An anonymous patient explains how her GP used shared decision making to help her manage her distress. Quiet listening can empower patients to lead conversations about their own care, she says, but is threatened by the effects of COVID-19, including more triage, remote care, and burnout among GPs
This is an edited version of an article that originally appeared on The BMJ
Creating quiet spaces
How might quiet listening fit with active listening, often taught to students in medical school? Instead of an emphasis on listening with fascination, quiet listening is more about empathy in practice, about quiet spaces in conversations.
I am both a carer and a patient. Often my GP and I discussed both in the same consultation. Moving between the two conversations can be jarring for me—“How is your husband?” “Ah, it’s been an interesting few weeks. He’s broken his arm, his leg, and been hospitalised for two major internal bleeds.” “Shall I examine that lump under your arm now?” This was a single conversation, but my GP paused after discussing my husband and watched me. My head was down, my eyes at the floor. When my body language told her I was ready—when I lifted my head, and looked at her—she smiled and asked if I was ready to be examined. It’s subtle, but important, this ability to create quiet spaces within a consultation.
With an emphasis on patient activation, which focuses on what you can do, it can be hard to find space for conversations about what you can’t do. Quiet listening makes space to speak about worrying that you can’t feed your children properly, not being able to buy their shoes, not having money to pay for a funeral. These are some of the things that distressed me the most. The Dutch anthropologist Annemarie Mol points out that care “makes space for what is not possible.” Quiet listening is an important part of this.
Continuity of care
A doctor who I trust, and who knows me well, is crucial in enabling quiet listening and to leading conversations about my own care. Seeing the same doctor over time also means that I don’t have to repeat my story to multiple, different doctors. Once is enough; some things are not fun to talk about. Seeing the same GP over time has a survival advantage similar to many drugs and complex interventions, evidence shows; high relational continuity is associated with lower mortality, better self-management of long term conditions, and fewer admissions to hospital.
The same GP can notice changes that would not be obvious to a doctor who doesn’t know me. I’m prone to ironic humour and making inappropriate jokes, for example, even about what was happening to me then. If I stop doing this, I’m in trouble. Losing my sense of humour indicates seriously deteriorating mental health. A GP who didn’t know me well couldn’t read that.
Since the pandemic quiet listening and relationship-based care have, arguably, become even more important, particularly for more than a million people in the UK with long COVID and those whose conditions have deteriorated while they have been unable to get treatment and care – including five million patients stuck on long waiting lists for hospital treatment in England.
Remote care and the future of quiet listening
At the same time, COVID-19 could have long term effects on the ability of GPs to offer quiet listening and face-to-face care to patients. In the acute phase of the pandemic NHS England was right to out in place remote ‘total triage’ and a shift towards remote consulting to protect patients and NHS staff – but what might be lost with this model, and with what unintended costs?
With so much recent concern about rising numbers of appointments, and demand on general practices, have we thought carefully enough about the risk of telephone triage adding to clinicians’ workload through duplication, for which there is good evidence?
We cannot assume remote care is the best option for most patients in the long term. Early evaluation of ‘remote by default’ care finds over-protocolised general practice can come with risk. Case-based judgment is needed to decide if remote consultation is best for a particular patient at a particular time. Complexity in primary care consultations include, for example, ‘doorknob disclosures’, when patients mention something crucial as they are leaving, and early detection of cancer through clinical intuition and timely investigation. In lung cancer, for example, clinicians believe face-to-face appointments are the best option for most purposes, especially breaking bad news.
Positioning remote care as the norm from which the traditional face-to-face consultation would deviate sits uncomfortably; decisions should be guided by evidence on the benefits, as well as possible unintended harms.
Alongside this, we should be careful not to take for granted the benefits of care that might be deemed ‘old fashioned’ by some. I never set out to find a GP whose talent was quiet listening and relationship-based care. I didn’t know I’d need her. It was pure luck that, when I needed a GP who offered this kind of care, I had one. In an age of machine learning and techno-optimism, the artful skill of quiet listening can easily be undervalued – but it makes a crucial difference to the quality of patient care and to value for the NHS.
The challenge ahead for general practice
General practice is now at a crossroads. Demand for appointments is rising, as is concern about the harms to GPs through the ‘moral injury’ that comes from being unable to provide the kind of care they believe that patients need.
We previously sought to find practical ways to provide continuity alongside better access to primary care. Now we need thinking that allows general practice to harness the benefits of remote consultations while holding on to the value to patients, and to clinicians, inherent in relationship-based care and quiet listening.
One starting point may be the realisation of National Voices’ vision for inclusive and personalised care.