WEBVTT - Special Episode: Dr. Rageshri Dhairyawan & Unheard 0:00:43.640 --> 0:00:47.120 Hi, I'm Aaron Welsh and this is this podcast will 0:00:47.200 --> 0:00:50.639 Kill You. You are listening to the latest episode in our 0:00:50.680 --> 0:00:54.680 special series we're calling the tpw k Y Book Club. 0:00:55.240 --> 0:00:58.520 This isn't your typical book club where you spend about 0:00:58.520 --> 0:01:00.720 ten percent of the time talking about the actual book 0:01:00.720 --> 0:01:03.520 selection and the other ninety percent eating tasty snacks and 0:01:03.600 --> 0:01:06.959 drinking tasty drinks and talking about a million other things, 0:01:07.360 --> 0:01:09.920 which I absolutely love. By the way, shout out to 0:01:09.920 --> 0:01:13.720 my real life book club. In the TPWKY book Club, 0:01:13.840 --> 0:01:17.120 which I also adore. We're staying on topic, getting to 0:01:17.160 --> 0:01:20.720 hear directly from the authors themselves about what inspires them, 0:01:20.880 --> 0:01:23.880 how writing change their outlook, what they most want people 0:01:23.920 --> 0:01:26.720 to take away from their book, and so much more. 0:01:27.240 --> 0:01:30.360 So far this season, we've explored books on topics ranging 0:01:30.440 --> 0:01:34.400 across the fields of medicine, science, and history, and there 0:01:34.480 --> 0:01:36.880 is still so much more to come. If you'd like 0:01:36.920 --> 0:01:39.000 to check out the full list of books we've covered 0:01:39.000 --> 0:01:41.640 so far and the ones later to come, check out 0:01:41.640 --> 0:01:44.640 our website This Podcast will Kill You dot com, where 0:01:44.720 --> 0:01:46.920 under the Extras tab you'll find a link to our 0:01:46.920 --> 0:01:51.520 bookshop dot Org affiliate page. There we have several TPWKY 0:01:51.560 --> 0:01:56.080 booklists covering everything podcast related, including a book club list 0:01:56.160 --> 0:01:58.280 where you can see all of the books featured in 0:01:58.360 --> 0:02:01.720 these book club episodes. And one last thing before we 0:02:01.760 --> 0:02:04.040 get into the book of the week, that is to 0:02:04.280 --> 0:02:08.160 please rate review Subscribe really helps us out so much, 0:02:08.280 --> 0:02:11.000 and also share your thoughts with us. We always love 0:02:11.080 --> 0:02:14.440 to hear from you. Think of the last time you 0:02:14.480 --> 0:02:17.080 spoke with a doctor about a concern that you had. 0:02:17.639 --> 0:02:20.120 How long did the doctor spend with you. Do you 0:02:20.160 --> 0:02:22.720 feel like they were present in the room or did 0:02:22.760 --> 0:02:26.280 they seem distracted checking emails, typing up notes with half 0:02:26.320 --> 0:02:29.040 a mind on the conversation. Did you get all of 0:02:29.080 --> 0:02:31.920 your questions answered? Did the doctor give you time to 0:02:32.000 --> 0:02:34.840 ask questions? How did you feel at the end of 0:02:34.880 --> 0:02:38.760 the appointment. Did you feel listened to, understood, cared after, 0:02:39.000 --> 0:02:44.880 reassured or did you feel gas lit, condescended to dismissed, unheard. 0:02:45.720 --> 0:02:49.359 Hopefully your experience falls into the first category of emotions, 0:02:49.400 --> 0:02:51.800 but I know that many, if not all, of you, have, 0:02:52.080 --> 0:02:54.840 at some point or another, been made to feel the latter. 