed for decades were insisting that I was helping them more than ever.
My patients were well educated, knowledgeable about the many recent scientific breakthroughs and the latest so-called miracle drugs. They did not seem to be craving cutting-edge science in their doctor; they valued something more. I am persuaded that the secret commodity was my interest in them as human beings rather than as a collection of malfunctioning organs.
With the passage of years my doctoring improved. Listening was a central aspect of it. Sound decibels may concentrate in our ears, yet the translation of words and body language into cogent meaning is made possible by empathy. The greater the empathy, the more the patient imparts and the more we understand. The more we understand, the more the patient imparts. The cybernetics seems boundless.
The Informative Pause
Interviewing a patient is never a stereotyped interrogatory. It is a dynamic interaction. The doctor constantly floats hypotheses. The patient expresses a distaste for something, an affinity for something else, or evades answering some question, raising new surmises to be explored. The following encounter a few years ago is illustrative.
The patient, a dignified man in his seventies, was enormously disabled by recurrent bouts of rapid heart action that had forced him to retire from his business. In the past five years he had visited numerous cardiologists and made many trips to the emergency ward. As I pursued the intake history, he responded briskly and succinctly. His gaze was direct and unflinching. I surmised that he was self-confident and successful. His lovely, still youthful-looking wife, sitting close by, adoringly held on to her husband’s every word. I reflected, what a happy marriage!
Then, an innocent question: How many grandchildren did he have? He bowed his head, avoiding my eyes; the hesitation, though momentary, seemed prolonged, for he had answered the previous questions snappily. A red light blinked. Maybe a grandchild had a behavior problem, was sick or disabled, or had died. Maybe he did not get on with a daughter-in-law. My curiosity was piqued. Clearly the matter demanded exploration. His wife, who up to this moment had been engaged and quite talkative, affirming or adding to what her husband had been telling me, now withdrew into mournful unease. My patient’s shoulders hunched into a posture of resignation. Surely a grandchild had died after a tragically long illness, I thought.
“Your grandchildren are healthy?”
Immediate response: “Yes, indeed.”
“No behavior problems?”
“No, they are well behaved.”
“They live close by?”
“Yes, we live in the same city.”
It was unclear to me why I posed the next question, but I felt compelled to ask, “You see them often?”
An oppressive silence was followed by a hesitant, “We have not seen our grandchildren during the last several years.”
I didn’t need to probe any longer; I needed merely to absorb. In staccato sentences, the enigma was exposed. The wife silently wept as he related that for a number of years their son had worked in the family business. He seemed well adjusted and was highly paid for his work. Then the business financed his getting an MBA in a leading university. Upon his return he wanted to transform everything. Disputes were constant. When his father refused to promote him as chief executive, he abruptly resigned and forbade his parents to visit their three grandchildren ever again. Our long ensuing conversation explored in painful detail why things unfolded as they had.
When I suggested we go to the examining room, he laughingly asked, “Why examine me? You have already solved the problem.” He puzzled out loud why the previous cardiologists never asked any questions about his family life. He was even more perplexed that he himself had never connected the strained relationship with his son to the malfunctioning of his heartbeat. The arrhythmia was thereafter easily managed. In the following decade he had no further recurrences.
Rethinking on this experience convinces me that life does not provide a deeper sense of fulfillment than healing a fellow human being.