The ART of LISTENING
Listen to your patient.
He is telling you the diagnosis.
— Sir William Osier
Several years ago, a chinese-canadian named Charles developed a nagging pain in his back. He was about 56 years old and, though he had prospered since he'd immigrated, and managed to save enough funds to own a building, he continued to work as a labourer, loading boxes of vegetables on and off delivery trucks. He continued to work through the pain for about a month but, eventually, it grew so severe that he had to stop. Through his employer, Charles consulted an orthopedic specialist retained by the Workers' Compensation Board. The doctor diagnosed osteoarthritis and prescribed painkillers.
But by then, Charles had also started to lose weight. He was sent for a series of tests, which indicated the presence of red blood cells in his urine. That finding raised the possibility of kidney disease, so he was sentto anephrologistwho did further tests, confirming that Charles's urine contained blood, and suggested that he might have IGA (immunoglobulin A) nephropathy, a common kidney disease that affects the organ's filters, or glomeruli. Although the condition is mostly benign, the kidney may, over time, lose its ability to cleanse the blood properly.
However, just as a precaution, he also decided to test for bladder cancer. So Charles was sent to his third specialist, a urologist, where he underwent a cystoscopy, a procedure that provides a better view of tumours or stones. The test came back negative, which appeared to reconfirm the original diagnosis of IGA nephropathy.
With that, the medical system was largely done with Charles. His family physician prescribed analgesics for the continuing back pain, but was otherwise at a loss to explain what exactly was going on. Unfortunately, the pain was getting worse and Charles had become virtually incapacitated. By the sixth month of his illness, sick and continuing to lose weight (about 30 pounds in total), he could hardly walk.
At that point the family doctor referred him to me. When Charles appeared with his wife in my office for the first time, he almost had to crawl into the room.
"Dr. Ho Ping Kong," he pleaded, "you have to do something. Otherwise, I'm going to die."
"Don't worry," I said, though I really had no reason to offer this assurance. "We will figure out what's wrong with you."
He sat down and began to recount his medical history.
Then, because I do it almost instinctively, I decided to start the physical examination by listening to his heart. What I heard, immediately, was the signature ivhoosh, whoosh of a systolic murmur, a five on a scale of six at his apex.
"I know what's wrong with you," I said. "You have subacute endocarditis" (an infection in the heart valve).
This diagnosis was confirmed by details provided by further examination — clubbing of his fingers and the temporary blackening of his little finger, a few weeks earlier.
Charles was admitted to hospital and, within 24 hours, a cardiac surgeon installed a pacemaker and replaced the diseased mitral valve with a mechanical one. The infection itself was treated successfully with antibiotics. Today, Charles functions at about 85 or 90 percent of what might be considered normal. In another month, without intervention, he would likely have died. His life was literally saved by the simple act of listening.
Instinctively, I had a sense that endocarditis might be at work. It was suggested by the combination of symptoms — excruciating backache, weight loss and blood in the urine. But his case also speaks to the compartmentalization that has come to characterize modern medical practice. Expertise is acquired in subspecialties, and that expertise is invaluable. But physicians often lose the ability to focus on the big picture.
A patient's testimony— CharlesM.
I was born in 1953 in a small village on mainland China. I came to Canada at 23, in 1977, after two months in Hong Kong. It was very bad time in China, for virtually everybody. Everyone wanted to leave the Communist system. You could not own your own house or car or business and you could not have independent ideas. You were forbidden to listen to outside radio or read foreign newspapers. It's better today, but still quite restrictive.
I had been a student. I came to Toronto and worked in a furniture-assembly factory, but not for long. I quit the job because I was using a spray gun to paint the furniture and it made me sick. Then the government of Canada gave me money to study English. I set up a factory to manufacture tofu for restaurants and supermarkets, which I eventually sold, after 16 years, to my brothers. When I sold it, it was grossing $1.5 million in revenue. That's a lot of tofu.
I became sick in May 2007 after coming back from China. I was nauseous. I was very tired and did not want to eat food. In June, I started getting intense lower back pain. I could not stand or walk. I was working in a clothing factory, as a labourer, but had to quit because of the pain. I went to see my family doctor who sent me to the hospital. They checked my kidneys, but it was normal. Then they checked my lungs because I was having trouble breathing, but they were normal. I went to three separate hospitals and had no answer. So I went to see another family doctor and he sent me to Ho Ping Kong.