0:02:55.680 --> 0:02:58.800 Going to a doctor's appointment, whether for a routine checkup 0:02:58.960 --> 0:03:01.800 or a specific prim problem or concern, can be a 0:03:01.919 --> 0:03:05.720 very vulnerable experience. It's no exaggeration to say that you 0:03:05.760 --> 0:03:09.640 are putting your life and health into their hands, and 0:03:09.720 --> 0:03:12.880 when that trust is broken, the damage can be severe, 0:03:13.240 --> 0:03:15.880 both in the short as well as the long term. 0:03:16.400 --> 0:03:19.880 What is it about the physician patient relationship and the 0:03:19.919 --> 0:03:23.840 way that medicine is practiced today that lends itself to 0:03:24.000 --> 0:03:29.000 this pattern of dismissal. That's exactly what doctor Ragastri Darowan 0:03:29.120 --> 0:03:33.720 explores and unheard the medical practice of silencing. Doctor Darrewan, 0:03:33.800 --> 0:03:36.240 who is a sexual health and HIV doctor with the 0:03:36.360 --> 0:03:40.240 NHS as well as a health equity researcher and science communicator, 0:03:40.600 --> 0:03:44.240 draws upon her own experience as both patient and physician 0:03:44.440 --> 0:03:49.200 to examine this nuanced topic from multiple perspectives. Through her research, 0:03:49.280 --> 0:03:52.640 she demonstrates that this problem of silencing patients is not 0:03:52.760 --> 0:03:55.720 a matter of a few doctors acting negligent or being 0:03:55.800 --> 0:03:59.520 too exhausted to properly listen, but rather a systemic issue 0:03:59.560 --> 0:04:02.640 in medicine, where the foundations of patient dismissal are laid 0:04:02.680 --> 0:04:06.280 out during medical school training and perpetuated by the medical system, 0:04:06.680 --> 0:04:09.880 and as minoritized groups are disproportionately more likely to be 0:04:10.000 --> 0:04:13.040 silenced by their health care providers. They are also more 0:04:13.160 --> 0:04:16.520 likely to suffer the negative health consequences that being unheard 0:04:16.600 --> 0:04:20.280 carries with it. Compounding this are the knowledge gaps that 0:04:20.360 --> 0:04:24.560 tend to be wider for conditions primarily impacting minoritized groups, 0:04:24.880 --> 0:04:28.600 a reflection of research priorities that designate funding and resources 0:04:28.640 --> 0:04:33.120 to more prestigious diseases. To say this matter is complex 0:04:33.400 --> 0:04:38.200 is an understatement in the extreme. Fortunately, doctor Derrewan's clear 0:04:38.279 --> 0:04:42.159 and compassionate approach in Unheard expertly guides readers through the 0:04:42.160 --> 0:04:47.440 factors enabling the continued silencing of patients and crucially suggests 0:04:47.480 --> 0:04:52.040 how positive change can be made by individuals during training 0:04:52.279 --> 0:04:56.000 at an institutional level and at a systemic level. I 0:04:56.120 --> 0:04:59.039 truly loved this book and this conversation for getting to 0:04:59.080 --> 0:05:02.200 the heart of this issue, for exploring not just why 0:05:02.360 --> 0:05:05.360 does it happen, but also providing a roadmap for how 0:05:05.400 --> 0:05:08.320 it can get better. And I am so excited to 0:05:08.400 --> 0:05:11.479 share this conversation with you all. So let's get into it, 0:05:35.880 --> 0:05:39.080 Doctor Darwan. I'd like to just first thank you so 0:05:39.279 --> 0:05:43.000 much for chatting with me today. Welcome to this podcast 0:05:43.040 --> 0:05:44.200 Will Kill You book Club. 0:05:44.839 --> 0:05:47.200 Thank you so much for the invites and I'm really 0:05:47.200 --> 0:05:48.240 really excited to be here. 0:05:49.120 --> 0:05:53.320 Your book, Unheard the Medical Practice of Silencing was a 0:05:53.440 --> 0:05:59.200 truly compelling blend of infuriating and enlightening, and I suspect 0:05:59.279 --> 0:06:02.520 that it will resid with many many people. I also 0:06:02.560 --> 0:06:06.120 think it should probably be required reading for medical practitioners 0:06:06.320 --> 0:06:09.920 as a part of both initial and continued training. Can 0:06:09.960 --> 0:06:12.920 you describe your journey to writing this book and how 0:06:12.960 --> 0:06:16.240 your experience on both sides of the power dynamic as 0:06:16.279 --> 0:06:19.600 both physician and patient influenced the approach that you took. 0:06:20.320 --> 0:06:22.200 So, I think it's been coming for a really long 0:06:22.279 --> 0:06:24.840 time and kind of this year is my twentieth year 0:06:24.880 --> 0:06:26.800 of being a doctor, so you know, probably all of 0:06:26.839 --> 0:06:29.680 my career it's been coming. And my work, my day 0:06:29.680 --> 0:06:31.960 work is I work in sexual health and HIV, so 0:06:32.040 --> 0:06:35.960 I work with some really kind of minoritized patients who 0:06:36.160 --> 0:06:39.600 are people who aren't heard generally in policy, who you know, 0:06:39.640 --> 0:06:43.560 who are often very poor, they have HIV stigmatizing disease. 