Listening

A PEDIATRICIAN WITH AN INTEREST in children's behavioral problems recently asked me why child psychiatrists so adamantly refuse to physically examine their patients and why this seems to be the norm. There is a 60-year history for this practice, but do the reasons still apply?

When psychoanalysis dominated psychiatry, the rationale was that such contact with a patient distorted the displacement and projection known as the "transference," an essential element of psychoanalytic treatment. Although there were questions about the "transference" in children, the physical examination asserted a dominance thought to unduly complicate the treatment.

There was also an economic rationale. Patients would be paying more for a physical examination by someone less experienced in physical medicine, leaving less time for the unique skills of attentive listening and observation and measured and targeted responses.

Even when psychoanalysis lost dominance to behavioral and cognitive therapies, and pharmacotherpay became part of psychiatric practice, the equation favored paying for listening and attention skills and not squandering efforts on what others could do better at less cost.

In my own child psychiatry practice, I preferred collaborating with the child's primary care physician throughout my evaluation and treatment. That was especially true if the child had a chronic physical condition, like asthma or diabetes. The child's primary care physician and I would supplement each other's observations.

Today, most pediatric involvement in psychiatry involves a differential diagnosis that includes Attention Deficit Disorder, for which the treatment of choice is likely to be a drug. If there is depression or anxiety, the treatment is also likely to be a drug. Medication regimes are more effective if supplemented with ventilation, guidance and behavioral, cognitive or other therapy — but cost controls dictate medications alone. Thus the psychiatrist acts more as an authority on medication than on listening and observing.

If the psychiatrist does not listen for the transference, or for relationships with family or friends, at school or play, why not examine the child physically? Psychiatric residents learn how to scan with "the third ear," how to lead to greater disclosure, but they also learn that they will have to jettison this "luxury" in the interest of a fiscally sound practice. Economics has defined clinical quality.

Patients, too, have learned. They bring in a list of symptoms and a list of expected treatments. Patients used to come to doctors, not only psychiatrists, with a meandering story of their illness, a cathartic revelation of what they thought and felt about their illness. Surveys show that patients still want that, but believe their doctors don't.

The same surveys show that doctors do indeed want to get to "the facts" quickly, without the time-consuming "nonsense" of listening and translating the patient's illness story. The surveys identify this lack of listening as a major source of patient dissatisfaction with their doctors.

Cultures have long known that sharing our stories is essential to establishing our sense of family and community. They have established rituals thought to protect and enhance listening.

The By-Laws of the Sacramento Medical Society, adopted September 1855, called for "a decorous silence" after the meeting is organized, "the officers and members retaining their respective seats." A member was required to stand when speaking, to "address himself to the presiding officer, and never consume more than fifteen minutes in his remarks, not speak more than twice on any one subject, except by permission of a majority of voters present." The speaker was also protected from interruption, "except by a call to order for the purpose of explanation."

In some Amerindian tribes, the tribal council requires a proponent of an action to present the pro story as fully as desired, without interruption. After a respectful silence, to be sure the speaker is finished, an opponent presents the con argument, again fully and without interruption. After a silence, the pattern continues until everyone who wishes to speak has been heard. The eldest thanks everyone for speaking and listening, summarizes their positions and announces a decision that is binding until the next council meeting.

Such uninterrupted listening may enhance professional relationships and patient treatment, but it is costly. It also imposes on the doctor the onerous burden of protecting the patient's "secret" — which becomes more difficult in a large, leaky health care delivery system hungry for patient information with sales potential.

Each of us must decide whether protecting patient privacy is worth the cost. Remember the anecdote about one psychiatrist who favored psychotherapy and another who favored pharmacotherapy. At the end of the day, the psychotherapist was glassy-eyed and drooping; his colleague bright-eyed, cheerful and whistling.

The talk-therapist asked how his colleague could listen to the day-long litany of gloomy stories and be so cheerful at the end of the day.

"Who listens?" was the answer.

edrudin@aol.com