By Peter Pronovost

First posted on Points from Pronovost on 1/5/12 |

Peter Pronovost, MD, Medical Director for Quality Patient Care, Johns Hopkins University

I was reminded again recently of how important it is to sometimes just sit back and listen to what our patients have to say. Every month, as part of our hospital-wide patient safety efforts, I meet with staff and interview patients, seeking to learn how we can improve the care we provide to them.

A young patient shared two stories with me, one telling me how we get it right and one reminding me how we sometimes get it wrong, even without realizing it. She was nervously awaiting a procedure in Interventional Radiology when a nurse sensed her anxiety and called in a child life specialist. The specialists came and significantly helped relieve the patient’s suffering. She listened to the patient, offered a comforting touch, and provided her age-appropriate reading material and Sudoku puzzles, a brilliant though infrequently used intervention. If anything could take your mind off of your illness, it is Sudoku.

What was amazing was that after all the patient had been through—weeks in the hospital, countless procedures, scores of clinicians—what she remembered was the nurse’s act of kindness by caring enough to call the specialist. The patient reminded me that though we can cure disease sometimes, we can relieve suffering always, often with nothing more than a kind word, a gentle touch or a warm smile.

As I listened, the patient, along with her mother, went on to tell me more. They told me how the patient has complex allergies and that her mom knew her disease better than any clinician. They had lived with the disease for a decade. Yet at times, neither the patient’s mother nor the patient felt they were being heard by the doctors. The mom expressed frustration that clinicians often dismissed her concerns and discredited her knowledge.

Such feelings are far too common: The concerns of frustrated patients, worried patients, anxious spouses, nervous nurses and uneasy residents too often go unheard. Indeed, in approximately 90 percent of errors that cause severe harm to patients, someone knew something was wrong but either didn’t speak up or spoke up and was dismissed.

Aviation used to have the same problems. In 1982, an Air Florida plane was rolling down the runway for takeoff on an icy December evening in Washington. A scared co-pilot expressed concern seven times; each plea fell on deaf ears. The plane crashed into the 14th Street Bridge and ended up in the icy Potomac River, killing almost everyone on board. The aviation industry investigated and found a hierarchical culture in which pilots placed little value on what co-pilots had to say, often ignoring their concerns.

The same behaviors occur in health care. Too many in the field feel that formal learning—the number of years you have trained—is the only important domain of knowledge. In this hierarchy, senior attending physicians, those who typically spend the least amount of time with a patient, sit on top of the totem pole, making the medical decisions. Health care needs to recognize that patients or their parents or spouses have the tacit wisdom, from years of experience, to understand the ins and outs of a particular scenario, and that this type of wisdom can complement the physician’s wisdom. Sometimes it is even more important.

To be certain, these two types of wisdom are not mutually exclusive; patients and non-physicians also have book wisdom, and physicians also have tacit wisdom. Yet often, the hierarchies of these two forms of wisdom are reverse, with attending physicians sitting at the bottom of this totem pole, letting the patient serve as a guide to her own disease. These two sources of knowledge go hand in hand. Both are essential if we are to make wise decisions. If clinicians had listened a little more to this patient and her mother along the way, at best, the patient would have had a shorter stay. At the very least, the patient would have felt more like she was part of team, responsible for improving her health, increasing the trust in each other, ultimately improving the patient’s outcome, lowering costs, and enhancing the joy for all..

So I encourage clinicians: Ask patients what you can do to improve the care they received. If you listen, you will learn.