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Podcast Episode 022: Dr Michael Buist describes the impact of limited listening training in the medical profession

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Not listening creates a huge cost to the medical system. Dr. Michael Buist is here today, to talk about that cost and the importance of listening in a medical setting. Dr. Michael Buist is a full time academic physician and intensive care specialist. He is a graduate of Otago Medical School in New Zealand (MB ChB 1983) and completed specialist training with the Royal Australasian College of Physicians in intensive care medicine (FRACP 1991, FCICM 2010).

In 2007, he graduated Doctor of Medicine with the submission of his thesis to Monash University; The epidemiology and prevention of in hospital cardiac arrests. He also has a graduate certificate in health economics from Monash University (2001). He is a Honorary Clinical Professor, Faculty of Health, University of Tasmania. In addition he undertakes private physician clinics in a community general practice in Wynyard, Tasmania and is a clinical coordinator for Ambulance Tasmania.

His academic contributions (80 peer review publications) are in the areas of health reform, evidence-based approaches to improving hospital systems and processes, and clinical engagement, on contemporary issues related to patient safety and patient centred care.

He has made significant contributions to patient safety that has had a substantial positive impact on hospitals, clinicians and communities nationally and internationally. This is best exemplified by his two publications on Rapid Response Systems in the British Medical Journal (2002 and 2007) and the Lancet (2005). Professor Buist has been a passionate and public advocate for health system quality and reform with a particular focus on patient safety.

In this episode, Dr Michael Buist describes the impact of limited listening training in the medical profession. Michael outlines the personal cost to him and his wife of not being heard whilst they were patients in hospital and the systemic implications across the medical and public sector which provides most of the funding to health care.

Tune in to Learn

  • How Michael is passionate about the role of listening in a medical context.
  • Michael’s athletic coach taught him how to listen with his own body to notice the congruence of what is being said and what the body is showing.
  • How the most important thing that can be changed in the medical profession is reforming the listening between patient and caregiver which takes place at the bedside.
  • The nuances of listening and observing children who are faced with life and death issues.
  • Michael shares powerful personal stories about life, death, and himself and his own family. These stories accentuate Michael’s passion for listening.
  • Transforming 21st century medicine to patient centered medicine.
  • Assuming that people are listening and not teaching people to listen well.
  • How not listening can lead to adverse medical events. Patients need to be listened to.
  • How patients who don’t have doctorates and aren’t highly educated get ignored.
  • The problem with healthcare is too based on how the healthcare system runs as opposed to patient centric care.
  • Asking what was the best part of your day instead of saying how is your day. Listening is about conversation.
  • When there is an equivalent level of verbal questions and listening that goes both ways people are hitting it off.
  • Teaching students to ask thoughtful questions from a medical perspective.
  • The power of exploring what is unsaid.
  • How a UK hospital had a culture of substandard care. A woman blew the whistle on the hospital on how her mother was treated there.
  • They found that the right culture needs to be created at the bedside, and a big part of that culture is just listening to patients.
  • Patients need to be treated as human beings who do understand their bodies.

Transcript

Episode 22: Deep Listening with Michael Buist

Oscar Trimboli:

Deep Listening, Impact Beyond Words.

Michael Buist:  

My wife was pregnant with our daughter Hannah, at about 26 or 27 weeks, and basically, she said to me the baby’s not moving. Went to the obstetrician, said the baby’s not moving. The obstetrician said no, you’re making it up, or get an ultrasound. The ultrasound guy looked at us for 15 minutes, baby’s not moving, but he just said it’s a lazy baby. Next morning my, Sarah says to me the baby’s not moving, we’re going to be burying this baby.

I ran into the obstetrician the day before and said I’ve spoken to my brother who is an obstetrician in Sydney, and we’re not happy with this. She said but it sort of doesn’t matter because if we deliver the baby it might be a high chance it might be impaired. We said we were prepared to take that chance, but she said no, I want to wait.

