As physicians, we have a privileged entry into patients’ lives. It’s like a diplomatic passport. We cross borders into the intimate details of an individual’s existence. Often we are asked to see and hear things that almost no one else is privy to know. I believe there’s something shamanistic about the role we have to play for patients. We need to create a sacred space for healing. We’re trying to reach a balance between a priest confessor, who hears the most intimate secrets, and a medicine man, calling upon the forces of nature to intercede on someone’s behalf. This is where entry into a person’s life becomes so critical.
As a physician, you’ve got to be patient. You must listen deeply, profoundly—what I call “active listening.” You’re listening energetically, with focus. Hang on every word. Plumb deep into the words being spoken. Drink in what’s being shared with you.
An exercise I have found helpful is I set myself a goal before I enter the examination room. I tell myself that I will speak as little as possible. I will only ask open-ended questions that cannot be answered with a simple “yes” or “no.” Finally, the patient should carry more than ninety percent of the conversation while I am taking down the medical history. By setting these guidelines, I ensure that I am in active listening mode rather than talking too much. The truth is that if two people are in a dialogue and one does not talk, the other usually will end up speaking to fill in the silence. I want the patient to be that person who does the talking. This is why it is so critical to give each patient enough time to tell you their story. You can guide them with a question here or there but the goal is to listen with all your heart and intellect. Native Americans have a wonderful expression: “Stop your tongue from talking before you become deaf.”
Let me give you a seemingly innocent scenario. This is a real one in which I was the culprit. I was in a mall in Tucson, strolling and shopping with my family on a Sunday afternoon. As I’m walking, I see a patient of mine, a young woman whom I had evaluated for a brain tumor, coming towards me in the other direction. She’s with two or three other people her own age. I couldn’t tell what her relationship to them might be. As we get closer, trying to be a nice, warm guy, I wave to her and say: “Hi, Mary (not her real name). How’ya doing?”
It seems innocent enough, doesn’t it? But it wasn’t.
Mary responds: ”Hey, Dr. Hamilton. I’m doing fine. I’ll see you around.”
A second later, as Mary passes behind me, I hear one of her friends ask: “Is he your doctor? What’d you go see him for? Wait, isn’t he that brain surgeon I’ve seen on TV?”
There it is: betrayal. I should have walked by without acknowledging Mary unless she greeted me first. Maybe she didn’t want to share with her friends that she had a brain tumor. Maybe one of her companions works with her on the job, and now Mary has to be concerned that her employer might inadvertently discover she has some kind of medical problem.
Obviously there is patient-physician confidentiality, one of the ethical cornerstones of Medicine.
As is laid out so beautifully in the Hippocratic Oath:
“And whosoever I shall see or hear in the course of my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.”
It’s not overt betrayal we need guard ourselves against. Such acts are punishable by law. It is the accidental slip, the covert treachery, that’s hardest to catch.
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