Learning to Listen: The Moment When Everything Changes
This July I was happy to join the Duke Family Medicine team for my second year of pharmacy residency, and was eager to learn the ropes and meet everyone. After a couple of weeks of orientation, I started seeing patients with my preceptor Brock Woodis, PharmD, BCPS, CPP. We had been asked to see a diabetes patient whose blood sugar had been elevated for several months and whose clinician was recommending starting insulin. Per the ADA guidelines, this would be an appropriate recommendation for the patient. With the patient’s blood sugar so elevated without significant changes, no oral medication would be able to bring the blood sugar to goal. However, there was one problem: the patient did not want to go on insulin.
This is not an uncommon feeling for most patients. One study, published by the American Diabetes Association, surveyed 1,267 diabetes patients and found that 28.2 percent of patients were unwilling to take insulin if prescribed, followed by 24 percent being slightly willing, and 23.3 percent being moderately willing. Only 24.4 percent reported that they were very willing. The survey found that the most frequent reasons for avoiding insulin listed were permanence of therapy, restrictiveness, low blood sugar, personal failure, and low self-efficacy. But how do you know what your patient’s reasons are?
It was once said, “The biggest communication problem is we do not listen to understand. We listen to respond” (author unknown). I think that this quote can often find itself true in health care. With so many demands on our day it can be challenging to take the time to listen. It is so easy to prepare for a patient visit and walk into the room with preconceived notions of what the plan is going to be. And then there is that moment, the moment when the plan is presented and the patient says something that stops us in our tracks.
For instance, “I do not want to take that medication.” After hearing those words, it is hard to stop your brain from spinning with all of the reasons why this medication is beneficial and all of the data supporting its use. But that is where the problem lies. I am thinking about all of the ways I can justify my plan and recommendations turning the encounter into a debate rather than a discussion. I am listening to respond.
One study, published in the Journal of the American Board of Family Medicine, looked at patient-centered care and its effect on health care utilization. The results showed that increases in patient-centered care within the one-year study period resulted in significantly decreased annual visits for specialty care (P .0209), less frequent hospitalizations (P .0033), and fewer laboratory and diagnostic tests (P.0002). Patient-centered care is obviously beneficial. However, if we truly want our patients to be at the center, then that means taking the time to understand.
Dr. Prabhjot Singh, director of systems design at the Earth Institute, Columbia University, said, “We spend a lot of time designing the bridge, but not enough time thinking about the people who are crossing it.”
To me, adding on insulin or a medication may not seem all that daunting. To me it might be the best path to reach the goal. For some of my patients, though, crossing that bridge means tackling their fears, anxiety, or overcoming their disappointment. All of my debate-ready responses are not enough to convince that patient to cross that bridge. I believe it takes true communication and understanding in order for us to cross over to the other side together.
Sarah Palacio is a second-year resident pharmacy resident with Duke Family Medicine. Email sarah.leonall@duke.edu with questions.
Editor’s note: Duke Family Medicine residents guest blog every month. Blogs represent the opinion of the author, not the Duke Family Medicine Residency Program, the Department of Community and Family Medicine or Duke University.