Then the next day, Sarah had a stillborn baby, so she was really cross, and I was really cross, but that we were just not listened to. She was saying this was the case, and we would have looked after a disabled baby if that’d been the case. We’re relatively well-off in the community. That was huge, just a huge thing that struck me and struck Sarah, that she just was not listened to. I get that all the time from patients, when they say something was wrong, and no one listened to me.

I’m sure that anyone who’s had anything to do with the hospitals and healthcare and doctors will have the same issue. Thankfully it usually doesn’t resolve in as bad an adverse event outcome as what we had.

Oscar Trimboli:

In this episode of Deep listening, I have the opportunity to speak to a doctor. Michael’s travelled from New Zealand to Australia, and is equally passionate about the role of listening in the medical context. Listen how during this interview as he talks about his best athletics coach who taught him how to listen to his own body, and how his coach listened carefully to him, to listen to the congruency between what’s being said and what the body’s showing. This helped inform Michael’s later work as a medical practitioner.

Listen carefully for Steve, the baby whisperer, as Michael says the most important thing that can be changed in the medical profession is the reform at the bedside between the patient the doctor the nurse and the family. He talks about the fact that Steve had a cat-like observation of the nuances in the most infant children dealing with life and death issues, and making sure that interventions were timed appropriately based on listening and observation.

Michael shares some very powerful personal stories, stories about life, stories about death, stories about himself and his own family, and you can see why he’s passionate about the power of listening, and why it’s required to transform the medical profession in the 21st century to patient centred medicine, rather than medicine centred patienting.

Let’s listen to Michael.

Oscar Trimboli:

When you were growing up, was there a teacher or a parent or an auntie or an uncle or maybe one of your siblings that taught you a really interesting lesson about listening?

Michael Buist:  

I think one of the things, I actually ran marathons for New Zealand University, and one of the things that was really important was trying to listen to your body. This was back in the days when we didn’t have much in the way of sophisticated training tomes. It was all about trying to listen to your body and do that, and in an effective way so you could train more efficiently.

I have to say that it’s interesting that you should ask me that question because I’ve only really come to thinking about listening very late in life. I can’t really, I don’t have any strong memories of people that listened, other than my running coach who was very good at listening and taking in what we had to say about how we were going.

Oscar Trimboli:

Looking back at your running coach now, what do you notice that he was doing really well in listening to you and the others?

Michael Buist:

He had to take action based on what we said, and there’s a fine line between listening in terms of I’m tired, I need this workout to end, as opposed to I’m overtired, and if I do finish this workout it’s going to damage me. That’s a very fine line with coaching because the coaches who get that distinction right of course train better athletes. Being able to listen, and it’s often sometimes not the words that are said, it’s the nonverbal cues that you put out, that listening to me is a lot about just not listening to words, it’s sort of taking in the whole environment and what’s happening.

Oscar Trimboli:

What do you think those visual elements and non-visual elements of listening that coach was doing really well beyond hearing people like yourself complain that they were really tired and they couldn’t really do another speed session?

Michael Buist:  

I think it’s body language. It’s looking at the body language and seeing what the body language is that’s congruent with the words that are being said. I think it’s a hard thing to pick up. You mentioned the business about listening in relationships, often that’s looking at how the body language is as opposed to the words that are being said.

Oscar Trimboli:

Very true. Michael, at university what were you studying?

Michael Buist:  

It’s a very long story, but essentially, I finished my undergraduate medical degree, and then worked as a house surgeon, and then worked as a medical registrar and intensive care registrar in Hamilton. Then had to finish my specialist training, so I went across to Adelaide Children’s Hospital, where I did an 18-month stint in paediatric intensive care. That was where I met a great sort of like a dog whisperer type of character, a chap called Steve Keeley, who was a very alternative lifestyle person who worked as one of the intensive care specialists, and he just had this unusual knack of being able to relate to babies, and just calm them down and to understand them. He was the one that said to me that kids and babies are so different to adults, they can’t tell you what’s going on. He would just say you’ve got to sit there at the end of the bed and just spend time, you’ve got to spend that time just sitting there watching them, feeling them, and just seeing how they’re going along.

