Learning to listen

Doctors have a reputation as poor businesspeople. (This applies mostly to doctors with an MD degree and not a dual MD\MBA.) Doctors also have a reputation for being poor listeners. Numerous studies have shown that most physicians interrupt a patient’s conversation after only 18 seconds.

Other studies show that compliance or adherence is significantly improved when doctors listen to their patients. Compliance also improves when doctors ensure that patients understand the instructions for treatment or tests that have been ordered.

Studies have confirmed that there is a placebo effect when the doctor creates a positive expectation that the treatment prescribed or administered will be effective and improve their condition. Although I am not an advocate of placebo therapy, I believe that physicians can have a tremendous impact on patients’ health through effective communication and listening to our patients.

For years, I have taken histories from men with erectile dysfunction who don’t have hypoandrogenism or a decrease in their serum testosterone levels. Many, if not most, men will admit that testosterone injections are homeopathic in the eugonadal male. The hormone injections will work initially, but their effectiveness will wane weeks or months later. I believe the injections' effectiveness results from the placebo effect wearing off. Perhaps if we listened to these men and reinforced our conviction about the injections, we might improve the results. By listening to our patients’ concerns, problems, and attitudes towards their medical conditions, we can significantly improve our relationship with them.

In the past, physicians could spend 15-20 minutes with a patient, write a prescription, gently pat the patient on the back, and say, “Take this prescription and make a return appointment in a few weeks.” Today, patients are medically sophisticated. Now, patients can read what appears in JAMA and NEJM before those publications reach the physician’s office. With AI and ChatGPT, patients can enter their symptoms and have a differential diagnosis before the doctor-patient encounter. Consequently, our patients are more knowledgeable about medicine and are more demanding of our time to discuss what they have learned online. Also, the contemporary patient is concerned about wellness and preventive medicine, which can take time to explain.

How can we be effective listeners and give patients more of our precious time when the demands on us are greater than ever before? The answer is to become more efficient and a better listener.

If we tell a hypertensive patient that they need to adhere to a low-salt and low-cholesterol diet, lose weight, and begin an exercise program, the likelihood of compliance is almost nil. However, if we listen to the patient and find out they are concerned about their blood pressure because one of their parents was hypertensive and suffered a stroke. Then we can tailor our conversation to suggest that lifestyle changes will decrease the risk of having a similar medication problem. This is also a situation where the physician should discuss nutrition or refer the patient to a nutritionist.

Unfortunately, most of us, including me, place emphasis on technology rather than on the patient’s needs and concerns. For example, doctors spend far too much time looking at the computer screen when they are with the patient in the exam room than looking at the patient.

Patients want to know that they are heard, understood, and responded to. Meeting such needs is perhaps the best way to ensure patient loyalty and return visits to our offices. This means being an effective listener.

How can we be effective listeners when the time demands are greater than ever before? Listening is a skill that can be developed. These skills do not require extra time; they do require making an effort to recognize the importance of listening. One technique is matching or mirroring, which includes restating the patient’s words or phrases when responding to their comments. For example, if a patient uses the phrases " lethargy and lack of energy, a mirroring response might be, “What happens when you have a lack of energy?” This indicates clearly to the patient that you are listening to them.

Another technique is to match the patient’s voice quality. It is a fact that how you say something is more effective than what you say. This requires the physician to follow the patient's lead regarding the use of phrases, speaking speed, and loudness. If the doctor is speaking quickly and abruptly to a slow-speaking patient who deliberately selects each word, it is equivalent to speaking in a foreign language to the patient.

Another example is to match a patient’s movements and hand gestures. If you notice a patient touching their ear, you might subtly touch your ear and comment that you “hear” what they are saying. This will reinforce that you are actively listening.

A final example is to match the patient’s posture, movements, and even eye contact. This is an effective communication tool and can account for more than half of your influence on the conversation. A good example is to match the patient's eye level. A female patient on the exam table, holding a gown or a cloth sheet around herself, will hear what a male physician towering over her recalls of anything the doctor discusses with her. However, if the doctor is eyeball-to-eyeball with the patient when she is fully dressed, the likelihood of being heard increases significantly.

I suggest you end each discussion with your patient by asking, “Have I answered all of your questions?” or “Is there anything else you’d like to discuss during this visit?” This avoids the uncomfortable situation of having closed the patient’s record, your hand on the doorknob, and ready to open the door when the patient says, “I have one more question to ask!” You can avoid this situation by allowing patients to write down their questions before the encounter with the physician. I provide patients with a 3 x 5 card to write their questions on while in the reception area or exam room. This also serves as a distraction to occupy the patient before their encounter with the physician. This will usually avoid the doorknob scenario that happens far too often.

Bottom Line: Patient loyalty increases when their needs are met. Meeting patients' needs involves more than providing medical care. Perhaps one of the best ways to obtain patient loyalty and return visits is to be a good listener.

Neil Baum, M.D., is a professor of clinical urology at Tulane University in New Orleans. Baum is the author of several books, including the best-selling book “Marketing Your Medical Practice-Ethically, Effectively, and Economically,” which has sold over 225,000 copies and has been translated into Spanish.