Getting in Tune

As I trained to become a doctor, I thought one of my goals should be to have all the answers. But now I know that it is more important to have questions.

Like most doctors, I try to hear patients’ concerns, share information, and brainstorm useful options together, partnering in decision-making. Surveys have shown that most patients want to know all their options, but only about half feel involved enough in decisions about their care. So, if patients want to be involved in their health decisions and doctors want to involve patients, why doesn’t it happen all the time? Because we need to learn to improvise better.

An office visit, like jazz, combines “technical mastery with the artistry of focused personal improvisation,” the authors of a 1998 article in The Journal of Family Practice observed. And like live jazz, two office visits for identical diagnoses should never sound the same.

But this is difficult because the emphasis during our medical training is still on amassing medical knowledge and less on communication. We think we engage in shared decision-making, yet we could all do better. Shared decision-making requires multiple skills: being present and listening to all concerns; communicating our understanding (and staying open to correction, if we get it wrong); and conveying appropriate information in a way that can be understood. Then—and only then—should we be discussing options. No wonder a fifteen-minute office visit often feels too short.

When a new patient come in to see me about a headache—let’s call her Elisa—it’s not enough for me to default to my usual tune about ibuprofen and neck stretches. I need to learn about Elisa. We must work within the context of her life. Medication won’t help if she can’t afford it, is worried she has a tumor, or is depressed but has a hard time admitting it. My first responsibility is to elicit her true reason for visiting, which coalesces as we speak. We take turns leading, her disclosures shaping my questions, which in turn influence her answers and may direct us to yet another path entirely. We have become a jazz combo, following each other’s cues.

Listening with openness and kindness makes it easier to learn about the person in front of me. This means making eye contact, explaining why I ask certain questions, and not judging her answers or actions. If Elisa feels accepted and heard, we can have an honest conversation. After all, it is my job to share pertinent facts in a way that makes it clear I have heard her concerns. “It’s almost never a tumor,” for example, is far less powerful than “I see why you were worried, but you have X, Y, and Z, whereas if you had a tumor, I would expect you to have A, B, and C.” Then I need to confirm that what she heard, and whether that lines up with my intention.

Once we understand each other, we can compose a plan within the context of Elisa’s values, circumstances, and priorities. Finally, we decide how to take my medical knowledge and apply it to her concern, working in harmony.

ANDREA GORDON is director of integrative medicine at the Tufts University Family Medicine Residency Program at Cambridge Health Alliance, as well as an associate professor of family medicine at Tufts University School of Medicine.

This article originally appeared in Tufts Medicine.