I took what he was saying with the great listeners you had in the family and the university, Steve was the first one that sort of got me thinking that you’ve got to actually spend time, you’ve got to spend time at the bedside understanding and getting a feel like the running, the body language. You just can’t pick up on body language in a quick interchange with a person or a patient. Steve was the first one that said you spend time not at the computer, at the main doctor’s terminal, you spend the time out there sitting with the patients and just observing them, and that’s how you learn.

Oscar Trimboli:

What do you think he was watching for at the edge of that bed looking at these babies who were struggling to tell people what was wrong with them?

Michael Buist:  

He was looking, intensive care is the specialty of cat-like observation and timely intervention. Whenever we’d do interventions in critical care, that could potentially damage the patient. If we put a patient on a mechanical ventilator they look as if their lifesaving on TV and it looks very dramatic, but that intervention of having to anaesthetise anyone to get the breathing tube into the lungs and then put them onto a mechanical ventilator, the data shows that it’s damaging.

It’s a bit little like the running coach. You want to be able to time your intervention to when it needs to be done, and when it can be done in a safe and competent fashion. That’s just sort of that clinical intuition, and Steve would just say that you develop that clinical intuition at the bedside just by looking, sitting, talking to the mother, seeing what the mother says, seeing how worried people are and just getting a feel in your own mind as to whether or not the situation’s improving with the treatment you’re giving, or if the treatment you’re giving is not doing the trick and you might have to do something else.

Martin Mackay:                 

Oscar has identified the critical skill executives need to lead effectively, but is often forgotten in a world where our attention span is defined by 140 characters. Deep listening creates trust and authentic action for leaders at all levels, and is crucial for the development and retention of talent. This is a highly valuable book.

Oscar Trimboli:

Thinking back to your university lecturers, I’m curious about the multiple lectures you would have had on listening, and the fact that like most medical students you had no lectures on listening, in fact none of us go to school or university and have any kind of lectures on any kind of listening. What’s your wish for future students in this intuition to be brought back into the education system of future doctors?

Michael Buist:  

The problem with listening is that we all are saying that people can listen, is this assumption that that’s something that we can do. Then you clearly make a living on the fact that we don’t. I completely agree with that in a medical context, that we don’t teach people to listen. There’s two things. They don’t listen, but we assume that they listen, and as such we don’t teach them how to listen. One of my, a couple of my publications this year revolve around the fact that you have to take the students to the bedside, ask them to take a history from a patient, and then essentially almost sentence by sentence analyse and feed back to the students on what’s being said and what’s not being listened to.

More often than not you find that the patients try to give clues to the students or junior doctors that are of relevance, but time and time again you often see very important information being ignored by the students. They ignore it because it’s not part of the checklist. We have this idea, and the students have this idea that you can follow a checklist and take a medical history, and that they’ll pass whatever test or examination they have as long as they tick off the issues or the matters on the checklist.

If the patient brings something out of left field, like a result of a CT scan, I had a CT scan yesterday and it showed that I’ve got lung cancer, to the student that might be totally irrelevant on how they need to progress through their checklist. Disconcertingly at medical school now we by and large pass our medical students based on doing short activities. I’m in a test called an OSKEE, which is objective structured clinical examination where the students get broken down, but it’s an examination, physical examination or history taking or laboratory interpretation or tasks down to five minute tasks, and each of those tasks is often broken down to 20 points.

I’ve taken you rather quickly through this what I think is a systemic problem, and that you’ve got a culture of social media, you’ve got this inherent belief that we listen, and we have a university examination system of medical school throughout Australia that we don’t need to test your listening and intuition, we’ll just test you on these OSKEE stations, and that’s how we’re producing our doctors.

