The Power of Deep Listening in Medicine

A conversation at a recent social gathering turned to the viability in the time-pressured present-day medical world of appointments of listening to the patient. We each recounted recent visits with physicians whose eyes were riveted on the computer screen, “click-clacking” notes during the visit to avoid spending additional time doing so after the encounter.

One of those present was a physician, but of the old school, who still sat down with a patient to talk about their symptoms and concerns! Astonishingly, this physician kept his attention on the patient. We marveled at this quaint practice.

Yet, focused, deep listening to a patient is not just nostalgic yearning or a practice that is irrelevant to modern-day medicine. It is critical for a correct diagnosis; it is crucial in providing a healing experience.

Failing to listen causes suffering.

In his 1982 New England Journal article, physician Eric Cassell observed that failing to understand the nature of patients’ suffering can lead to medical intervention that not only fails to relieve the individual’s suffering but also becomes a source of it.

Consider this commentary in 2014 by Robert Swendiman when he was a fourth-year medical student. He described an emergency room encounter with a patient in her mid-60s, a heavy smoker who was emaciated, having lost 80 pounds over the past six months. Her presenting complaint was that of constipation. How was he to understand her?

Dr. Swendiman wrote that his first-year clinical medicine professor had two rules: 1) Sit down with every patient. Why? It was comfortable, and it made the patient feel more at ease. 2) Never act like you were in a hurry, even if you were.

During his medical examination of the patient, after pressing on her belly, it quickly became evident that she had cancer that had metastasized to her liver. When Dr. Swendiman told the patient and her husband, after confirmation through tests, of the terminal nature of the diagnosis, they were both angry. Not at the diagnosis, but because over the last two months, the patient had been to the same emergency room, urgent care, and even their primary care physician, only to be sent home with laxatives. Though Dr. Swendiman acknowledged that an earlier diagnosis would not have changed the prognosis, the patient had been left to suffer.

Failing to listen erodes trust.

The electronic record health formats may compound the problem, as it is easy to copy and paste from prior history. Heavy workloads and administrative demands, such as completing mandated health checklist assessments (e.g., depression, anxiety, suicide, affirming mental capacity to consent to treatment, confirming understanding of the information being conveyed), all crafted to reduce liability, add another layer of work for the physician. Cumulatively, these demands erode rather than enhance an understanding of the patient’s suffering. It is no surprise, then, that much of what the patient is experiencing is lost in this morass.

Epstein and Beach, in their 2023 review of the literature, described the impact of deep listening by physicians to their patients in medical contexts. They noted that listening enhances patient trust and relieves suffering through fixing, witnessing, and transformation. Epstein and Beach observed that listening is “the sine qua non of effective healthcare”; even in the most technologically driven specialties, the description of a patient’s symptoms comes from their experience of the malady.

The human brain likes shortcuts.

So, why is listening so difficult? It may be what cognitive neuroscientist Itiel Dror, in his work on cognitive biases among forensic scientists, has observed: that the human brain uses shortcuts and templates to organize and make conclusions. Many times, the wrong ones. Itiel Dror notes that the human brain’s impulse is toward apriori assumptions and conclusions often influenced by irrelevant information.

Epstein and Beach make a similar point. The physician who sees an older male with urinary problems will come to a diagnosis even before talking to the patient. The relevant information, that of the patient’s complaints, becomes irrelevant. Epstein and Beach call this “premature categorization,” where the patient is asked “yes or no” questions that drive to support the physician’s hypothesis. Epstein and Beach suggest that the physician ask themselves, “What am I assuming that might not be true?” What enhances deep listening may not be very complex: It takes interest and effort. They suggest that such listening “involves habits of the mind that invite curiosity and openness” and self-questioning.

Deep listening attentiveness refers to the other person being aware, present, and focused as a listener. It requires cultivating respect for the other person, their experience, and their desire to speak and be heard. Australian indigenous people describe it as “dadirri,” a practice of listening deeply, with full attention and quietness to the other person. Deep listening has been characterized as both interpersonal and spiritual in its impact.

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Listening to understand rather than respond

Listening to understand is a difficult proposition, particularly for those who may harbor conscious or unconscious professional arrogance. This type of “listening to respond” rather than “listening to understand” can be destructive personally, professionally, and even spiritually. This move toward listening and taking a patient’s complaints seriously and respectfully requires what Epstein and Beach characterize as a shift in institutional values and priorities. It may be time to reassess the importance of listening and focusing first on how to treat the patient and then on the malady.