The Sounds of Silence

Listen closely, healthcare organizations and professionals: those sounds you are not hearing are the voices of people not speaking up, including patients.  And that's a problem.

Let's start with the elephant in the room: a new study found that even when physicians actually asked patients why they were there, on average they only listened to the patient's explanation for eleven -- that's 11 -- seconds before interrupting them. 

Think about that, and then think back to a doctor's visit you had about something that was worrying you: could you have explained it in eleven seconds? 

Believe it or not, that's not the worst of it.  Only 36% of the time did patients even get a chance to explain why they were there.  Even then, two-thirds of them were interrupted before they had finished. 

Primary care doctors did better, allowing 49% of patients to explain their agenda for being there, versus only 20% for specialists.  Hurray for the primary care physicians...

Lead author Naykky Singh Ospina, MD, MS, drolly concluded: “Our results suggest that we are far from achieving patient-centred care."

Now, sometimes the physicians already know, or think they know, why patients are there, and sometimes the interruptions are to ask clarifying questions.  But, as Dr. Singh Ospina added:

If done respectfully and with the patient’s best interest in mind, interruptions to the patient’s discourse may clarify or focus the conversation, and thus benefit patients.  Yet, it seems rather unlikely that an interruption, even to clarify or focus, could be beneficial at the early stage in the encounter.

The researchers say there are many reasons why physicians aren't listening better, including time constraints, burnout, and lack of communications training.  But still...11 seconds?  For the minority that even get the chance to talk?

As Bruce Y. Lee said in Forbes, "A doctor’s visit shouldn’t feel like a Shark Tank pitch."

As bad as this is, it is not the only area where not feeling able to speak up is a problem  in healthcare.  For example, a study in BMJ Quality and Safety found that 50% to 70% of family members with a loved one in the ICU were hesitant to speak about common care situations with safety implications.  They didn't want to be labeled a "troublemaker," they thought the care team was too busy, or they simply didn't know how to speak up.  Only 46% felt comfortable speaking up even when they thought there was a possible mistake in care. 

Co-lead author Sigall K. Bell said:

Speaking up is a key component of safety culture, yet our study—the first to our knowledge to address this issue—revealed substantial challenges for patients and families speaking up during an ICU stay

If patients are hesitant to speak up when their loved one is in the ICU, how reluctant must they be in other healthcare settings? 

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It's not just patients who are silenced.  One study found that 90% of nurses don't speak up to a physician even when they know a patient's safety is at risk.  Another survey, of medical students in their final year of school, found that 42% had experienced harassment and 84% had experienced belittlement. 

A couple of years ago ProPublica looked at why physicians stay silent about other physicians they know commit medical errors, including ones who do so repeatedly.  The reasons are varied, of course, but include concern about losing referrals, fear about causing lawsuits, lack of seniority, and gender or racial discrimination.

One physician, speaking about his hospital, told them: 

There’s not a culture where people care about feedback.  You figure that if you make them mad they’ll come after you in peer review and quality assurance. They’ll figure out a way to get back at you.

Anyone who has worked in an organization -- big or small, for-profit or not-for-profit, academic or commercial -- has probably had the experience of not feeling they can speak up, and healthcare organizations are no exception.  Even when the ones not speaking up are physicians themselves. 

The TV series The Resident (which I gather is one of Dave Chase's favorites) is about the trials and tribulations of a resident and a nurse who dare to speak out about senior physicians who are impaired and/or unethical; one of duo is [SPOILER ALERT] falsely imprisoned as a result.  It's TV, so you can rest assured that all will end well for our heroes, but, in the real world, things don't always work out so well for outspoken people. 

It's about power: who has it, or at least who we think has it.  We trust our doctors (although not as much as our nurses!).  We assume that more experienced doctors have more knowledge than newer doctors, that doctors know more than nurses, and that healthcare professionals know more than we do.  We're at the bottom of the knowledge tree.    

But that may not be true.  Dave deBronkart -- e-patient Dave -- likes to cite Warner Slack's great quote: "Patients are the most underused resource."  

I also think about what Dr. Jordan Shlain (Tincture's founder & leader) realized about patients: "No news isn't good news.  It's just no news."  This epiphany led him to found Healthloop to help ensure physicians were always hearing from their patients.  

But healthcare professionals must be willing to listen, and they must ensure that they ask.  And we must take the initiative to speak up.   

When it comes to our health, we are the experts.  We are the only ones who can report what we are feeling.  We are the ones who suffer the consequences of missed diagnoses, ineffective treatments, and medical errors.  We cannot be passive and we cannot be silent.

Our values are wrong if we allow reimbursement considerations to squeeze our time with physicians to the point we're not talking and they're not listening.  Our values are wrong if we're conditioned to think our opinions and concerns do not matter.  Our values are wrong if everyone is not only empowered but also expected to speak up, especially when we see or experience something we think is a problem.

Anybody listening?