Oscar Trimboli:

Michael, if you had a wish and I could grant it, what would it be for the one thing that you could implement into either the medical system or the training of doctors that you think could make the biggest impact, and what do you think the cost of not listening is today for patients for governments who fund medical systems and beyond?

Michael Buist:  

Firstly, I would bring back the long case as a summative assessment. As students before they graduate to be a doctor should be assessed on their ability to sit down with a patient over at least 30 minutes, and take a history which is asking questions and listening to what the patient says, and perform a physical examination and then put all that information together. That’s the one thing. I would not graduate people if they could not do that to an appropriate standard. That’s the way I had to pass my, graduate when I graduated in 1983. There’s various reasons why that’s gone, but if you’re asking for the wish I would say that that would need to come up. That would force the students, they’d have to go out like when I was talking about Steve Keeley, he said you’ve got to get away from the computer, get away from the doctor station, and go out and sit there with the patients, so there’s that constant, there’s that thing that I’m talking about.

Trying to measure the cost, before we went online Oscar, you mentioned the Staffordshire enquiry, a big part of my research has been patient safety and what goes wrong in hospitals. There is no doubt that at an individual level, when I look at adverse events where I work and I’ve even had medical adverse events myself as has my wife, and there’s been an Australian story about that, and both of our adverse events the situation was quite simply that we were not listened to.

We’re intelligent, we know what’s going on, and we were not listened to. God knows what it’s like for other patients who don’t have doctorates and doctors, and who are highly educated. They just get ignored.

Oscar Trimboli:

For those of us who maybe are listening and haven’t had a chance to hear about the Australian story and your family examples, I think it’d be a great opportunity to share that with our listeners.

Michael Buist:  

Just briefly back in 2008, my wife was pregnant with our daughter Hannah, at about 26 or 27 weeks, and basically, she said to me the baby’s not moving. Went to the obstetrician, said the baby’s not moving. The obstetrician said no, you’re making it up, or get an ultrasound. The ultrasound guy looked at us 15 minutes, baby’s not moving, he just said it’s a lazy baby. Next morning my Sarah says to me the baby’s not moving, we’re going to be burying this baby.

I ran into the obstetrician the day before and said I’ve spoken to my brother who is an obstetrician in Sydney, and we’re not happy with this. She said but it sort of doesn’t matter because if we deliver the baby it might be a high chance it might be impaired. We said we were prepared to take that chance, but she said no, we just wait.

Then the next day, Sara had a stillborn baby, so she was really cross, and I was really cross, but that we were just not listened to. She was saying this was the case, and we would have looked after a disabled baby if that’d been the case. We’re relatively well-off in the community. That was huge, just a huge thing that struck me and struck Sarah, that she just was not listened to. I get that all the time from patients, when they say something was wrong, and no one listened to me.

I’m sure that anyone who’s had anything to do with the hospitals and healthcare and doctors will have the same issue. Thankfully it usually doesn’t resolve in as bad an adverse event outcome as what we had.

Then three months later, I’m actually having a laparoscopic vasectomy, and it’s a long-complicated miracle story, but briefly I was bleeding after the event, and I was assessed by a system of care called the medical emergency team, who said no, you’re having an acute myocardial infarction. I said no I’m not, I’m a former athlete, as we’ve just been talking about, I haven’t got chest pain, the ECG you’re looking at is unchanged from the one than I use for tutorials, but again not listened to. I was sent to the cardiac catheter lab and given anticoagulants, and essentially nearly bled to death until I said you’ve got to take me back to the operating theatre.

I had to use the forcing function to be listened to. I had to use the F word, you know, get the effing surgeon. With that, the use of that forcing function, the staff listened to me, rang the surgeon, and when they opened me up I had about three litres of blood in my belly. So, to me, again, not listened to. It was rather dramatic to me.

After 2008, I thought from now on I am just going to spend time with students teaching them how to listen, and that’s how I’ve come about the research and publications with publishers here, teaching students to listen and getting them to focus on that, focus on the real issues that the patients say.

