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Listening in health care is not so different from any other setting: it’s about paying attention, not seeming hurried, showing that you care. But in health care, the stakes can be particularly high.
For example, in 2007, MaeMargaret Evans, a retired teacher who lives in Los Angeles, contracted pneumonia and needed surgery to remove her gall bladder. When it was time for her to be discharged, a nurse said, “Before you go home, we have to take out your stitches.”
This didn’t sound right to Evans. She pointed out that it had only been four days since her surgery. “They said, ‘No, you can’t go home with these stitches,’” she recalled. Evans asked the nurse to check with her doctor. “They said, ‘It was the doctor’s orders,’” she remembered. “In other words, they wouldn’t listen to me.”
Her son flew in to help her. He later told her that she looked gray, and he didn’t think she would make it through the night. She had an appointment to see the doctor the next day. When she arrived, “The doctor was furious.” He began throwing things and cursing. He told her, “You are gangrenous.” He cleaned her up and said that they could not sew her back up because the wound had to heal. “It was so painful,” Evans recalled, “I can’t tell you how much it hurt me.” She was bedridden at home for six weeks while her wound healed.
The physical pain was compounded by feeling dismissed and disrespected. “They didn’t treat me like I had my own thoughts or [care] what mattered to me,” Evans said. “Even when I kept saying, ‘Could you please check?’” She remembered the doctor saying, “This should never have happened to you.”
In our ongoing efforts to improve care for older adults, IHI recently spoke with some members of the Age-Friendly Health Systems initiative Older Adult Advisory Group to learn what matters most to them in their interactions with health care providers. The importance of listening emerged as a high priority.
Randel Smith, a retired corporate controller who lives in Maryland, noted that he can tell whether a clinician is listening. “It’s very simple. It’s like with anyone else,” Smith said. “Do you have eye contact? You’re trying to talk to them in the office, and they’re typing on the computer. When they’re doing that, you know damn well they are not giving you their full attention.”
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Elissa Brown, a retired clinical nurse specialist, echoed those sentiments. “I can tell when the providers are looking at me and when they pay attention to what I’ve told them. There are some who only look at the computer.” She says that she is not against computers. At the same time, “They have to hear what I’m saying and be willing to stay and listen to other things that may be going on.”
Evans, who ended up with gangrene, still wonders if she should have done things differently. In retrospect, she said, “I think I [could] have been more insistent.” She also noted, however, that older patients are especially vulnerable and don’t necessarily behave in the hospital as they normally would at home. “I don’t [typically] have a hard time sticking up for myself,” she pointed out. “I’m a teacher. But I was just so ill. I think sometimes seniors, if they’re as ill as I was, you don’t have any fight in you. You don’t have any pluck.”
At the other end of the spectrum, a positive experience with a health care system can be deeply gratifying and life-affirming. Marian Hoy, a 72-year-old former pilot and police trainer, and small business owner, recalled a time in 2014 when she was hospitalized for 21 days with sepsis. “They were on my side,” she remembered.
“The physicians and nurses were sincerely concerned with my well-being. They’d enter my room every day, pull up chairs, and talk with me about my health. They behaved as if, at that very moment, I was their only patient,” she said. “Not only did they provide the best possible care, but they did so with courtesy and respect. I’ll always be indebted to them.”
Figure 1 — Age-Friendly Health Systems 4Ms Framework for Age-Friendly Care
One of the key elements of the 4Ms Framework for Age-Friendly Care (Figure 1) is asking What Matters to know and align care with each older adult’s specific health outcome goals and care preferences. The Age-Friendly Health Systems advisors shared some thoughts about how to approach getting that information. For one thing, directly asking “What matters to you?” may not always be the right approach.
“I don’t think she uses those words, but she asks how everything is,” Brown said of her primary care physician. “And she doesn’t let me leave until she asks, ‘Have we covered everything?’” Brown added, “What Matters most might not be a question that people know how to answer.” She suggested other questions, after asking What Matters most, that may elicit the needed information: “How is everything? Is there anything else that we can help with so you can feel better about things?”
The Age-Friendly Health Systems advisors have also noticed some changes over time in health care. “Back in the early days,” said Smith, “people kind of thought that whatever came out of a doctor’s mouth was God’s words and you should always listen to them.” Now, people have begun to realize, “You have the right to ask questions. Who better knows you than you?”
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