As a family physician faculty, I’ve learned from patients and my medical learners for more than 20 years. My patients have taught me that a powerful place to address health equity is in the room where it happens—in our exam room. As such, I’ve come to the point in my career where at the end of each encounter with a patient, I ask them, “Do you feel that you have been heard, and do you feel that I have listened to you?”
I do this for all my patients regardless of how they identify. If they say “yes,” I thank them for coming to see us and allowing us to care for them and their family. If they say “no,” I sit down, take my hands off the computer, lean my head forward and to the side, and ask a third question, “Could you please help me better understand your needs today? We can’t always fix things, but we can try to address them. I want to understand what you need me to hear, and I will learn to listen better.”
An interesting thing I’ve found is that it seems 99% of the time, they say, “Yes, I do feel that you listened and that I have been heard.” So why ask a question where the answer is almost always yes? I realized years ago that knowing I was going to ask those questions at the end of the visit really makes me try to practice the skill of active listening while in the visit. From the moment I walk into the room and ask, “What is the best way to say your last name?” “Who is it that you have brought to the visit with you today?” “Could you please introduce me to these folks?” I begin with the end in mind: I want my patient to be heard, and I want to be the one who listens.
Very often, when it is a patient who has not seen me before, they express great appreciation, “No one has ever asked me that question before.”
Sometimes, I inquire, “No doctors?”
And they say, “No one. Period.”
Think about all the challenges we’ve had around equity, especially for our Black and Brown patients. Think about all the stories you’ve heard of diagnoses that were missed, delayed care that occurred, and even deaths. It would not have solved every problem, but how many could’ve been averted had these last three questions been asked at the visit?
I, like all of us, have many identities. I am a Black woman, lesbian, and as the proud daughter of immigrant parents, I am a first-generation American; as the cherry on top, I am also a very proud family physician. So when it comes to issues of equity in health, people often ask me what to do. It is interesting to think that any one person would have the answers to our challenges. I do not. I can teach you what I do, and I can continue to learn from my experiences and my mistakes. The number-one thing I have found to be most important is finding ways to hear people. To hear and listen to what patients are really saying and to help us understand what that really means to them. A patient treated in this manner may also find it easier to express themselves and other health care situations once they have felt respected and heard; it may become a welcome expectation.
The number-two thing is to advocate for that patient, their family, and their communities. We have spent time in that room with that patient and their family, we have engaged in that relationship, we have been put into the bonds of trust, and we have listened to a voice that may be in need. Understand this: we can become a voice for stories, and stories that are appropriately told in the right venues are a powerful path to change. Equity really means putting resources where they are needed the most. As physicians, we hear so much about where these needs exist. Listening in that exam room and reaffirming to the patient that they have been heard is a tool for getting to the point of understanding our patients' motivations, concerns, resources, and needs. Advocating for those needs at many levels is how we will get to equity in our health care outcomes.
Appropriately sharing those stories with stakeholders and policy makers is one of the ways that we as physicians can, at a population level and at a systems level, contribute to the policies that provide the scale of change needed to truly address our challenges.
The way I have grown to think about this is that as I enter the room, I’m driving toward the goal of caring for this patient in a manner where they feel their voice has been heard and I have listened to them. It’s a critical part of my caring for them. It’s clear to me that many of my learners get concerned that asking these questions will extend the time of the visit. I let them know that it won’t extend the time of the visit if the patient feels like they were heard, so get in there and listen. If it does extend the time of the visit, it needed to be extended. I don’t promise patients that once I understand their challenge, I or anyone can immediately fix it. But they will know they are not alone in striving to address that challenge. We will walk that path with them. We can’t always cure, but we can always care. Equity in the exam room may start with us using and growing our active listening skills, but to truly attain health equity we must share those stories and continually advocate better for systems of care and the consideration of health in all policies.
Recently, I saw a patient who had been in a motor vehicle accident. She was in significant pain. She had come in many hours after the incident and had muscle spasms over one side of her body, no bruising, and no deformities. After the conversation, some ketorolac, and an exam, we made some shared decision-making around treatment and whether or not to get an x-ray, and what red flags she should be looking for over the next few days.
“Do you feel like you’ve been listened to? Do you feel like you’ve been heard?” I asked.
“Yes,” she said, “and thank you for asking. You know people don’t always listen to us,” she said, with that understanding look that we both knew meant “us” as Black people. I looked back with that same knowing look, nodded my head, and said, “We are trying to change that. I see you.”
She left with a smile, a prescription, a plan, a little less pain, and an understanding that we cared for her right to be understood and that we all deserve to feel heard.
Three simple questions have helped me be a better doctor and provide better care. In our quest for true health equity, we must recognize the need for significant changes on a grand scale. By teaching ourselves and our learners to listen actively, we lay the groundwork for better patient care and genuine equity. The surgeons' saying, "A chance to cut is a chance to cure," finds its parallel in family medicine with the sentiment that a chance to hear is a chance to care. Equity starts with each patient encounter, and the room where it happens is the exam room, the hospital room, the emergency room, and the labor and delivery room… we are family medicine, we are there. Equity starts with us.