Oscar Trimboli:

Michael, thanks for sharing that story. I’m sorry for your loss.

Michael Buist:  

Thank you.

Oscar Trimboli:

It makes the cost quite real, and when you multiply that by the number of patients that move through the medical system, I can hear many doctors saying that you don’t understand the pressures we’re under, and the funding on which, and the reports that we need to create, and the outputs we’re expected to achieve, and the quality standards that we’re held to. We just don’t have time to listen Michael.

Michael Buist:  

That is just absolute rubbish. Let me give you some examples. Just recently I referred a patient, recently I was looking after a patient, and it turned out that I had to do a chest x-ray. Then there is a lung cancer, and I talked to the patient, and she said yeah, listen, I sort of knew about that two or three years ago, and I’m seeing a respiratory specialist, and I just sort of didn’t get fired up. I thought well that doesn’t sound very good. Then she said but look, I don’t really want you to do anything about that anyway.

I said are you sure? I said look, we should probably be a bit more surgeon about this, so I’m happy to do a CT scan, but I’m taking it on-board that you don’t want chemotherapy, radiotherapy, or surgery. She said all right, I’ll let you do that. I do the CT scan, it comes up with sure enough with lung cancer. I then say … The family didn’t want to get involved. The family are a little concerned that they would at least like to think that mum might have the appropriate operation query, chemo query, radiotherapy, but she’s adamant that she doesn’t want that. I say to the family, we’ll just make a compromise. Let’s just get an opinion from a respiratory specialist.

I sent her off to another specialist, a proper respiratory specialist. I’m just a general physician in this context. I say to the guy, look, she doesn’t want anything one, she doesn’t want an operation, she doesn’t want radiotherapy, she doesn’t want chemo, but the family would just like to also hear that from you. I see her the next day, I ask how’d your appointment go. She says well, to be honest, I’m not very happy. I’ve been booked on a list for a bronchoscopy, he’s ordered another special sleep study test for me, and I just want to be left alone. I know this will make me pass away, but that’s the way I want it to be.

Essentially, the traditional specialist wanted to go down the pathway of doing all the right things for the patient, which costs money, costs a lot of money in the healthcare system, and I see elderly people all the time with similar stories, they don’t want to have the chemotherapy, the radiotherapy, or the surgery in a lot of situations, and we don’t give them the options, and we don’t listen to their thoughts about this because we’re too busy to do that. We’re all very happy to spend three hours during the procedure and billing them for that, and then putting elderly people through very onerous radiotherapy and chemotherapy schedules without listening about whether or not they really want it, because we don’t have the time to listen to them for all those reasons you have just said.

If we turn that on its head and if we actually spend that time having a decent chat with the patient and the family and working out what they actually do want, and putting to them what … You know, my son’s got ADHD, and I’ve learned that I’ve got that, and the critical thing that I write about is asking the thoughtful question. The thoughtful question of these patients is do you really want to go through all of this? So many times when I ask that thoughtful question the patients are so relieved to have someone who’s on their side listening to them and advocating for what’s the best way forward.

Oscar Trimboli:

Given the effort you’ve gone to undertake the research and build this body of evidence, what are your major findings from the research?

Michael Buist:  

The main finding is that students, and there’s data and research to support this, are driven by the summative assessments. We as educationalists have failed them. If we set the goal posts to get your medical degree you have to do A, B, C, D, and E, that is exactly what the students will do. It’s not the students’ fault. It’s those of us who design the curriculum, and who have to take responsibility for that.

Oscar Trimboli:

Knowing it’s a microeconomic reform that needs to take place at the bedside, what does your research tell policy makers about that?

Michael Buist:  

I don’t think I’ve got much of a message for policymakers. I think the problem with healthcare is we’re too much into macroeconomic reform, changing how the health system looks and runs, as opposed to focusing on what I call patient centred care. We just need to look at how general practitioners are generally squeezed on their the way they’re remunerated, by virtue of the fact that we’re stuck in a model of fee for service for a lot of medical services. Sitting down and listening to a patient doesn’t get much remuneration, whereas if you don’t listen to them and take them straight to the operating theatre and do a two-hour operation, the remuneration is generous.

