Leana Wen, M.D., Baltimore’s city health commissioner cowrote a book entitled When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests, which has stirred up some controversy amongst the medical community.
Dr. Eric Topol, editor-in-chief of Medscape interviewed her to discuss the issues covered within the book and makes for a very interesting conversation.
In response to Dr. Topol’s question as to how doctors can listen to their patients better, Dr. Wen responds as follows.
“It’s nobody’s fault, but there are things that we can do. How can we focus on the fact that 80% of diagnoses can be made by listening? How can we go back to the diagnosis and why it is so central? How can we do patient-centered care and not just check off a box saying, “We have consulted a patient and therefore it’s patient-centered,” or “We have talked to one community member and that’s community participatory research”? There is a tendency for all of us to say, “We have done it. We did this very basic thing and we’re done.” But how can we focus on what it means?”
Getting Away From Unnecessary Tests, Misdiagnoses
Dr Topol: “How do we avoid misdiagnoses and unnecessary tests? Almost 12 million serious misdiagnoses are made in the United States annually. “
“How can we focus on the fact that 80% of diagnoses can be made by listening?”
Dr Wen: “I have three quick suggestions. Better listening is critical. I find the 80% figure for “diagnosis from listening” astounding. If we could invent a test that would give us the right diagnosis 80% of the time, we would consider it a miraculous test. We would be investing millions, if not billions, of dollars in it. Instead, as a result of technology and pressure on a doctor’s time, we are spending less and less time listening. A lot of what I did in academic medicine was to teach, “If we can listen in the extremely busy and chaotic setting of the ER, and if we can focus on our patient, not only will it save time, but it will also present misdiagnoses.” Teaching about listening, and then modeling that behavior, is really important.”
The second suggestion is to focus on not just what the patient doesn’t have but on what they do have. A patient comes in with chest pain and leaves with a diagnosis of chest pain. What does that really mean? We say, “We have ruled out pulmonary embolism, myocardial infarction, and broken ribs,” but what is causing this patient’s chest pain? Why are we so hesitant to say, “This is musculoskeletal chest pain” or to say, “This is gastroesophageal reflux disease” or “This is cholecystitis”? Whatever that hesitation is, we need to get away from it as clinicians, and we also have to encourage our patients to actively be involved in this process.
Rather, for patient environment, I would encourage patients to really understand themselves, to tell a better story, and not be afraid to advocate for themselves, but in a way that is collaborative with their physician.
“If we could invent a test that would give us the right diagnosis 80% of the time … We would be investing millions, if not billions, of dollars in it. Instead, as a result of technology and pressure on a doctor’s time, we are spending less and less time listening.”
“The third tip is patient empowerment. People might think of patient empowerment as when a patient brings a stack of papers and asks for five MRIs and three medications. I would say that this is not the right approach, because it implies that you don’t trust your doctor and that you know what is best. Rather, for patient environment, I would encourage patients to really understand themselves, to tell a better story, and not be afraid to advocate for themselves, but in a way that is collaborative with their physician.”
Dr Topol: You get the docs going by saying that they need to be transparent—the Who’s My Doctor? thing had some backlash. Can you tell us about that movement?
Dr Wen: If doctors are being paid by drug companies, they need to inform their patients of this.
“We have a responsibility to our patients to be totally transparent. Our patients are coming to us at a time of extreme vulnerability.” Very few patients, if any, are going to ask me, “Do you take money from drug companies?” or “Are you affiliated with a medical device company?” I
Dr Topol: With it being voluntary, why do you think so many doctors revolted against this concept?
Dr Wen: The main thing that I am saying is that doctors aren’t listening and that we should be doing better. I am the doctor who listens; these other doctors, they are the ones who don’t listen.” We see the same thing, in which studies have been done about whether doctors perceive conflicts of interest with drug companies. They will say that other doctors are influenced, but that they themselves are not. By disclosing, I assume that these doctors are saying, “Look, somehow this is implying that I am influenced, and I should be immune from that.” Dozens of studies show that we are influenced by drug company advertising and marketing, or else why would they bother doing it?
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