I was so sick. I was losing weight. I thought I would die. I could not sleep or walk. Painkillers helped, but only for a few hours. I was very lucky. Ho Ping Kong saw me the next day. I was late for the appointment and I worried that he'd have left. But he waited. My wife brought me. I was in a wheelchair. Parts of my body had turned black and swollen. My fingers, the soles of my feet. It was bacteria in my blood. He asked me very detailed but clear questions. I was with him an hour. I was admitted for two weeks. I was very sick. I was scared because I knew something serious was wrong. So they eventually confirmed the doctor's diagnosis, but they also had to repair the valve, which the bacteria had eaten away. So I had the surgery and since then I feel better, normal. My appetite returned. So I am very grateful. Now I walk two hours every day, but slowly, because otherwise my heart goes too fast. Dr. Ho Ping Kong has helped me with everything, even with helping me fill out forms for social security. We are all very lucky to be in Canada. It gave us a chance. It saved us.
Charles's case also underscored the signal importance of listening to the heart. Not long ago, Toronto Western Hospital played host to Dr. Rory McCallum, a promising Irish nephroloX gist who was here as a visiting clinical fellow and is now on staff. He expressed an interest in medical education, so I introduced him to Harvey, our high-tech cardio-pulmonary simulator. We use it to teach some 25 separate cardiac functions, including blood pressure, heart sounds and a variety of heart murmurs. In about 10 minutes, I showed him four different murmurs.
Afterward, in a little test, he was able to correctly identify two out of the four. He was not terribly happy with the result, but the very next week, he was doing rounds at the Toronto General Hospital when he met a patient suspected of having IGA nephropathy, because of red blood cells in the urine. What did he do? He immediately put the stethoscope on the patient's heart and heard the systolic murmur and said to his startled residents, "Change the diagnosis. This man has endocarditis."
At the centre of the art of listening lies the humble stethoscope. Invented by Rene Laennec in Paris in 1816, its first incarnation was scarcely more than a wooden tube. It functioned much like the ear trumpet, a device that augmented sound for the hearing impaired. Another 35 years passed before the first binaural stethoscope appeared, invented by Irishman Arthur Leared. The design of the modern instrument was established in the early 185 os as well, although a variety of technical improvements have naturally been made.
The stethoscope — from the Greek words stethos for chest, and scopos for examination — puts an educated ear to several key organs : the heart, lungs, abdomen, intestines, even specific veins and arteries. In tandem with the sphygmomanometer, it is also used in one of the most essential medical readings — blood pressure.
During my training in Jamaica, where we used murmurs to diagnose dozens of cases of rheumatic heart disease, the stethoscope was an invaluable tool. Patients encouraged us to use the device, which they called a trumpet. "Doctor," they would say, "you haven't yet sounded me with the trumpet." No visit was complete without that procedure. For them, it was viewed not only a method of diagnosis, but as a form of therapy.
But as my Toronto Western Hospital colleague Dr. Lisa Richardson has observed, the stethoscope is more than it might seem. It also serves to forge a connection between doctor and patient. It's more than a symbolic link. Active listening signals to patients that you care about them and are willing to take the time to listen to their organs. The judgment works the other way as well. If you don't use the stethoscope, it tells the patient that you are too busy or simply don't care enough to listen, an interpretation that will do nothing to nurture trust.
This is not a trivial issue. With the exponential increase in medical malpractice suits, physicians have lost the high level of trust they were once accorded almost automatically. Now, we are just as likely to be regarded with caution, wariness, even suspicion. Increasingly, patients are on the alert. A surgeon with a 95 percent success rate in the operating room may be entitled to respect, but the rest of us must earn it, every day.
Trust, rapport, communication — by any name, it's a critical component of the art of medicine. Various studies, in fact, have demonstrated that a high percentage of lawsuits result from a simple failure to communicate with patients.
So how do you encourage a patient to trust you? The answer may be as simple as eye contact. Far too many doctors spend too much time looking everywhere but at the patient. They are glancing at the desktop computer or reading the patient's file, but seldom actively engaging with the other person in the room, eye to eye. I once treated a British-Jamaican woman who insisted on coming back to see me in preference to her own family doctor. When I asked her why, she said, "Because you always look me in the eye."
When I first meet a new patient, I often ask questions that have no apparent connection to the matter at hand, the illness or problem that brought them to me. Where were you born?
What kind of work do you do? Tell me about your family. Simple questions, unlikely to tell me anything useful for diagnosis, but invaluable for establishing a solid foundation for the doctor-patient relationship. Such inquiries signal to the patient that he or she is not simply a disease or a syndrome, but a human being.