When we look at the work that’s being done with Safer Care Victoria, look at the work with Francis’ report out of Mid Staffordshire, time and time again we say that it’s how those things operate at that microeconomic level where we have a failure in the culture at the workplace, for lack of a better word, that leads to these poor outcomes. No one has really grappled with the situation that it’s micro-economic reform that we need to have. I’m sort of like a sole voice in the wilderness, not being listened to.

Oscar Trimboli:

The irony is not lost. The irony is not lost on me at all. Michael, are there other cultures or countries that are getting this right?

Michael Buist:  

It was interesting, I spoke at the Ramsey Health Conference, it was up in Brisbane. Again, it’s lovely when these people invite me. I donate my speaker fees. The woman who was on before me, I can’t remember her surname, was Jane, who is CEO of Jet Star. She spoke a lot about the culture with aviation, which struck me in how it’s changed. I thought it was a very patient customer focused and also worker focused environment that they strive for everyday on every flight. One of the things that example that she mentioned was that when is a potential problem or adverse event the pilots stand themselves down. When this problem is solved, I’ll go back to flying, but then the organisation supports the pilot, supports the system, look at what went wrong, fix the problem, and they turn that around in two weeks.

For health to do that would just be… I think if your listeners are in health they’ll know exactly what I’m saying. I think we can, there are cultures where we see that working really well. I’d have to say listening to the CEO of Jet Star clearly that’s something that they strive for and continue to work to a higher level with.

Oscar Trimboli: 

Michael, if we think about the main pillars of your research findings, are there any others you’d like to share with our audience about the importance of listening?

Michael Buist:  

It was interesting when you said at the very start that you can improve your personal relationships. I often say at the end of my talks, I try to give the audience something to go away with, that there’s something that they can do now to improve what they’re doing in their organisations, and I jokingly say it will also apply in your personal life. I say just try this.

Just go home and say to your partner, wife, husband, boyfriend, girlfriend, whatever, child, and just ask them a thoughtful question, and listen to what they have to say. Rather than saying how was your day, and getting the response fine, and then you can go and watch the TV, why don’t you ask what was the best part of your day? Then the respondent has to give more than one word and more than one sentence. Then you can ask what was the worst part of your day. Before you know it, you’re actually having, because listening is about conversation, it’s about I often try to in my tutorials with the students say and I’ve got a lot of this in this interview, I’ve been the one who’s been mouthing on, I haven’t been listening to what you’ve said very much at all, Oscar, and we know that when you’re dating that such people are quite boring.

We also know that when you are the one, you know they’re quite boring, but you know when you’re sort of hitting it off when there’s an equivalent level of verbal communication and listening that goes both ways. Ask a thoughtful question and listen.

Oscar Trimboli:

I’m curious how those thoughtful questions translate in the context of your tutorials, and I’m just wondering what are the characteristics that you teach these students about thoughtful questions from a medical perspective.

Michael Buist:  

I think the first thing is often when we’re giving a medical interview or taking a history it’s quite didactic and checklist. I think if someone has to use the example, the fictitious example of someone having the lung cancer, asking the patient how they feel about that, what do you really think about this, they can often give you very early and useful information about potential therapeutic strategies. When you think about it, all of us think, have thought, I’m not saying we’re all depressed, but all of us have thought somehow about how our lives might end. When you sort of pop the question or statement that there’s a lung cancer, often it’s interesting that the patients might say yeah, I’ve always thought that there might be something like that, and I’ve already thought through how I want you to manage this, doctor. You know what I mean? It’s a case of using the listening to get on the level with the real person. It’s why I use the dating analogy.

