The Art of Listening
One of the most important clinical concepts for me was voiced by the legendary physician William Osler. "Listen to your patient, he/she is telling you the diagnosis." After treating literally thousands of patients, it can become almost second nature to quickly discover clues which reveal the underlying diagnosis. I receive a large amount of referral patients for "hard to treat" cases in my clinic and in almost all of the respective cases, there is nothing mysterious about the presenting issues. In almost all of the "hard to treat" cases, it eventually manifests that the patient revealed key symptoms which were not "heard." Why the previous clinician missed the clues is hard to say and not my main concern. My ultimate concern is for the well-being of the presenting patient and the resolution of the presenting disharmony, ultimately listening to the patient.
The following is a random case study I pulled from my files of supposed recalcitrant cases. I feel this particular one is an excellent example of a case which, on the surface, had a clear cut solution yet the details presented by the patient revealed important clues to the diagnosis.
Patient: 63 year old Caucasian male concerned about being diagnosed with Type II Diabetes. Main presenting symptoms are elevated fasting blood sugar levels, elevated cholesterol levels, recently discover Mitral Valve issues, lower back pain, night sweats, recent kidney stones and chronic tinnitus. Energy levels were high, excellent mood, good quality sleep, strong digestion and high motivation for improving the quality of his life were all present. Tongue was dark red, absent coat, deep cracks spread over entire surface of tongue. Pulse was thready and fast.
The respective patient arrived at my clinic as a referral with previous paper work listing his TCM pattern diagnosis as Kidney Yin Vacuity and was prescribed a patent formula of Liu Wei Di Huang Wan dosed at eight teapills, TID. The patient had taken the prescribed formula for two months and had seen no improvements in any of his presenting symptoms. I asked the patient about his diet and lifestyle habits which were not listed on any of the clinical paperwork. He described his diet as "paleo-based" and had a fairly inactive lifestyle of office work and little exercise besides waking for 20 minutes three days a week which he enjoyed and described as the "best part of his day." I asked for him to provide a food diary which revealed his daily diet as follows: no breakfast except "bulletproof coffee," a large lunch typically based on large servings of beef or poultry and a salad with ranch dressing, moderate sized dinner typically of a serving of poultry or meat and a vegetable. The patient was also eating large amounts of sweets on the weekends as a "treat." He had not been counseled on diet with his previous practitioner. Patient was recommended to take standard prescription meds from primary care physician, but refused to comply and informed the physician of his choice to choose other options.
After reviewing the entire clinical picture, I agreed in part with the previously prescribed diagnosis. However, I was shocked at the lack of dietary discussion, as was the patient who said, "I asked for help with my diet but we decided to try acupuncture and herbs first. Can you please look over my food diary and tell me if you see any issues?" This was obviously a huge key to the resolution of his and his primary care physician's main concerns: Type II Diabetes and elevated cholesterol. The patient said to me, "I'm not that concerned about my tinnitus and night sweats, I'm more concerned about my heart!" My main concern was to address and listen to his main concerns. Targeting his diet, we modified his approach from a self-described "paleo-based" approach to a more Mediterranean based diet which basically consisted of large servings of steamed/grilled vegetable, lean meat or fish 2 to 3 times a week (rather than twice daily as was the current approach), as much berries and apples as he desired, and brown rice or quinoa as desired. We also discussed eliminating the "weekend sweets" and his "bulletproof coffee" was replaced with a small breakfast meal of his choice. He was extremely enthusiastic about the approach and said, "I have always wanted to try a diet like this!" We also increased his waking from 20 minutes to 45 minutes three days a week, which was also enthusiastically embraced. I adjusted his TCM herbal prescription to a stronger concentrated tablet formula of Zhi Bai Di Huang Wan dosed at 4 tabs, BID.
After one month on the above protocol, the patient's cholesterol dropped from 259 to 219, and his morning fasting blood sugar had shifted from the previous 140-189 levels to 108-120 mg/dl. I recommended the patient visit his primary care physician for a check in as he had obtained his new lab date at a recent hospital based community health fair. The patient's lab values were almost the exact same levels when measured by his primary care physician which was an extremely positive sign for all involved. The physician was happy with his progress and recommend he return in three months for evaluation. After three more months on the modified protocol, the patient's cholesterol was at 179 and his blood sugar was measuring in the ranges of 98-110 mg/dl. The primary care physician was extremely happy with his progress and encouraged him to continue and scheduled a follow up in 12 months. After four months of the modified protocol, the patient was also experiencing no more night sweats or lower back pain. His tinnitus was unresolved. His tongue was a normal color with a thin wet coat, tongue body still presented with deep cracks, pulse was slippery and regular rate.
At this point, the patient was encouraged to continue to follow the modified dietary protocol and his TCM prescription was modified to the standard Liu Wei Di Huang Wan formula in concentrated tablet form dosed at 4 tablets, BID. Patient was encouraged to check his blood sugar one to two times a week and keep in contact with myself and primary care physician if any issues appeared. At a sixth month check in, all signs were still trending towards improvement however tinnitus was not resolved. The patient thanked me again for "giving him a chance" and "taking the time to listen to my questions about diet." Overall, this was an extremely easy case to manage in large part due to the highly motivated and enthusiastic attitude of the patient. However, I hope practicing clinicians can see that in many cases, we need to simply ask questions and allow the patient to reveal the diagnosis. If we open our ears, the answers will often reveal themselves. This is when the healing experience becomes more than a TCM formula, and more than a special acupuncture point prescription. When we take the time to "listen" to the lifestyle and heartfelt concerns of the patient, a true doorway of rapport can open. This doorway allows the patient and practitioner to co-create a new vision of health and transformation. And that is the true magic of listening.