PRACTICAL WISDOM: Finding the balance in listening & asking. (9 JAN 2017)

When someone is trying to communicate an unidentified problem, the person, who wants to help, be she a doctor, counselor, empathetic stranger or friend, must exercise skill & wisdom. This post is both a discussion & a book review. Over the years, I have (in general) witnessed most doctors being pretty lousy at diagnosing things. This is not only my evaluation, the late Dr. Allen B. Barbour, who specialized in taking cases that other doctors had failed to evaluate, said that the medical system does not work in the care of “most patients”! Perhaps you have felt vulnerable, hopeless, and run rough shod over by the people you needed help from. Perhaps you have been on the flip side, trying to help but getting frustrated. And one of the culprits in the whole process is just simply time…listening can take time. But if something is worth doing…it is worth doing right. A saying I learned when Amish was: “A lazy man will work himself to death.” Allen Barbour, by taking more time to listen & think, would single-handedly solve medical problems that had puzzled a whole series of doctors…so the lazy evaluations actually end up working the medical system to death…well not exactly, because they are making money the whole time.

Doctors aren’t the only ones who are deficient. The few investigations I have been familiar with left me shaking my head at the total incompetence of the police & FBI. Their listening skills are more deficient than doctors. But getting back to the doctors…typically they run a $1,000 worth of worthless tests, only to tell the suffering person that they did not find anything wrong…meanwhile the patient continues to suffer. Doctors have a monopoly on doctoring, so the poor patient doesn’t have many options. Both doctors & patients are getting jaded by the whole distorted, out-of-balance system. Bear in mind that some doctors may own the test equipment they refer you to. Drug companies give all kinds of monetary incentives to doctors to use their pharmaceuticals. Long story short: practicing medicine is commercialized. Money is in the driver’s seat, integrity can have a back seat.

WHAT IS NEEDED TO BE WISE IN EXTRACTING CLUES FROM SOMEONE. One has to have a balance between empathy & detachment. I would also add that trust is the foundation of communication, and a haughty distrustful attitude ruins the possibility of good communication. We have to read the person, often from non-verbal clues so that we can get inside of what is happening to them…while also being able to step back from the patient’s perspective enough to see the situation better than they see it. One study found that on “average” (actually the mean time) that doctors wait before interrupting a new patient and taking control of the conversation is 18 seconds. Once they take control, they ask closed-ended questions…increasingly steering the conversation to probe for the condition the doctor thinks he or she has before him. Extrapolating this to life in general…when should we frame questions, and when should we listen??…it is quite a skill.

“Caring for Patients: A critique of the medical model” by Allen B. Barbour. (Stanford, Calif., Stanford University Press, 1995, $45. ISBN: 0-8047-2389-3.) Allen Barbour, a practicing doctor for 40 yrs., was the former head of the Division of General Internal Medicine and chief of the Stanford Diagnostic Clinic and a revered legend. Just before he unexpectedly died in 1993, he finished his book Caring for Patients, which is based upon 403 difficult cases that the doctors referred to him after they gave up trying to figure them out. Allen called his method “person-centered care”; & indeed he was a caring & thoughtful person. He states, “By person-centered care I refer specifically to becoming familiar with the patient’s personal situation in its crucial relationship to the source of illness.”

Caring for Patients is written primarily for internists, family physicians, and other primary care practitioners. However, the book’s message obviously extends to physicians in specialty and subspecialty practice as well as nurses, pastoral counselors, and other health professionals. What Allen does is lay out principles that are helpful for listening to people to extract the information needed to solve a problem. In this respect, his book serves as a template for many of us in many situations. Allen’s critique originates from his concern that the medical system has become a commercialized system that is frequently unconnected with patients’ personal lives. Health care professionals, who have realized Allen’s perspective, will enjoy his shared wisdom.

WHAT IS WRONG. Allen’s book finds fault with the contemporary medical model & its emphasis on organic pathophysiology, pharmacotherapy, & high-technology procedures. Allen diplomatically contends that the medical model simply does not work in the care of most patients, because it fails to take account of the psychosocial context of patients’ lives. His approach focuses on persons, not patients; illness rather than disease; an understanding of the personal situation, not just the biologic situation; clinical judgment rather than diagnosis alone; healing rather than curing; collaboration with patients, not just treatment of them; and the achievement of health rather than the eradication of sickness. The physician’s role in patient-centered care is involved, not detached. Allen Barbour emphasizes the responsibility of the individual patient in health maintenance & disease prevention, w/ the physician acting as a partner. I agree wholeheartedly. Our system acts like the doctor is God, & patients are not taking enough responsibility. In a way, this article builds upon a previous article I wrote last year on how traumatized people (like refugees) who go to counselors & doctors seldom get asked about their refugee traumas which often relate to their problems.

FINAL THOUGHTS. There you have it, a few short thoughts on how the wisdom to counsel and problem solve often involves balancing empathy & detachment to gain a better perspective. In the long run, doing the job right actually saves time & effort for everyone involved. On the other hand, patients need to take more responsibility, incl. doing things that can assist the caretaker or doctor, as well as themselves. Feel welcome to share your experiences or wisdom. And may God continue to bless you my friend.