Clinicians must combine modern treatments with the time honoured skill of attentive listening, argues Meagan Brennan

On the hierarchy of evidence pyramid, randomised controlled trials sit close to the top. The only things better are systematic reviews and meta-analyses. We are told to steer clear of the categories of individual case reports and single clinician experience. As doctors, we are scientists. We need to practise evidence based medicine, and to do this we need large, randomised trials and meta-analyses so we have evidence that is rigorous. We want to remove confounding variables and are schooled to believe we must avoid anecdotes. We want homogenous groups of people in huge trials so we can make valid comparisons and conclusions. But in the pursuit of more “pure” science we are, I’d argue, erasing the individual characteristics that make the “subjects” (our patients) human, and this mindset risks being carried over into clinical practice, as well as research. 

It is the anecdote that connects us to our patients, it is understanding the individual for whom we care that brings us joy, and it is connecting with their personal experiences that makes our work so rewarding. 

Hearing the stories of illness and bearing witness to the journeys of our patients is a fundamental part of the art of medicine, yet it is one that is becoming lost. In our high tech world, we do tests and more tests to get to a diagnosis. We make treatment plans for patients using the latest drugs. Usually they work well, but when they don’t we label the patient “non-compliant.” After all, they must be doing something wrong because we have enacted an “evidence based” plan. The problem with this approach is that we omit the most crucial piece of evidence of all: the patient perspective. The years of life experience and the beliefs, goals, and preferences that a patient brings to their illness is the evidence that cannot be ignored. When this critical element is excluded from the equation, treatment can often fail completely or even do more harm than good.

In contemporary medical care, there is a big focus on “personalised medicine.” The name would suggest that it is an attempt to reconnect with the human side of medicine, or even a response to the realisation that we can only develop effective individual treatment plans if we understand the lived experience of the patient. Unfortunately, despite its name, personalised medicine is taking us even further away from the heart of doctor-patient interactions and deeper into the realm of impersonal science. Personalised medicine’s focus on genetics to predict disease development, response, and outcomes allows us to make recommendations for care without even having to speak to or look at the person it’s for. This is what we’re packaging as “tailored care.” 

The progress that medicine has made in the past 100 years is staggering. The diseases that can now be cured and the resulting increases in life expectancy must be celebrated. We can offer our patients wonderful treatments that let them live longer and better quality lives. It is important, however, that we combine our modern treatments with the time honoured skill of attentive listening. Only then will our patients be truly cared for, and not just treated.  

The process of close and active listening without judgment or interruption is a skill that can be learnt. So how can we teach and nurture it? One idea is that the emerging disciplines of medical humanities and narrative medicine can achieve this, through their emphasis on the centrality of the patient’s story to care.¹ Academic departments of medical humanities are increasing in number and aim to understand the human experience of illness through the study of poetry, art, and literature. The study of medical humanities is now part of several undergraduate medical programmes in the UK^{2 3} and the US.^{1 4 5} Its advocates contend that it can develop empathic practice and a social justice conscience in medical students. It is also being explored as a tool to enhance job satisfaction and reduce burnout in consultant physicians and junior doctors.⁶

Modern medicine is making us forget the humanity of our patients and ourselves, but we can rediscover this and reconnect with our patients’ stories through the art of close listening. The lived experience of the patient may just be the missing piece of “evidence” in our search for truly evidence based practice. 

Meagan Brennan is an Australian breast physician, researcher, and medical educator. She works at the Westmead Breast Cancer Institute and the Universities of Sydney and Notre Dame Australia. She is a strong advocate for patient centred care.

Competing interests: none declared.

References

1. Department of Medical Humanities and Ethics. Division of Narrative Medicine. Columbia University Irving Medical Center. https://www.mhe.cuimc.columbia.edu/our-divisions/division-narrative-medicine.
2. King’s College London. The Centre for the Humanities and Health. https://www.kcl.ac.uk/research/the-centre-for-the-humanities-and-health. Published 2021. 
3. University of Aberdeen. https://www.abdn.ac.uk/smmsn/.  Published 2021. 
4. Gowda D. Using narrative medicine to better understand patients’ stories. Kaiser Permanente Bernard J Tyson School of Medicine. https://medschool.kp.org/news/using-narrative-medicine-to-better-understand-patients-stories. 
5. Center for Medical Ethics and Health Policy Baylor College of Medicine. Narrative Medicine. https://www.bcm.edu/academic-centers/medical-ethics-and-health-policy/community-events/narrative-medicine. 
6. Slavin S. Preventing physician burnout: satisfaction or something more? Isr J Health Policy Res. 2019;8(1):34.