The Art of Listening

Reflecting on the start of my medical studies and career, I realize that it took me more than ten years to refine my ability to practice the art of listening. Partly that may have been because English is not my mother tongue; but it was also because listening is an arduous task. As Kate Murphy writes in her book You’re Not Listening: What You’re Missing & Why It Matters: “Understanding is the goal of listening, and it takes effort.”

My first hard lesson in this area occurred when I was a medical student, doing research at a needle-exchange program. A patient named Haris had been screened for HIV, and his test result was positive. He was the first patient to whom I had to give such bad news.

Without engaging in any preliminary remarks to prepare him, I told him flatly, “I’m sorry, you’ve tested positive for HIV.” A deafening silence followed.

Haris looked stunned, his face drained of color, as if he’d seen a ghost. Slowly he leaned forward, placed his elbows on his knees and clasped his hands together as if in prayer. His body was telegraphing just how upset he felt—but in my inexperience, I missed these cues. Suddenly I felt compelled to fill the vacuum of silence with medical terminology.

“It’s okay!” I said casually. “This is just a screening test.” I went on to explain the difference between screening tests and diagnostic tests, when I should have sat quietly, letting him digest the news before proceeding with the consultation and letting his responses guide its direction.

After this epic failure at reassurance, Haris nodded, mumbled, “Okay, Doc,” and walked out of the room.

I shook off an uncomfortable inner sinking feeling and moved on to the next patient, waiting outside the room. Amid this consultation, a staff member named Zaidah burst in.

“Doc, we need you upstairs now!” she said. (Although I was just a medical student, everyone called me “Doc,” as a sign of respect, I imagine.) Behind her, I heard loud, chaotic noises.

I walked up the narrow, stained concrete stairs to be greeted by several angry-looking transgender staff members. They were huddling around Haris, some soothingly massaging his shoulders. Meeting their piercing glares, I wondered desperately what could have happened.

One stood up, pointed at me and said loudly, “You told him he has HIV! And he nearly jumped out of the window!”

Silence. More silence.

Trying hard to steady my nerves, I looked at Haris, who sat wordlessly, face cupped in his trembling hands.

“Can you please come back downstairs with me so that I can rectify my mistakes?” I asked.

After a pause—no more than a few seconds, but it felt like forever—he nodded, to my intense relief. Together, we returned to the office below.

“I’m sorry for my ignorance,” I started. He nodded, then broke down, sobbing in anguish.

“It is not a death sentence, Haris,” I went on, hoping that he could hear me through his tears. “It’s a manageable disease. With treatment, you can live a normal life. With God’s mercy, maybe one day there will be a cure….”

I took my time, pouring out comforting words as he wept. He cried so hard that I could hear his pain. I finally heard him.

A doctor should provide a cure and give hope, I admonished myself, wondering, Did I just indifferently crush his hope?

“Have faith, Haris. God does not create a disease unless there is a cure,” I said, trying to shine a glimmer of hope into his anguish.

When I reported the incident to my supervisor that night, she nonchalantly told me to explain to clients that HIV patients’ life expectancy on antiretroviral therapy is similar to that of non-HIV patients. At the time, I felt a bit disappointed by her reply; now, I see that she hadn’t heard the fear behind my words—the fear that I would repeat my mistake in the future.

Although this episode alerted me to the importance of listening, it took more lessons, less dramatic but equally persuasive, to really bring the point home.

A few years later, as a new-minted primary-care physician, I was dismissive of mothers-to-be who’d beg me for additional medications to help ease their severe, intractable nausea and vomiting—a condition far worse than normal morning sickness.

The medications I’ve already prescribed them should have helped, shouldn’t they? an indignant inner voice would mutter as I quickly scribbled a prescription for a higher dose, leaving it to the nurses to manage.

I persisted in this attitude for a couple of years—until I myself became an expectant mother, succumbing to the same affliction with all three of my pregnancies. In retrospect, I feel that it was karma at work—particularly when I look back on my treatment of nausea in a mother of two whom I was admitting to the hospital for this side effect of chemotherapy.

Feeling pressured for time and seeing her case as straightforward and uncomplicated, I rushed through her admission as quickly as I could.

She was feeling crushed and fragile, running out of strength in her battle against her crippling cancer. Lying curled in a fetal position, she wept and choked out, “Help me, please. I’m a strong mother—I have always been the caretaker for my boys—but now, I just can’t do anything….I’m useless.”

As she lay there sobbing, I nodded, pretending to listen to her as my pager kept beeping. Inwardly, I was counting how many admissions I still had to get through: In that moment, she was just a number that I needed to check off my list.

I heard her, but I was not listening. I remember with painful clarity how I stood at the end of her bed, scribbling on the chart and feigning attention while glaring at the pager. It is not a memory I feel proud of.

Over time—fourteen years, to be exact—I gradually came to appreciate the wisdom in the words of the Stoic philosopher Epictetus: “Nature hath given men one tongue but two ears, that we may hear from others twice as much as we speak.”

After many challenging moments and much trial and error, I finally feel comfortable with listening to my patients in silence—and I’m glad of the many profound ways I can communicate with my patients without words. This is not at all to say that I’ve reached perfection, but I do feel grateful for my progress.

Last week, a patient came in feeling distraught about various stresses in his life. Our time together mainly consisted of his breaking down in tears, with very few words spoken.

When our eyes met, I just offered him a cup of coffee.

That was enough to call forth a smile. For what it was worth, we both knew that I’d meant to comfort him; and that no words were necessary.