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A patient says her hip has hurt for a while. Whether she leaves trusting her doctor depends on what happens next. Alan P. Feren, a retired surgeon, health care consultant, and patient advocate, separates active listening, which makes a patient feel heard, from careful listening, which changes the reasoning. This episode is based on his article “Trust in medicine is restored by method, not empathy,” published on KevinMD. He says the history alone gets you about seventy-five percent of the diagnosis, and that the step squeezed out of a fifteen-minute visit is the one deciding whether a plan is usable. He talks about patients called non-adherent who cannot afford the medication, cannot reach the appointment, or are working two jobs. He also explains what happens when a patient arrives with a story already shaped by an AI tool, and why the clinician has to stay its author. You will hear the three things he tells busy physicians to establish first, and the questions he tells patients to ask when the answers never come.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Alan P. Feren, retired surgeon, health care consultant, and patient advocate. Today’s KevinMD article is “Trust in medicine is restored by method, not empathy.” Alan, welcome back to the show.

Alan P. Feren: Thanks, Kevin. Glad to be back.

Kevin Pho: All right. Tell us why you decided to share this latest article on KevinMD, and then talk about the article itself for those that didn’t get a chance to read it.

Alan P. Feren: Sure. I’m not arguing against empathy. I think empathy is extremely important. As we know, I think of empathy as basically a preamble to what is going to happen as you take the patient’s history. And I think it’s important to clear up first the difference between what people talk about as active listening versus the listening that I am describing, which is careful listening.

So first of all, why is listening so important? It’s not just a preamble to the diagnosis. It’s really where the diagnosis is made. If we look at prospective outpatient studies, the history alone can give us 75 percent of the diagnosis. When you add physical examination, it reaches somewhere in the neighborhood of 90 plus percent, and then you can add the labs and so forth for confirmation.

So this is where we talk about trust, because it’s built not only on how a patient is listened to, but on what happens clinically because the clinician has listened. So let’s talk about the difference between active versus careful listening. Active really helps the patient feel heard. The careful listening that I talk about ensures not only what was heard, but what will change the clinical reasoning. So active listening is really a communication discipline, if you will, and careful listening is a diagnostic discipline built on the active listening portion.

So patients really will trust a clinical method when they can recognize that their story is part of that reasoning. It’s not merely the fact that somebody has listened to it. And if you are trusting your physician, you will see the cascade of events that happen from the fact that he or she was listening to you and then is developing the diagnosis, helping with clarity and shared understanding.

One way to think about this is that listening really begins trust, and visible reasoning confirms trust. Naming uncertainty really protects that trust, and feasibility, which I talk about, makes that trust usable, and then follow-through sustains trust.

So the method that I’m talking about really is the method that all of us were taught during our training, which is we listen to the patient. We then do the complete physical examination based upon that listening. We develop a differential diagnosis. We then share our understanding with the patient in terms of what has been excluded, what’s most reasonably the cause of what is happening, what is left as the uncertainty, and then move on to developing our treatment plan.

And the part that gets compressed because of the 15-minute constraint is the feasibility and the treatment burden. And we’ve talked about that before. That’s a really important part. But if the treatment plan is not usable, patients then lose trust in the whole sequence. So my vision of this is that sequence really is what establishes the trust, and a breakdown in that sequence is the reason that patients lose their trust. So it’s the disciplined clinical sequence that makes medicine understandable and makes it usable for patients.

Kevin Pho: Now, can you give us an example or a case study of what careful listening would look like, and maybe contrast that with encounters that don’t involve careful listening? Just give us a story or case study of those practical examples.

Alan P. Feren: Sure. A patient may show up and say, “I have this pain in my right hip and it’s been bothering me for quite a while.” So active listening would be, “I see that you are very concerned about this pain in your hip.” Careful listening would be not only “I’m aware that you have this pain,” but “I need to know a little bit more about when did it start. Have you done anything different that might have caused this pain? Does the pain go anywhere? Does it radiate? Is it localized? Tell me on a one to 10, what is the severity of your pain? What is limiting you in terms of the pain as a result in your daily life?”

So that is really the careful listening that then leads to, let’s go into this examination. And a patient should be able to see his or her story on every part of that clinical sequence.

Kevin Pho: Why do you think careful listening isn’t used as often as it should be?

Alan P. Feren: Well, I think it’s the compressed system that all physicians are currently working under. One of the issues that has been raised in some of the articles that I’ve written is, well, I really can’t do all this in that 15 minutes. And what I’ve come to the conclusion is that that’s true, but not everything has to be done in that 15 minutes.

So I begin to be thinking about allocation of time. What can you get done in this 15-minute compressed period? Let patients know this is what we can accomplish today, and I’m separating really the encounter from the episode. In other words, the whole episode of care is not going to be completed in that 15 minutes. But what you can establish is develop the careful listening, establish the trust, begin the diagnostic workup, and then reallocate time if you need to in a further clinical encounter.

Kevin Pho: In your article, you also place weight on some of the social determinants of health, because sometimes the feasibility and treatment burden is not isolated in a vacuum, right? They can’t afford medication. They have no transportation to go to specialists or physical therapy. They may be caregivers themselves or working two jobs. So part of the listening involves understanding some of those social determinants.