If you actually listen carefully and then respond carefully they can very quickly get onto a level with the patient that really has you thinking about what does this person really want, what do they understand, how can I help them, and where do we go from here.

Oscar Trimboli:                  

Exploring what’s unsaid is quite often the most powerful thing my clients say to me makes the difference in their listening. How do you help your students or how do you yourself explore what the patient isn’t saying?

Michael Buist:  

It’s those clues, and I’ve cited a few of the researchers looking for the clues and keeping your mind open for the clue. I don’t know if you’re a rugby fan, Oscar, but often in the days that I played rugby you scored tries, and because there were big gaps in the defence and you just ran through them. In this day and age defence is so well organised that you’ve got to make and build on half breaks, half breaks, half breaks, and then you score a try. We love it when there’s those beautiful bits of free-running rugby that result in tries, but history taking is like modern rugby. You get a bit of a half clue from the patient, and you’ve got to follow-up on that clue, and then follow-up on the next clue they give you. It’s a case of being like a detective. The patients often only give out half clues. The disturbing thing I find is they all too often, and we can do it so easily, it’s that the half clue is shut down or ignored by the student doctor or the junior doctor, or even the senior doctor. It’s just dismissed as not relevant.

Although often the patients don’t know really what they’re talking about, they’re not that stupid either. They offer up the half clue, the half break. The art of listening is to be able to say well, they’ve mentioned that. Just how is that relevant? Maybe I need to ask another thoughtful question, and then you might get another response from the patient and it doesn’t still add up. What I try to say to the students is that if it doesn’t add up, still stay with it. Pursue the issue.

Oscar Trimboli:

Michael, take us to the bedside, and help our listeners come to a place where you’re in front of that patient. What does a half clue sound like?

Michael Buist:  

To me I think I’m quite… First of all, the half clue as you said before is often the thing that is not said, and often it might be things that are said right at the end of the consultation, the by the way doctor, I’ve got this problem. Of course, because you’re now out of consult time, and you’ve got the next patient or patients waiting, you just sort of totally dismiss that or say we’ll talk about that next time.

The first thing, one of my main strategies, is to try and maintain a normal friendly conversation with the patients, keep it informal. Try and be on the lookout for clues. I think if we teach people to look out for the half clue, half break, and then jump on it we’ll follow it up. How it looks is that it’s often unsaid things. Often the patients offer up quite a substantial bit of bait, or often it’s more than a clue, often it’s barn door that’s what disturbs me. It’s that when we look at adverse events, often when go back through them it’s not a clue that the patients were putting up, it was an open barn door and it just got ignored. It’s not so much about a doctor being clever, or clever at listening, as they’re not shutting out information they’ve been given and hearing it as irrelevant.

Often patients will say, I’ll give you an example, we’ll stick with lung cancer. I say to a second year medical student, you say why did you come into hospital? I needed to come up because I had a CT scan yesterday. Then the student will go on with other questions, and I’ll stop them and say okay, the patient had a CT yesterday, why did you not ask them if they knew the result of the CT. Eh, because I didn’t think to. Well, ask the patient do they know the result of the CT scan.

Student asks the patient, what was the result of the CT scan. Then often the patients have been told quite quickly after the CT scan what the result is. The CT scan result could be that they had lung cancer. If the student had naturally followed up when the patient said why did you come here, I come here for a CT scan, now you or I might think it’s totally reasonable that we should then say do you know the result, or has anyone explained to you what’s going on with that. I kid you not that more than half the students that I would look at would just go on to the next question, and totally ignore that clue that the patient had a Ct scan yesterday. That is because they view it as cheating, that if I ask the patient if they know the diagnosis as students, that it’s cheating to go all the way and get the answer so early on in the consultation.

I say no, that’s fine. If you get the answer that they’ve got lung cancer, you can then escalate the level of conversation to one that relates more to how you feel about this, what would you like done about it, what do your loved ones think about it, you can get onto a more meaningful level.