Occasionally, it is true, I will encounter a patient that resents such questions. An immigrant, for example, may interpret the question, "Where are you from?" as suggesting that he or she is not truly a Canadian. Others may feel that such information is none of my business. But in most instances, such questions help "break the ice" and facilitate the building of trust.
Particularly in the grey areas of medicine, where neither surgery nor pharmacopeia can cure disease, trust is vitally important. To some extent, trust byitself can be a kind of healer, assuring the patient that he or she has not been forgotten by the system, that everything that can possibly be done is being done, that someone in authority actually cares.
At times, it's a combination of listening and visual observation that proves diagnostically decisive. I recall seeing Brenda, a 50-year-old Jewish woman from Cape Town, South Africa, suffering from what is known as arteriovenous malformation (AVM) — a hereditary condition that makes a jumble of the body's arteries and veins.
avms can occur anywhere in the body, but they are particularly challenging when they appear in the brain. There, they behave like space-occupying lesions, producing (depending on the severity) headache, epilepsy, vertigo, muscle weakness, problems with balance and coordination and, most worrisomely, bleeding. The latter development can be catastrophic.
Brenda had already been to see a colleague of mine, Dr. Karel Terbrugge, an interventional neuro-radiologist. He'd successfully performed embolic therapy, with glass beads or glue to prevent bleeding, a very delicate procedure. A cavernous AVM is a significant medical problem. It wasn't that long ago that we had no good treatment for this condition.
When I finally met Brenda, she told me that, some 20 years earlier, she had been treated at Cape Town's prestigious Groote Schuur Hospital. That, of course, is where the late Christiaan Barnard performed the world's first successful heart transplant surgery, in 1967. There, Brenda had been diagnosed with Takayasu's disease, a form of giant-cell arteritis. A disease of the aorta, it generally affects young or middle-aged women, mostly of Asian origin. In my career, I had encountered it once or twice. It seemed unlikely that a Jewish woman from South Africa would have an Asian disease, but who was I to argue with the Groote Schuur Hospital?
I began to examine her and put my stethoscope on the skull. Instantly, I detected the bruit or vascular murmur. I could literally hear her av malformation, even through the skull. But what was causing it?
I asked her to flex the joints of her thumb. To my surprise, she was able to bend it backwards almost 180 degrees. This, I knew, was a distinguishing feature of Ehlers-Danlos syndrome, a relatively uncommon connective tissue disorder named for a Danish and a French physician respectively. The disease manifests itself in various ways, including both hyper-flexibility of joints (the result of defects in the connective tissue) and blood vessel disorders that may lead to a AV malformation.
Brenda had waited 2 o years for the correct diagnosis. We were able to manage the illness for about a decade, but its progress is inexorable. Eventually, the bloodvessels ruptured, causing internal bleeding and a lethal stroke.
When we speak about the art of listening, I am generally referring to the use of the stethoscope to hear heart murmurs or bruits indicative of other diseases. But listening to the patient can also mean something else — actually hearing what he or she tells you. Some time ago, a colleague asked me to see the husband of one of his attending staff. Fred, 49, was a grain broker who'd been ill for six months, suffering from anemia and an enlarged spleen. He was awaiting an appointment with a hematologist. I agreed to call him, not sure what exactly Fd be able to do.
After.the telephone preliminaries, I started asking questions.
"What seems to be the problem?"
"Well, doctor, Fm sweating at nights and have lost about 10 pounds and may have a slight fever. I'm not sure."
"Have you been sick before?"
"Well, I'll try and see you in the next few days, but maybe I can speed things up by asking a few-more questions. You're sure you've never been sick?"
"I've never been sick," Fred insisted. "I only have a mitral valve prolapse. I've had it for 20 years."
MVP occurs when the valve between the heart's left atrium and left ventricle fails to close properly, which can lead to leakage. At any time, about 15 percent of the population walks around with this condition, usually without any problems.
"Are you on medication for it?"
"Do you have a heart murmur?"
"Yes, doctor. I've also had a murmur for the last 20 years."
Bingo. "Listen, go the lab now and have some blood cultures done. Come and see me tomorrow. I think I know what's wrong with you."
Examining him the next day, I found both the enlarged spleen and a subconjunctival hemorrhage and heard his murmur, quite distinct, a five on a scale of six. The blood work further indicated that he was slightly anemic, had an elevated sedimentation rate (suggesting inflammation), tested positive for rheumatoid factor, had red blood cells in his urine and was growing a strain of streptococcus bug.