Alan P. Feren: Correct. Oh, absolutely, Kevin. You hit on exactly what I describe as the feasibility and treatment burden. If you look at patients, if they cannot afford their medication, or if the medication is not covered, they don’t have transportation, they’re a single parent, they have issues with child care, all these are very, very important.

If it’s not really feasible for them to do the treatment plan, then the trust is eroded. These are the people who are the recalcitrant, the non-adherent. And so this is what really needs to be extracted, and sadly it’s a part that’s commonly compressed because of the 15 minutes.

Kevin Pho: In your article, you also see a role for artificial intelligence, right? So how does that play a role in terms of what we’re talking about today?

Alan P. Feren: Artificial intelligence, I think, can be helpful if it’s understood properly. I talk about something called authorship, which means that when patients typically now are starting to go beyond just Google and going to artificial intelligence to help them understand their story, physicians need to be sure that that story has not been shaped by artificial intelligence and is truly the patient’s story.

So this becomes part of the careful listening that patients need to have, because the physician needs to be the author of the entire clinical sequence. One point that I would make is that a visit can be concluded when the appointment ends, but it’s only completed when understanding travels with the patient and is usable.

Kevin Pho: So you’re saying that sometimes patients will turn to artificial intelligence, and that’s going to influence the story that they share with the physician, and that could affect the authenticity of what the patient is presenting. Is that what you’re saying?

Alan P. Feren: Absolutely. That’s it in a nutshell.

Kevin Pho: But patients, they’re going to use it regardless, right? So should there be guidelines in terms of how they should use it, the types of prompts they should use, and how that may affect their relationship with their physician during an encounter?

Alan P. Feren: Well, I think you’ve raised an interesting dilemma, which is that patients today sometimes will measure the effectiveness of clinicians by the difference between what they identify on artificial intelligence tools versus what the clinician is saying in his or her differential diagnosis. So it becomes an important point that when a patient comes in and has tried to prepare but has used artificial intelligence and has been led down a different road, it’s up to the clinician to help shape that patient’s story in a kind of a disciplined way.

Kevin Pho: Now, for the patients who are listening to you now and perhaps have more faith than they should in artificial intelligence, give us some reasons why they shouldn’t completely trust the path that AI suggests.

Alan P. Feren: Sometimes AI typically may not have all the clinical context that the clinician will have. So there are things in the family history, there are things in the types of medications you may take, there may be problems with a number of comorbid conditions that you have. And those things are not typically entered into the AI tool. The clinician has that information from their training and experience. And it’s important to rely on that training and experience in conjunction with what AI is saying to really come to a more narrowed, more complete differential diagnosis.

Kevin Pho: I was reading something on LinkedIn yesterday. In addition to what you said, they’re not going to know the feasibility and treatment burdens a particular patient has. They’re not going to know some of the social determinants of health that a patient has, because typically that’s not entered into the prompt either, and that plays a huge role in terms of the treatment path that’s offered.

Alan P. Feren: Absolutely.

Kevin Pho: So, I know we touched upon this earlier, but for those busy physicians who only have 15 minutes per patient, what would you say is the top thing that they can do to incorporate some of this careful listening to make sure that the clinical sequence is appropriately followed?

Alan P. Feren: Well, I think we begin by the careful listening aspect, and then make sure that your reasoning is visible to the patient, and name uncertainty. With those things, patients begin to really establish trust with their clinician. Trust breaks down when reasoning stays inside the clinician’s mind. Patients need to know enough of the reasoning to understand and employ their treatment plan. So if you can just establish those first three things and then help a patient understand what would change that treatment plan, I think that will help make the encounter more complete, although not completely finished.

Kevin Pho: We’re talking to Alan P. Feren. He’s a retired surgeon and patient advocate. Today’s KevinMD article is “Trust in medicine is restored by method, not empathy.” Alan, as always, let’s end with your take-home messages to the KevinMD audience.

Alan P. Feren: OK. I think for patients, it’s important for them to remember the five disciplines which I’ve spoken about before. When your clinician hasn’t given you all the information that you feel you need, think about the five disciplines.

The first is what’s most likely. What do I have? What’s most recently been ruled out, because they want to know I don’t have something serious or a life-threatening illness. What remains uncertain and still under consideration? What would change my treatment plan? And when should reassessment occur, and what are the responsibilities? What am I responsible for? What are you and my clinical team responsible for?

For physicians, make sure that you are listening as carefully as you can to the patient’s story, because the careful listening makes the story clinically usable. And from the clinical story, you’re able to maintain the clinical sequence that I’ve described, which is again the careful listening, the careful physical examination, the differential diagnosis, shared reasoning and understanding, treatment planning, and feasibility.

And if you have to shortcut any of these things, make sure your treatment plan is feasible and you understand the treatment burden. And if not, typically most physicians will have some assistance with their nursing staff, PAs, NPs, that can help them address some of the education needs that patients have. Be referred to social services to examine what are the issues that may prevent them from following your treatment plan.

So it’s a team effort. Don’t feel that you have to get everything done, but get the important things out of the way so patients really can begin to trust the method and the things that you have suggested in the treatment plan.

Kevin Pho: Alan, thanks again for sharing your perspective and insight, and thanks again for coming back on the show.

Alan P. Feren: Thanks, Kevin. Glad to be back.

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