Missing in medicine: time to listen
One recent afternoon I found myself busily chatting up my new hair stylist, a pleasant-looking woman who was competently wielding her scissors on my wayward mop. Suddenly she excused herself, to return moments later with two thick magazines, Vogue and Glamour. Not only were these two magazines of little interest to me, but, clearly, a message was being delivered: ``Please stop talking!"
I had always thought that hair stylists belonged to the sacred group of listeners: rabbis, pets, Judge Judy, dental patients, and physicians. The abrupt cutoff by my new stylist made me consider how much listening I had been doing lately in my own work as a pediatrician.
I thought back to the prior week when a busy afternoon brought a flurry of well-newborn exams, camp physicals, rashes, earaches, and the usual assortment of playground-induced afflictions. In particular, I remembered a visit with two boys, ages 4 and 6, who were brought in by their mother for a yearly physical.
Although we usually allot 20 minutes for an annual exam, primary-care doctors must also fit in same-day sick patients -- those who cannot wait another day for a visit. Thus, the two boys' visit was sandwiched in between jaundiced babies and feverish toddlers.
And, as with most patients, I took up most of the time by following the official script for a pediatric visit, questioning the mother and boys about issues important to other people. As a result, I didn't leave enough for the kind of listening that can make a real difference in a child's health.
It was the usual orderly chaos in the office: babies screaming, toys scattered everywhere, nurses rushing from room to room weighing babies and giving immunizations, phones ringing, mothers and fathers anxiously peering out of exam rooms to see where their physician was, and my hardworking colleagues, moving from one room to the next, trying to perform a job that has become harder and harder to do well.
Amid that bedlam, I needed to do the following for both boys, according to the American Academy of Pediatrics, malpractice insurance agencies, coding overseers, legislators, consumer groups, and all the other well-intentioned groups that decide standard-of-care guidelines for physicians:
A full physical exam then follows, assuming that the now-bored and energetic boys can be lured from dismantling the printer and cajoled into sitting on the table. A full assessment of all findings must then be given and entered into the electronic medical record followed by ``the plan."
The plan for well-child physicals now includes immunizations to be given, referrals to specialists, new medications ordered, safety tips given, including advice on flossing, dental visits, bike helmets, TV watching, excessive and indiscreet Internet use, bullying at school, exercise plan, seat belt use, depression screening, discipline advice for parents, junk food discussion, plus need for calcium, sun block, insect repellent use, smoking cessation plans for parents, and inquiries about domestic violence at home. And this is not a complete list. Imagine if the patient also had a chronic medical problem such as Crohn's disease or asthma?
I was ushering the boys and their mother out the door, knowing that other exam rooms beckoned with impatient families, when Mom hesitated. ``One other thing." Looking meaningfully at the boys, she pointed to a scrap of paper. I watched her write out, ``divorce."
So there we were, out of time and our so-called comprehensive visit complete, and the most important event that could have grave implication on the boys' health, mental and physical, hanging in the air.
Is there a listening problem in healthcare today? I imagined if Mom and I had sat down together with lots of toys and books for the boys and chatted quietly over a cup of tea, with lots of time to let conversation flow, this devastating family issue could have come to the fore earlier. We could have addressed family dynamics, support for all family members, and preventive suggestions to avoid custody battles, depression, and future impaired relationships for the boys. We needed time, a relaxed setting, and a willing listener.
Instead, most providers, given the long list of imperatives that must be accomplished in a healthcare visit, stand tensely at the computer, firing off directed questions, interrupting long-winded or off-subject answers, entering data, and taking multitasking to a new level. How many times have I been listening to a child's heart while playing peekaboo with the baby and also squeezing another question to a parent? Sometimes I am so busy multitasking that I ask the same question twice.
Having Glamour magazine slapped in my lap while chattering amicably in the hair salon reminded me about the sacred art of listening.
I wonder whether we should shed the long list of healthcare priorities and go back to listening to our patients' stories. Many of the so-called data entries could easily be performed by modern technology. Perhaps some issues -- like wearing a bicycle helmet and locking up firearms -- could be better handled by a public health campaign than a pediatrician.
We still need human beings to listen, assess, empathize, and, perhaps, recommend, and that is the art of medicine.
Dr. Victoria McEvoy is the chief of pediatrics and the medical director of the Mass. General West Medical Group, and assistant professor of pediatrics at Harvard Medical School. 