If you look at all the inquiries into adverse events, it boils down to poor culture. Often that poor culture revolved around a lack of respect. When you have lack of respect, you don’t listen. There’s and I’ll get back to our dinner table back in New Zealand just to sort of close the loop on all this, and everyone has had way too much to drink, everyone’s actually really having a good time, but we’re all just mouthing off, and no one’s really listening.

I sometimes think hospitals are a bit like that, and I think about Steve Keeley and the way he would just spend that time just sitting there doing nothing, just taking it all in. We need to reteach that.

Oscar Trimboli:

Michael, as we come to the conclusion, one of the things I’d love you to help our audience understand, you’ve referenced Mid Staffordshire a couple times in the dialogue, and most people probably aren’t familiar with the systemic issues that happened in that healthcare system, and the huge costs. Could you draw a line and help the audience understand what were the findings of the inquiry in the UK in this area health service, and what’s actually changed since the findings?

Michael Buist:  

Mid Staffordshire was about a trust hospital in the United Kingdom that eventually it was found to have a culture of bullying, substandard care, and poor patient outcomes. Now the interesting thing is that Mid Staffordshire was what was called a Foundation Trust Hospital, so it was considered by all the measures that we look at hospital systems to be a high-preforming hospital, and so they were allowed to operate somewhat independently. All of this would have gone unchecked if it wasn’t for some one woman who I had the pleasure of speaking after just before a conference called Risky Business in London, a couple years ago, who blew the whistle on the fact that her mother died there, and she was really unhappy not only with the way her mother was treated, but the fact that she repeatedly wrote to the hospital, she repeatedly wrote to members of Parliament, she repeatedly wrote to the minister for health, and essentially no one responded, listened, or did anything about it.

My take on all of that, and bearing in mind we’d just had the Baker’s Marsh issues in Victoria, that we keep seeing these students of these inquires like myself, we keep seeing them, and that is because the government and healthcare systems undertake macroeconomic reform, and we need to spend more time doing microeconomic reform, which is spending that time with the junior doctors, junior nurses, creating the right culture at the bedside, and big part of that culture is just listening to the patients, patient centred care.

I’d just like to reiterate, well, I haven’t said this enough, I think that we treat our patients as human beings that do understand their bodies, they’re not stupid, and they often have something sensible to say, and we should be listening to what they have to say.

Oscar Trimboli:

What a great place to finish, Michael, thank you.

Michael Buist:  

My pleasure.

Oscar Trimboli:

I’m not sure about you, but listening to Michael with Johnny in the studio we were both visibly shocked when he was telling his stories about the costs of the medical profession not listening for him personally, for his family, for the child that he lost, and for the many other examples where listening wasn’t happening. It’s the first time I really had to pause during an interview and collect myself to stay focused during the interview, because I was visibly shaken by him telling these two stories.

I was thinking about how much blood three litres of blood is, and I was visualising two litres of orange juice, and then realising it was still another litre to go, and imagining what that would look like inside somebody’s body and the pain that must be causing for them because somebody wasn’t listening to them.

I’m excited that Michael’s on this journey, and I’m excited by his research to bring evidence around the cost of listening. I’m excited by the role he plays in helping students understand how to listen, in that simple skill form, technique, that says ask a thoughtful question.

For each of us as we listen to Michael, and to honour the child he lost, I think that’s the gift we can take away from the conversation. How can we ask the next person or the person we’re in conflict with or a person we might not even know, a thoughtful skilful question? Those who don’t listen to history will repeat it, and whether it’s Staffordshire or Becker’s Marsh in Australia, the medical system continues to repeat these mistakes because they’re not listening.

But there is a flicker of light in the examples that Michael talked about. He talked about the fact that they can look to the aviation industry as a great example of an industry that listens and learns from its mistakes and supports its professionals during the process of learning from that. Let’s hope this can be applied to the medical profession in the 21st century. Otherwise, the cost is not worth thinking about. Thanks for listening.

Oscar Trimboli:

Deep listening. Impact beyond words.

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