Please Hear What I'm Not Saying: The Art of Listening in the Clinical Encounter.

Introduction Near the end of Anne Fadiman’s book, The Spirit Catches You and You Fall Down, a tragic account of two cultures at odds with each other, the author tells the story of a Hmong patient who was being referred to a specialist for further treatment and, instead of inquiring about the physician’s skill or credentials, he asked, “Do you know someone who would care for me and love me?” It is an honest question that bears asking, and yet within its naked simplicity lies the deepest complexity. It is not the type of question one responds to quickly or without reservation, but it is one that deserves a thoughtful answer. It would not be incorrect to assume that beneath our own culture’s fiercely held value of independence lies the very same question, for when all is said and done, isn’t this what every person desires? Unfortunately, the trajectory of medicine’s increasingly one-sided focus on science and technology over the humanities has created an ever-widening gap between physicians and patients, resulting in decreased trust and confidence in a relationship that needs and depends on it the most. “The price for a technologically sophisticated medicine,” says physician Rita Charon, MD, “seems to be impersonal, calculating treatment from revolving sets of specialists who, because they are consumed with the scientific elements in health care, seem divided from the ordinary human experiences that surround pain, suffering, and dying ... Patients long for doctors who comprehend what they go through and who, as a result, stay the course with them through their illnesses. A medicine practiced without a genuine and obligating awareness of what patients go through may fulfill its technical goals, but it is an empty medicine, or, at best, half a medicine ....” 2p6 Given these upsetting developments, the physician still remains a symbol of hope in a patient’s search for relief from pain and suffering. The singularity of the clinician-patient relationship is what sets it apart, for it is the primary conduit by which all else follows. Characterized by a level of physical and emotional intimacy not found outside of the romantic relationship, the clinician-patient relationship connects the experience of illness with narrative meaning powerful enough to affect a patient’s course of treatment and quality of life far beyond what one would imagine, oftentimes standing at the center of our most taxing bioethical dilemmas. Intimacy Without Intimacy The clinician-patient dyad forms a relationship that is as unique as it is powerful, as rewarding as it is demanding. It is an intersubjective space fraught with many variables, and the vagaries brought on by illness and the potential chronicity thereof significantly heighten the stakes of such intersubjectivity, for the disruption of one’s health and well-being and its accompanying fears and anxieties pose special requirements, obligations and demands that do not exist in other relationships. The vulnerability of a patient who sits nearly naked under the glare of fluorescent ceiling lights as s/he waits to reveal details of a highly personal nature is such a repetitive scene that it’s often taken for granted or overlooked by clinicians, and yet herein lays the paradox of intimacy without intimacy in the clinical encounter. The exposure of a patient’s underbelly for the sake of a cure, of redemption, an ease of suffering, or simply a listening ear has traditionally been met with the stance of professional distance, resulting in a relationship of disappointment and compromise, wherein trust is easily breached and suffering is heightened. Yet it is in this very exposure and the intimacy it engenders that an accurate diagnosis and healing lie, for vulnerability is transparency in its purest form.