The Listening Environment

An important element in the listening environment is the physician’s sense of attention with the patient, and whether the patient feels the physician is listening to his or her concerns (Table 14-1). If the physician is running behind schedule, has had several difficult encounters during the day, or is tired from lack of rest, the patient will often pick up on various subtleties in the physician’s behavior that communicate a “lack of presence” to the patient (i.e., countertransference). Some patients may feel the need to help a hurried physician and may withhold important information (Pollock and Grime, 2002).

Table 14-1 Ritter LISTEN Paradigm for Interviewing and Assessment

Health care providers generally seek to collect as much information as possible while avoiding unnecessary information gathering that uses up valuable time. However, the interpersonal dialogue during the interview is vitally important, and the additional information often provides essential clues for more effective differential diagnosis and therefore more comprehensive treatment planning and case management.

The following LISTEN paradigm is only a suggestion, and health care clinicians should modify it for their own practice situation and environment. The purpose of the paradigm is to provide a structural mnemonic that moves the conversation logically and holistically throughout the interview. As determined by the clinician, any particular part of the interview may be expanded as the situation warrants, and any part may be minimized. By covering each part at least minimally, the clinician can achieve a general overview of the functioning and strengths of the patient or client, as follows:

The Ritter LISTEN paradigm provides the clinician a moment-in-time assessment of this person, who is on a journey of growth and change. The conclusions are tentative because they do not indicate how the person will be in the future. Nevertheless, the LISTEN assessment provides information for holistic treatment planning and intervention (see Table 14-1).

The physical environment of the room should be welcoming and inviting, creating a sense of comfort to the patient. Sometimes, a nonmedical picture, such as a group picture of the staff or a family picture, can enhance the conversation.

In initiating the interview, the physician should sit down and strive to maintain good eye contact. By having comfortable chairs for the patient, the intention is conveyed that the physician desires for the patient to be comfortable during the visit. Taking notes on what the patient is saying is appropriate, but it should not interrupt the flow of the conversation or break a sense of continuity. By allowing patients to tell their story in the opening minutes of the interview, the physician gains a context for understanding how they view the problem being presented. Sometimes, the seemingly irrelevant information being presented by a patient becomes valuable contextual information for diagnosis, treatment, and compliance.

Maximizing the Time

When the physician invites the patient to move to the examination table, there is a cognitive shift for the patient that is explicit and implicit. Explicitly, it is a change of place that conveys that a shift is taking place in the process of the visit. Implicitly, it prepares the patient for the more physical aspects of the visit. It may even be appropriate for the physician to offer assistance to the patient during this transition.

As the physician examines the patient, each action is preceded by an explanation of what the patient can expect to happen next. These brief informative comments build respect and rapport because the patient is more at ease not having to guess what is going to happen. In this regard, each intervention is a request for informed consent. “I am now going to listen to your heart.” The implied question is, “Is that all right?” Each statement carries this implied question, which is a way of being respectful and conveying the message that the patient is participating in the actual care being given and received. It is a collaborative and interactive conversation.

The Interview Process

As the physician talks with the patient, the natural flow of the conversation is itself a part of the diagnostic environment. How the patient interacts with the physician in the closeness and intimacy of the examination room is descriptive for how the patient relates with others outside the office context, whether at home or at work or at leisure and play.

During the interview, the physician’s own feelings and intuitions can help the physician understand how the patient is dealing with the illness (Borrell-Carrió et al., 2004). Sometimes, in the scientific world of medicine, physicians may believe that keeping their own feelings out of the process is the best way to be objective and relevant. However, if the physician is mechanical and distant because of discomfort with personal sensitivity, the patient will quickly notice the distance.

Psychiatrist Harry Stack Sullivan (1954) observed that the work of the physician is to be a “participant-observer” in the process of the interview. The physician maintains a scientific observer perspective, while also being available and present to the patient as a fellow human in the journey of life. As the physician becomes more sensitive and aware of the interview process, there is the experience of “reciprocal emotion,” the continuous reflecting of another’s feelings. The openness of the interview is further enhanced by the physician “mirroring” the body posture of the patient, such as crossing a leg, leaning forward, or leaning back (see Chapter 12).

The Participating Patient

Patients are more likely to accept recommendations from the physician if they feel they are a part of the process of treatment. Physicians often have different agendas than do patients for the clinic visit. The physician wants to find the problem, identify it, and bring hope and healing to the person. The patient wants to tell a story, to help better understand the illness, as well as find healing and recovery.

The patient can be encouraged to tell the story, even within the time constraints of the visit, with a statement such as, “We have about 15 minutes together today. How do you want to use this time? What do you want me to know?” In this way, the physician structures the time for the patient, and also gives the patient the freedom to express what he or she thinks is important. As the diagnosis and recommendations are made, the physician may ask the patient a question such as, “How do you want to participate in your treatment?” As Stone and colleagues (1998) observe, the physician is encouraging adherence rather than insisting on compliance: “Compliance implies an involuntary act of submission to authority, whereas adherence refers to a voluntary act of subscribing to a point of view.”

Difficult Patient Situations

Difficulties sometime arise during patients’ visits that are not anticipated. For example, a patient may be feeling so poorly that without realizing it, cooperation is difficult. It is the physician’s task to make the patient feel at ease and as comfortable as possible. In other cases the staff may not have fully prepared the patient for the physician. It is the physician’s demeanor that sustains the interview with a sense of ease as the difficulty is addressed or the omitted information attained.

Sometimes, the patient is difficult from the very beginning because of the illness, personality, or the process of moving through the office system. Already under the stress of not feeling well, the negative attitude of the difficult patient is only exacerbated by the many small issues that may arise in the interview. Some patients are irritated about having to wait; having no clear diagnosis; or being denied their request for an antibiotic to treat a viral infection.

Psychiatrist Beryl Lawn (2004) says that the difficult patient is most often afraid; it is this deep fear that something is wrong that the patient cannot control. The personality of the difficult patient may lack the flexibility or resilience that is necessary for coping with other people and with day-to-day living. In the stress of the medical environment, difficult patients may become angry and try to take control of the process as a way of controlling their inner fears of inadequacy.

Sometimes, stepping back or to the side provides the upset patient with some personal space to regain composure. The physician then continues the interview, without trying to analyze or explain the difficult behavior. It is the work of reconnecting with the patient, of maintaining respect and working to establish rapport and relationship.

Another difficulty is the patient’s ambivalence, such as hesitancy in making a medical decision or a lifestyle change decision. The physician may offer a respectful response such as, “I cannot decide for you. However, I do believe that it is an important decision, and I will respect whatever you decide.” In this way, the physician assures the patient that medical treatment will be continued, regardless of how the ambivalence is managed. Some people are paralyzed by ambivalence, and they may remain at this point of indecision for some time. Some people do nothing until some externally imposed deadline, such as a job application drug screening, makes the decision for them (Ubel, 2002).

Whatever the difficulty, the physician maintains rapport, respect, and relationship with these difficult patients by listening for their concerns. By giving the impression of being unhurried and having time to listen, the physician maintains relationship and conveys to the patient that the physician-patient relationship will continue, undamaged by the present difficulty. In this way the relationship becomes a part of the healing process.