“Listen to your patient, he is telling you the diagnosis”- William Osler
“Dr. Elliott- the patient in room 24 has just refused his Chest Xray”- radiology tech. “Dr. Elliott, the patient in room 24 does not want any further testing and wants to leave”- ED nurse.
I was somewhat surprised. Yes, I have had patients who want to leave prior to finishing treatment, but usually I am aware of that risk before I leave the room based upon the initial encounter. You can just tell the patient that does not want to be here, has better things to do, or is here only because a family member forced them to get things checked out.
The patient in room 24 however was a very nice, somewhat anxious gentleman being seen for chest pain. It is a rather atypical pain- occurs in only one spot and is worse with movement. He comes from an alcohol detox facility where he is a voluntary patient. He has been there for about one week and is doing very well, no significant withdrawal at this point and appears rather motivated to succeed. He was simply sent for a workup because he complained of some sort of chest pain to the staff, who then felt obligated and concerned enough to have him sent in for a workup. His first EKG is normal, and my simple plan is the usual serial troponins, repeat ekg and follow up based upon his low risk presention.
After being in the room for only about one hour, suddenly I get the above feedback that he wants to leave. I am surprised. He did not seem anxious to leave when he first arrived, and seemed satisfied with the plan to make sure he was not having a heart attack! I also do not recall any type of negative interaction, which does happen to all of us, which might lead to him wanting to leave early.
Now at this point I had several options. I could have gotten upset- and told the nurse that he is obviously competent to make a decision and instruct the nurse to sign him out AMA. I could also choose to get upset and see him myself at this point, walk in the room with all the reasons why he cannot leave AMA and that he is putting himself at risk and making poor decisions for his health.
Thankfully I chose the 3rd option- I just went in the room and listened. I simply stated “Mr. Jones, the nurse and the radiology tech tell me you are not wanting any further testing and you want to leave. A few minutes ago, you seemed fine with the plan, can you please tell me why suddenly you would like to leave?” His answer as he looked at the clock was simply “They are getting ready to serve lunch at the rehab facility and if I don’t leave, I will miss lunch.” My heart sank. Everyday we all take our own lunches for granted and have no worries where they will come from. I simply told him that I will immediately get him one of our lunches if he would agree to wait for the final testing and he agreed.
Mr. Jones is a perfect example of the importance of the Social Determinants of Health (SDoH)[i] impact on health. According to the World Health Organization, SDoH are “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels”[ii] In a study on National County Health Rankings focusing on identifiable health factors, medical care overall is responsible for only 10-20% of health outcomes for an individual.[iii]
In reviewing these County Health Records from the American Journal of Preventative Medicine, the four main contributors to health were Socioeconomic, Health Behaviors, Clinical Care, and the Physical environment. The following chart shows the influence of each of these factors, with again our own direct medical care attributed to less than 20% of the overall outcome.
Mr. Jones did well, stayed to make sure there was truly no ischemia, and discharged without a problem, only AFTER he had his lunch. He illustrated the importance of the Social Determinants of Health Care as he was sent from his rehab, a product of his alcohol health behavior. He did have access to care but mainly in the Emergency Room. His housing was being taken care of by the rehab, but it was his Socio-economic issues which came to the forefront in the illustration of making sure he did not miss lunch. As shown- his community safety, economic concerns as well as behaviors explained fully 70% of his own health outcomes.
Now that we realize how his SDoH are affecting his acceptance of medical care, it is important we remember that it was active listening which led to this realization. After all, two previous care providers discovered he wanted to started refusing care, however neither of them had found out the reason why.
Active listening is defined as “the act of mindfully hearing and attempting to comprehend the meaning of words spoken by another in a conversation or speech.”[iv] The Studer Group defines active listening as “to hear with thoughtful attention”.[v] It essentially means to listen to what is being said, while seeking to understand the person’s values, thought and attitudes. The Studer Group goes on to give six tips to improve our listening, which includes watching non-verbal cues, make a point to not multitask when listening, wait until the patient is finished before speaking, and asking clarifying questions. It is also useful to use appropriate touch if the patient seems upset which can show empathy.
A Harvard Business Review article points out that hurried encounters without active listening can result in ineffective or undesired treatment plans, which serves to diminish the joy of serving patients and leads to dissatisfaction not only for the patient but also for the provider.[vi]
So, keep listening, because sometimes the most important thing we can do may not be related to the medicine.
Feel free to comment- would love to hear your experience.
-Mark Elliott, MD, MBA