0:06:43.640 --> 0:06:46.000 So part of that is my work with them, I think. 0:06:46.080 --> 0:06:47.880 But what really. 0:06:47.640 --> 0:06:50.679 Instigated the book were my experiences as being a patient. 0:06:50.839 --> 0:06:55.120 So I was diagnosed with endometriosis when I was trying 0:06:55.160 --> 0:06:58.320 to get pregnant, which was unsuccessful, and kind of went 0:06:58.360 --> 0:07:02.120 on to have fertility treatment. And during one of those 0:07:02.160 --> 0:07:05.840 fertility cycles, I was on a lot of hormones and 0:07:05.920 --> 0:07:09.800 I developed really really bad abdominal pain, like excruciating pain, 0:07:09.880 --> 0:07:12.880 the worst I'd ever had. So my husband took me 0:07:13.080 --> 0:07:17.040 to the emergency department. Initially I was seen, I was given, 0:07:17.120 --> 0:07:19.640 you know, really strong painkillers, and then I was admitted 0:07:19.960 --> 0:07:21.880 to the ward and they were really worried that I 0:07:21.920 --> 0:07:24.680 had this thing called ovarian torsion, which is when the 0:07:24.680 --> 0:07:27.920 ovary is so big from the hormonal stimulation that it 0:07:27.960 --> 0:07:31.400 twists on itself and you need urgent surgery. But a 0:07:31.480 --> 0:07:33.480 scan showed I didn't, but I was still in a 0:07:33.520 --> 0:07:36.560 lot of pain, which I thought was due to kind 0:07:36.600 --> 0:07:39.000 of a flare up with the endometriosis. 0:07:38.280 --> 0:07:39.040 From the hormones. 0:07:39.080 --> 0:07:42.240 And whilst on the ward, I asked for more pain relief, 0:07:42.320 --> 0:07:46.600 but I refused it. Basically the medical team didn't seem 0:07:46.640 --> 0:07:49.280 to believe that I was in so much pain. They 0:07:49.360 --> 0:07:52.800 treated me like I was just trying to get morphine 0:07:52.880 --> 0:07:56.000 because I wanted it, and it was a really shocking 0:07:56.040 --> 0:07:58.600 experience for me. At that point, I'd been a doctor 0:07:58.640 --> 0:08:02.160 for quite a long time senior, and I just thought, 0:08:02.200 --> 0:08:04.720 you know, if this could happen to me, this experience 0:08:04.800 --> 0:08:07.440 of being disbelieved when asking for pain relief, what on 0:08:07.440 --> 0:08:11.360 earth happens to everybody else? And in the end, I needed, 0:08:11.760 --> 0:08:15.200 you know, my partner to advocate for me. I thought, 0:08:15.240 --> 0:08:17.800 you know, what if you can't speak English, what if 0:08:17.840 --> 0:08:20.120 you don't have a partner. I know how the healthcare 0:08:20.160 --> 0:08:22.679 system works. What if you don't know how it works? 0:08:22.720 --> 0:08:25.640 What happens to everyone else? So that was really what 0:08:25.760 --> 0:08:28.200 instigated it. And also the fact that at the time 0:08:28.320 --> 0:08:31.880 I didn't complain, and I didn't complain afterwards either. I 0:08:31.880 --> 0:08:36.120 felt really ashamed and I felt silenced for quite a 0:08:36.120 --> 0:08:39.800 long time. And it wasn't until kind of maybe six 0:08:39.920 --> 0:08:42.360 or seven years later that I started to do some 0:08:42.440 --> 0:08:45.000 writing and I ended up writing about this and really 0:08:45.000 --> 0:08:47.920 reflecting on why did I feel so silenced? And this 0:08:48.040 --> 0:08:51.400 really came together into the book. But also the factor, 0:08:51.400 --> 0:08:53.400 you know, I'm a patient, but I'm a doctor patient, 0:08:53.440 --> 0:08:55.800 so I'm not just any old patient. And I'm a 0:08:55.800 --> 0:08:59.119 doctor and I know very well that despite my best. 0:08:58.840 --> 0:09:01.000 Intentions, I don't always listen well. 0:09:01.400 --> 0:09:03.360 And you know, much as I love to say that 0:09:03.400 --> 0:09:05.440 every single patient I've seen will say they had the 0:09:05.480 --> 0:09:06.640 best experience with me. 0:09:07.200 --> 0:09:08.480 That's probably not true. 0:09:08.920 --> 0:09:11.200 So I thought the book was a really good opportunity 0:09:11.280 --> 0:09:14.240 to look at why we don't listen and who doesn't 0:09:14.240 --> 0:09:14.840 get listened to. 0:09:15.960 --> 0:09:18.920 In your book, you use the terms deliberately silenced and 0:09:18.960 --> 0:09:22.600 preferably unheard to describe those patients who are ignored by 0:09:22.679 --> 0:09:26.520 medical practitioners. Who are those individuals most likely to be 0:09:27.040 --> 0:09:30.520 and what does being silenced or unheard look like? Because 0:09:30.559 --> 0:09:33.800 it can be a great many things, sometimes maybe not 0:09:33.880 --> 0:09:36.880 as obvious as just like thinking about, oh, someone is 0:09:36.920 --> 0:09:39.960 going I don't believe you like that is not often 0:09:40.000 --> 0:09:41.920 how it comes out. 0:09:42.400 --> 0:09:44.360 I think when I started the book, I thought it 0:09:44.400 --> 0:09:47.360 was just some people who go unheard, But during my 0:09:47.520 --> 0:09:51.160 research I actually found out that actually all patients go unheard. 0:09:52.040 --> 0:09:54.160 And I'm sure we'll talk more about why that is. 0:09:54.240 --> 0:09:56.920 But obviously some patients go more unheard than others. And 0:09:56.960 --> 0:10:00.360 these are often people from minoritized groups. So these people 0:10:00.400 --> 0:10:03.600 who when they speak, they're seem to be less credible 0:10:03.640 --> 0:10:06.079 when they speak, so they're less likely to be seen 0:10:06.120 --> 0:10:08.840 as trustworthy and less likely to be believed. 0:10:09.480 --> 0:10:10.439 And these, as I said, are. 0:10:10.360 --> 0:10:15.080 People who from minoritized groups, people of color, women, people 0:10:15.080 --> 0:10:18.040 who are very old or very young, people who are 0:10:18.120 --> 0:10:21.800 LGBTQ plus, so they're just less trusted and therefore less 0:10:21.840 --> 0:10:25.000 listened to. And I realize it's not just patients you 0:10:25.080 --> 0:10:29.760 go unheard in healthcare. It's also minoritized doctors, minoritized researchers, 0:10:30.160 --> 0:10:32.439 and this can happen at a global level as well. 0:10:32.760 --> 0:10:34.360 And that kind of thing about when you think about 0:10:34.360 --> 0:10:38.199 the patient doctor kind of contact thing, people are dismissed, 0:10:38.320 --> 0:10:40.559 they're not believed. They can feel like they're being gas lit. 0:10:40.760 --> 0:10:43.360 So you know, that's really that phrase, it's all in 0:10:43.400 --> 0:10:46.120 your head. They might feel like that, and they just 0:10:46.200 --> 0:10:48.640 may feel like they've been ignored. So they've gone, you know, 0:10:48.760 --> 0:10:51.600 at their most vulnerable with their concerns to their doctor, 0:10:52.200 --> 0:10:55.120 and the doctors kind of said okay, but then they 0:10:55.160 --> 0:10:57.640 haven't acted on their concerns, so perhaps you know, they 0:10:57.679 --> 0:11:02.000 haven't reassured them or refer them or done a test. 0:11:02.200 --> 0:11:04.360 So I think there are different ways in which people 0:11:04.360 --> 0:11:06.880 can feel unheard, but I think that feeling of being 0:11:06.880 --> 0:11:08.560 gas lit is a really common one. 0:11:09.480 --> 0:11:13.280 You also introduce the term epistemic injustice as a framework 0:11:13.360 --> 0:11:16.800 to understand the ways people feel unheard in medicine. Can 0:11:16.840 --> 0:11:19.280 you take us through this term in the different types 0:11:19.320 --> 0:11:20.679 of epistemic injustice. 