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September 27, 2004

Why Doctors Don't Listen
Karen Ritchie MD

A 1984 study in the Annals of Internal Medicine showed that doctors listened to patients for an average of eighteen seconds before interrupting.

Perhaps physicians have never been very good listeners. Those who practiced in 1904 apparently were not, as Dr. William Osler felt compelled to urge them to "Listen to the patient. He is telling you the diagnosis."

But in Osler's time listening was considered essential, an integral part of the art of medicine. Now insurance companies have decreed that listening to the patient is a waste of time and will not pay for it.

While the physician's traditional role was to balance the science of medicine and the art, somehow the balance became instead a competition, a question of which was more important. Science won. Science is our new religion, the savior that will rescue us from all human problems.

This situation was not imposed on physicians: we did it to ourselves. When the managed care industry set out to eliminate waste from the delivery of health care, it asked doctors to define quality medical care. We answered, and continue to answer, in the language of science only. Good quality medical care, we say, is:
Making a correct diagnosis with the least effort
Providing the latest treatment, one best treatment for each disease, as defined by scientific studies in prestigious medical journals
All else is wasted time.

Science has won and the art of medicine has lost, or at least it has run out of money. For science, what is real is only what can be counted or measured. Anything that is not visible is unscientific and therefore does not exist. Physical reality is the only reality.

Science reduces an object to its parts in order to study it. In doing so, it often loses sight of the whole. So scientific medicine tends to reduce people to bodies and bodies to their parts. Disease has meaning only as an enemy to be fought.

The science of medicine focuses on the biologic fact of disease, the art of medicine on the patient's experience of illness. Without art, medicine treats only the body, when it's the life that is broken.

Scientific medicine aims to find the one best treatment for each disease. Everyone with the same disease is presumed to be the same, and quality medical care is measured by how it conforms to the one best protocol.

Once the doctor used scientific studies as a guide to design a treatment for the patient, to fit the treatment to the individual. Now we fit the individual patient into the currently accepted treatment. Dissatisfaction with health care is high, and keeps rising. Patients want to be treated as individuals, they want to be respected and listened to, they want their humanness acknowledged. But the art of medicine, we are told, is a luxury. It is not in the budget.

Health care in the United States is now over 14% of the Gross Domestic Product. It is expected to rise to 16% by the year 2007. Presumably that 16% will buy ever more gadgets, and less humanity.

There is no contradiction between the art and science of medicine, and neither is more important than the other. For the huge insurance premiums you're paying, you should be buying both technical expertise and being treated as a whole person. If you go to an expensive restaurant and pay $100 for dinner, you should not have to choose between good food and good service. For that much money you should get both.

Medicine seems to be unable to improve this situation, so it is up to patients and potential patients, who are paying the bills, to demand change. If no one is listening, you may have to shout.

from the book Angels and Bolters: Women's Cancer Scripts

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