‘Thanks for listening’. Doctors are delighted when patients use this phrase, describing an apparently simple process. Such thanks can be a sign of the most powerful and satisfying processes in medicine. If patients feel understood and accepted, then healing, changes in behaviour and effective management of their illness are all more probable. Yet listening deeply and effectively turns out to be neither simple nor easy to achieve. Indeed, listening itself is easy to understand, but hard to explain.

In this chapter, the skills needed to listen to patients with MUS will be explored; including getting the consultation started on the right footing, how to use ‘deep’ listening skills to enhance mutual understanding and acceptance, and how to develop personalised strategies for managing symptoms. Finally, additional techniques, useful for all patients are described.

All doctors set out to listen. So why is it sometimes so hard? And why does it sometimes go wrong? Here is a typical case history.

The doctor has tried hard, given lots of time and slumps back exhausted wondering what else she could do.

Similar scenarios will have been encountered by most doctors. Sometimes things just do not work out in one consultation. By arranging an early follow-up, this doctor has shown a key commitment to their continuing relationship.

Doctors can be ambivalent about patients with MUS. Patients may also feel uneasy, picking up that they are not welcome or fearing dismissive approaches. This leads to mutual frustration. Anticipate a positive experience, and prepare yourself to attend to what the patient is saying in an open and relaxed way. Greet patients warmly and by name, show you remember them (e.g. by remembering a telling detail, or an event they have mentioned). If it is a follow-up, thank them for coming back to see you.

Think about your opening statement. Asking ‘how can I help’ may be doomed to failure as you often cannot do what the patient wishes for. When people come with new problems, your silence will leave a gap for their opening statements. With MUS, especially at follow-up, it may be more helpful to focus on the patient’s perceptions of priority. Thus, ‘What would you like to prioritise/talk about /focus on/today?’.

Explore the pros and cons of different openings in your own consultations. Try different approaches at different times and see what works best; most patients with MUS will be seeing you a few times. Adding your own agenda items (‘I would also like to check on the progress of your diabetes’) means that you create space to treat the treatable and ensure that chronic disease is attended to fully. This is important when MUS coexists with medical conditions.

If you are picking up from a previous consultation, specifically ask about progress with the agreed management plan. Listen carefully for the emotional and cognitive content. Use opportunities to show empathy and kindness whenever possible. The practical strategies in Box 14.1 can demonstrate your commitment to, and interest in the patient’s distress.

The skills of ‘deep listening’ (also called ‘enhanced listening’) help doctors to achieve a closer understanding of the patients’ illness and of their suffering. Many patients with MUS feel that they are not treated respectfully or taken seriously. All too often they feel dismissed or unheard. Listening deeply means attending to, and remembering everything the patient communicates. Use encouraging skills (‘go on’, ‘tell me more’, or‘ please tell me the details’) rather than a barrage of questions. Clarifying details after the patient has finished speaking (avoiding interruptions) will demonstrate your interest. Show that you accept what they are experiencing via empathic comments (‘So the burning night pain really affects your sleep’).

Try emphasising the ‘feel’ in the question, ‘what does it feel like?’. Then listen carefully to what the patient chooses to communicate with you. Sometimes an evocative description will follow (‘it is really like a knife going in ’), sometimes a concern (‘ it feels like it is going to burst’), or maybe an insight into their despair and fear (‘It feels as if it will never give me any peace!’).

When summarising or reflecting back, reflect the overt content (‘so the back pain never leaves you, and it’s a severe jabbing sort of pain’) and the emotional overtones (‘you are concerned it will never get any better, so you won’t enjoy your grandchildren’).

Less is more

Rather than asking many medically focused questions, reflect back the words the patient uses. This usually stimulates more detail.

Patient: I told the consultant that it still hurts after the surgery, but he just fobbed me off.

Doctor: Fobbed you off?

Patient: Yes…that well…it made me…made me wonder…perhaps something went wrong inside.

Doctor: Went wrong inside?

Patient: Yes, with the op, maybe he left something there.

These specific ideas can then be used when creating explanations, and using the patient’s own exact words later on will increase engagement. Explanations are more credible if they pick up on the patient’s own words and ideas. In the above situation, explanations could reflect the fact that restoration and repair processes can be uncomfortable or distressing too. Highlighting emotive terms (‘it feels like you are all blocked up?’) or terms that indicate the impact on them (‘So you can’t go out because you will need to go to the loo all the time’) will also help the patient to feel understood and accepted.

Using non-verbal (body language) and paraverbal (tone of voice) information

Be aware of minimal clues to the patient’s thoughts and feelings. For example, minor hesitations, looking away, the tone and loudness of their speech, may all speak volumes about their state of mind. Empathising with the feelings they express (‘you seem a bit hesitant…’) validates their experiences. Can their underlying anger, frustration or disappointment be verbalised? Patients often express a need for an explanation. This can be put to good use, as the doctor can lead into one of the explanatory models described in other chapters.

Exploit the paraverbal aspects of your own communications to patients; a kindly tone of voice, attentive body language, making the patient comfortable during examinations etc.

Picking up when listening is not working

At times the sensitive doctor will be aware of signs that rapport is being lost; changing approaches will help to avoid frustrating repetition and conflict where the doctor and patient have different views and goals.