Listening for What Matters profiles a decade of work to identify and begin fixing a serious problem: doctors often propose the wrong treatments for their patients, not because they have the science wrong, but because they fail to understand that what is right for one patient may not be right for another. Extraordinarily, it’s based on over a thousand covertly recorded doctor-patient encounters. This is a book that gracefully ties research rigor with a deep understanding of human suffering. It offers copious insights not just to health professionals but to members of the lay public who ask themselves (as I do) “Why do my doctor’s visits so often seem to involve fruitless exchanges of information without fixing anything?”
To understand the problem, consider this story from one of the early chapters:
A woman with kidney failure keeps getting admitted to the hospital because she has missed her outpatient dialysis appointments repeatedly. The chart says she is “noncompliant” with care. She is told, each time, that it’s critical she not miss her dialysis anymore. As Weiner and Schwartz detail, no one asked her the obvious question: “Why do you keep missing your appointments?” It turned out the patient had her dialysis at an outlying clinic while the grandson under her care required specialty services every week at a teaching hospital. Moved her dialysis to the same hospital and boom: problem solved.
As the authors have it, doctors are educated and trained in ways that leave them routinely unable to see when to ask what would seem to be blindingly obvious questions in which a modest level of engagement and curiosity could prevent wasted time, wasted resources, and lead to a patient who actually gets better.
This is a book where the authors lay out what they have learned from over a decade of federally-funded research, including both Veterans Affairs hospitals and private academic medical practices. They explain the problem in brief, compelling narrative.
They lay out their creative series of experiments to illustrate how frequently doctors overlook obvious life challenges patients face (“contextual red flags”), and then send them out with a care plan that is doomed to fail. They did it by audio-recording doctor’s visits (with the doctors’ permission), first with trained actors (secret shoppers) and then with real patients carrying covert recorders. They show this problem to be prevalent, that the skills involved in “contextualizing care” are teachable, and that physicians (for the most part) like learning about it. They also let readers see up close and personal just how as a team they navigated extraordinary challenges that encumber the bureaucracies of both research and quality improvement.
The authors make abundantly clear that this is NOT yet another book on making doctors more humanistic, caring or compassionate. Rather it’s the story of how doctors either notice or fail to notice and explore information that actually matters to whether the patient is offered the wrong plan or the right one.
But they are also clear that their methodology focuses on a set of teachable behaviors that are ultimately easiest to learn for the professional who begins by seeing patients as fellow human beings, neither looking down on them nor putting them on a pedestal. Engagement emerges from respect for patients. The work of engagement, in their research, actually did not add extra time to clinical visits. In fact, it prevented wasted time due to offering treatments that were wrong in the first place.
What glues this book together are four things that make it particularly compelling. First, the authors make the human problem clear from the start and they know how to name and describe the shortfalls that afflict medical care in a way that is entertaining at times, and often touching. When the authors describe the gentle exploration that revealed how a fear of needles from a prior history of abuse led a dental patient to seek antibiotics and not a dentist for a rotten tooth, it’s palpably emotional for the reader. Moments like that recur throughout the book.
Second they convey ingenious research designs with utterly clear language, in a book that is reasonably short. This is not a hard book to read.
Third, they show from their own research that the problem they study is addressable.
Fourth, what makes this book inspirational is that it is infused with a coherent, commonsense ethical respect for patients, and for doctors as people who can and should recognize that the cookbook quality metrics of today’s health care should never get in the way of actually helping patients get better. Chapter 8, titled “What We Cannot Measure,” describes what it truly means to respect and help a fellow human being while maintaining one’s own boundaries. It should be required for any health care provider.
The ideas in this book demand a paradigm shift in what it means to make the right medical decisions for patients. The authors go way beyond describing “what ails medicine” or proposing marginal refinements to how quality is enforced by payers.
This work takes the discussion of health care back to its original purpose: professionals need to help real patients with real problems. Our methods of teaching medicine and enforcing quality sometimes unintentionally cripple that worthy objective.
But the problem can be observed, measured, and remediated using the methods this team developed. This book grounds its intellectual innovation with a deep and compelling understanding of what it means to help others. As a health services researcher, I can state that it offers some of the most innovative thinking on improving health care I have ever seen.
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This book grounds its intellectual innovation with a deep and compelling understanding of what it means to help others.
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