DGIM Generally Speaking

Bit of Balint

By: Karen Carlson, MD

“If the doctor asks questions in the manner of medical history-taking, he will always get answers—but hardly anything more. Before he can arrive at what we called deeper diagnosis, he has to learn to listen….”
- Dr. Michael Balint. The Doctor, His Patient, and the Illness, 1954.

How can we listen to our patients? We all want to be good listeners because we know that making the right diagnosis requires it. But competing demands make it difficult to hear a patient’s story: the need to record information as well as listen, examine, order tests and treatments, and develop a plan of action, all under enormous pressure of time. 

One of the biggest challenges we’ve faced in the past two years is learning how to capture a patient’s story in EPIC. The solution of using checkboxes for medical history-taking, while helpful for simple problems, fails miserably in documenting the complexity that we often deal with in primary care. The movement toward scribes, both live and virtual, has grown out of the recognition of this reality. Working with a scribe has enormous potential to help us bring our attention from the computer back to the patient and her story. 

The first time I saw a patient’s history transcribed by a virtual scribe, the difference between what I typically recorded and what the patient actually said was striking. Laid plain were the patient’s worries, hopes, and attributions. Had I really been listening? It is easy to lapse into a tunneling mindset when under pressure: quickly formulate an assessment, make a plan, and move on to the next problem. Reviewing the patient’s own words helped me to see aspects of the story that I might have overlooked. It invited me to step back and think about what was really going on. 

Looking at a patient’s story from a different angle is part of the work of a Balint group. By hearing about each other’s challenging cases and exploring different perspectives on what is going on, we hone the faculty of listening – to the patient, and to ourselves. Let’s hope the greater use of scribes will help us reclaim some time and space to listen, and in so doing, to strengthen the clinician-patient relationship.

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Interested in finding out more about Balint groups? There is an ongoing on-campus group and growing interest among clinicians at off-campus practices. Please contact Karen Carlson (Carlson.Karen@mgh.harvard.edu) for more information.

Read more articles from the Winter 2018 edition of Generally Speaking