0:11:21.679 --> 0:11:24.920 This was a term which comes from philosophy, So the 0:11:24.920 --> 0:11:28.480 British philosopher Miranda Frica coined it in two thousand and seven, 0:11:29.040 --> 0:11:32.360 and she basically define this as being a wrong occurring 0:11:32.400 --> 0:11:35.560 to someone in their capacity as a noah. So basically, 0:11:35.600 --> 0:11:39.040 as humans, we like to create knowledge and we like 0:11:39.080 --> 0:11:40.600 to be able to pass it on. It's part of 0:11:40.600 --> 0:11:42.679 what makes us human. And when we can't do this, 0:11:42.840 --> 0:11:46.000 we experience an injustice. And you know, this is one 0:11:46.040 --> 0:11:49.520 injustice amongst many other injustices that people who are minoritized 0:11:49.600 --> 0:11:53.040 might face. And there are a couple of types of 0:11:53.080 --> 0:11:57.319 epistemic injustice. There's one called hermeneutical injustice and one called 0:11:57.600 --> 0:12:00.440 testimonial injustice, and I talk about both, but I think 0:12:00.600 --> 0:12:03.800 I want to concentrate more on testimonial injustice here because 0:12:03.800 --> 0:12:07.880 I think it's something that people will identify with. With 0:12:08.040 --> 0:12:13.000 testimonial injustice, it's basically, when someone speaks, the listener is 0:12:13.080 --> 0:12:15.680 less likely to believe what they say or listen to 0:12:15.679 --> 0:12:18.680 them because they don't feel they're credible due to aspects 0:12:18.720 --> 0:12:21.679 of their social identity. So for example, if you are 0:12:21.760 --> 0:12:23.880 a woman of color, you may not be seen as 0:12:23.920 --> 0:12:26.200 being credible, so you're less likely to be listened to. 0:12:26.760 --> 0:12:31.280 So it's often minoritized people who experience this testimonial injustice, 0:12:31.320 --> 0:12:34.600 and they experience what's called a credibility deficit, so they're 0:12:34.600 --> 0:12:37.600 not seen as being credible speakers by the listener. And 0:12:37.679 --> 0:12:39.600 actually it can happen in the other way as well, 0:12:39.640 --> 0:12:42.360 so you can experience an injustice if you are taken 0:12:42.440 --> 0:12:46.040 too seriously, so you can have a credibility excess. So 0:12:46.440 --> 0:12:50.400 you know, quite commonly it's white men who speak on something. 0:12:50.520 --> 0:12:53.319 Actually they don't know that much about. I don't know 0:12:53.360 --> 0:12:54.319 if you've seen this anywhere. 0:12:54.640 --> 0:12:56.600 Noe, never, I've never experienced that. 0:12:58.280 --> 0:13:00.520 So they say something and people are like, yes, probably right, 0:13:00.600 --> 0:13:03.280 so I'll believe them. So they actually also experienced an injustice, 0:13:03.280 --> 0:13:05.400 but perhaps one that doesn't cause them harm so much. 0:13:06.200 --> 0:13:09.640 When a medical provider does not listen to or ignores 0:13:09.679 --> 0:13:13.400 their patient's concerns, that can impact both whether that person 0:13:13.640 --> 0:13:16.560 receives care at all, as well as the quality of 0:13:16.600 --> 0:13:19.480 care received. What are some of the immediate and long 0:13:19.559 --> 0:13:21.920 term health impacts of being unheard. 0:13:23.160 --> 0:13:25.640 So I think the most kind of immediate thing is 0:13:25.640 --> 0:13:28.440 that you just you don't get treated or diagnosed. So 0:13:28.600 --> 0:13:31.800 you're telling you know, your doctor your symptoms and then 0:13:31.840 --> 0:13:34.520 nothing is done, so you may not be referred for tests, 0:13:34.960 --> 0:13:37.240 so you may have like a delayed diagnosis, or you 0:13:37.280 --> 0:13:41.000 may have the wrong diagnosis misdiagnosis, or you may get 0:13:41.000 --> 0:13:44.040 the wrong treatment or no treatment at all. And I 0:13:44.040 --> 0:13:47.640 think in its extreme sense, it can be very dangerous. 