"You have endocarditis, and you have to be admitted to hospital immediately."
"I need to pick up my kids," he protested.
"You'll have to find someone else. I want you to go straight to Toronto General."
We started treating him with antibiotics and he responded well. One day, however, driving home from work, Fred developed dizziness and a cerebral embolus, a legacy of his heart valve problem. After a confirming mm, we decided to replace the valve. At the time there were two choices, a pig valve, which lasts lo years, or a mechanical valve, which lasts 20 years. The latter option, however, requires anticoagulation drugs. An active skier, Fred opted for the pig valve. But he was lucky enough to end up in the hands of Toronto General Hospital cardiac surgeon Tirone David, who managed to repair the original valve.
Twelve years later, Fred is thriving.
One day, denise, a 32-year-old woman, came to visit me, complaining of high blood pressure. A civil servant, she had a high-stress job that might have been to blame, managing more than 1,000 people. Feeling unwell, she had paid a visit to a walk-in clinic. Her blood pressure was measured at 190/90 and she was-prescribed blood pressure medication. The drug helped, reducing her blood pressure to 160/90, but she still felt stressed. I saw her a few weeks later.
Her history revealed no sweating or palpitations. Apart from the elevated blood pressure, she was a healthy young woman. I then looked for secondary evidence, given her relatively young age. I put my trusted stethoscope to her right kidney and immediately heard it — a distinct bruit, as loud as I had ever heard, a six on a scale of six. I immediately rounded up some students to listen to it as well. Normally, the sound you hear has a clear to-and-fro quality. In Denise, there was no such flow, just a consistent one-way, systolic sound.
The bruit was an unmistakable sign of renal artery stenosis, a narrowing of blood flow to this vital organ. Because of it, the body's hormonal equilibrium had been upset, yielding hypertension. Fortunately, we had discovered the problem at an early stage, which enabled us to insert a surgical stent to open the artery and restore proper blood flow. Ten years later, Denise requires only a small amount of medication to control her blood pressure, and has experienced no further problems.
Sometimes, the art of listening can be used to integrate other clinical evidence and come to a more precise diagnosis. On one occasion, I led a group of medical students to examine Felix, a 50-year-old Portuguese man diagnosed the previous night with deep vein thrombosis, a blood clot in his leg. He was already taking heparin, a blood thinner, to prevent further clotting.
"Feel the leg," I instructed one of the residents. "How does it feel?"
"Cold," he said.
"And if you have a deep vein thrombosis, it should be... what?"
"Warm," he said.
"Correct. . . Therefore, this is not a deep vein thrombosis. So what is it? Look at his head. What do you see?"
"It's moving," another resident said.
"And that is known as ... ?"
"The head nodding sign."
Formally known as de Musset's sign — after French poet and dramatist Alfred de Musset, who died at age 47 of heart failure — the head nodding sign is an indication of aortic insufficiency, typically involving a valve malfunction. The head bobs involuntarily in tandem with the beating of the heart.
We took Felix's blood pressure, which was 140/50.
"What does that tell us?" I asked.
"His pulse is collapsing," offered one of the students.
"Correct. So we have a cold leg, a collapsing pulse and the head nodding sign. Which means there's a leak somewhere, and we should be able to hear it."
Sure enough, when we listened to his heart, we heard the distinct whoosh, whoosh of a murmur, over the aortic valve.
The residents then took turns listening to the murmur.
Then I pressed the stethoscope onto Felix's femoral artery. Here, too, we could detect an audible diastolic murmur. This is Duroziez's sign, another indicator of aortic insufficiency. It is named for 19th-century French physician Paul Louis Duroziez, a pioneer in cardiac medicine.
"So this patient," I said, "unfortunately has endocarditis. His temperature was as high as 102 degrees. So why is the leg cold? It should be warm."
The students weren't sure.
Then one of the senior residents offered the right explanation. "Part of the vegetation on the aortic valve broke off and went to his leg. It has embolized and is thus blocking the flow of blood."
"That's correct," I said. "The likely culprit is a bacteria like staphylococcus aureus."
We immediately changed the diagnosis, from deep 'vein thrombosis to septic embolism, and began administering antibiotics for the endocarditis.
The next day, surgeon Dr. Tirone David replaced his infected aortic valve and, in the process, invented a new procedure to treat his septal abscess. We were unable to save Felix's leg — the infection had progressed too far — but we saved his life with the surgery and the antibiotics.
For me, this case represents the critical importance not only of listening and palpating, but of then integrating the knowledge gleaned to reach the diagnosis.