0:13:47.640 --> 0:13:49.760 It can be very harmful. I think we see all 0:13:49.760 --> 0:13:53.640 the time in kind of patient safety reports. So for example, 0:13:53.640 --> 0:13:56.560 there's been a lot about maternal mortality, both here in 0:13:56.600 --> 0:13:59.480 the UK and in the US, and a lot of 0:13:59.480 --> 0:14:03.080 the reports say that women and their relatives say that 0:14:03.160 --> 0:14:05.520 they are not listened to or believed when they are 0:14:05.600 --> 0:14:08.880 experiencing care. So kind of at its worst, it can 0:14:09.040 --> 0:14:11.800 even cause death. In terms of kind of the more 0:14:12.080 --> 0:14:15.360 other long term things, I think if you are routinely 0:14:15.440 --> 0:14:19.040 not listened to by your health care provider, routinely not heard, 0:14:19.720 --> 0:14:21.880 it means that you're kind of less likely to go 0:14:22.000 --> 0:14:23.960 back to them, so you don't trust them. 0:14:24.000 --> 0:14:26.040 It increases mistrust. 0:14:26.040 --> 0:14:29.000 And you might think, you know, I actually don't want 0:14:29.040 --> 0:14:30.840 to tell them what's going on. So you may avoid 0:14:30.920 --> 0:14:34.160 healthcare or you may self censor. So if your doctor says, 0:14:34.160 --> 0:14:37.600 you know, what's happening with your treatment, how's it going 0:14:37.640 --> 0:14:40.200 for you, and you've told them time and time again 0:14:40.280 --> 0:14:42.960 that you're getting side effects, you might just give up 0:14:43.000 --> 0:14:45.760 and say, oh no, they're fine. But in your own time, 0:14:46.080 --> 0:14:48.400 just stop taking the tablets for example. So I think 0:14:48.480 --> 0:14:51.080 you can have, you know, a real effect of silencing 0:14:51.520 --> 0:14:54.119 mistrust and kind of health care avoidance. 0:14:55.440 --> 0:14:57.920 Let's take a quick break here, and when we get back, 0:14:58.040 --> 0:15:18.440 there's still so much to discuss. Welcome back everyone. I've 0:15:18.440 --> 0:15:22.040 been chatting with doctor Ragashri Derewan about her book Unheard, 0:15:22.120 --> 0:15:25.120 the Medical Practice of Silencing. Let's get back into things. 0:15:26.400 --> 0:15:30.120 The dismissal of patients by healthcare providers is not something 0:15:30.120 --> 0:15:33.640 that happens spontaneously, as you point out, it is an 0:15:33.720 --> 0:15:36.880 explicit and implicit part of training where the foundations are 0:15:36.920 --> 0:15:40.760 laid out for their hierarchical relationship between physician and patient. 0:15:41.240 --> 0:15:43.440 Can you talk about what that training is like and 0:15:43.520 --> 0:15:46.480 why it's viewed as an essential part of patient care. 0:15:47.680 --> 0:15:50.000 Yeah, so I talk quite a bit about medical school 0:15:50.120 --> 0:15:52.440 in one of the chapters because I think that's really 0:15:52.440 --> 0:15:56.280 where we start to develop this almost skepticism of the 0:15:56.320 --> 0:16:00.320 patients already coming from a thought that we don't believes 0:16:00.360 --> 0:16:02.600 right from the beginning. So one of the ways in 0:16:02.600 --> 0:16:04.920 which we talked about medicine, particularly in the West, is 0:16:04.960 --> 0:16:08.320 the bimedical approach. So this is where we think of 0:16:08.680 --> 0:16:12.440 the disease being separate to the patient, so it's not 0:16:12.560 --> 0:16:14.600 part of them as a whole. It's a separate thing. 0:16:14.720 --> 0:16:17.680 And our job as doctors is essentially to find the 0:16:17.760 --> 0:16:21.520 diagnosis and then treat the patient, So we don't really 0:16:21.560 --> 0:16:23.640 think of a patient as a whole, and it means 0:16:23.680 --> 0:16:26.560 that we don't necessarily provide holistic care. 0:16:26.680 --> 0:16:28.320 So it really teaches. 0:16:28.080 --> 0:16:30.880 Us to keep a distance from the patient, and it 0:16:30.960 --> 0:16:33.400 means that we're more likely to have boundaries. And I'm 0:16:33.440 --> 0:16:36.360 not saying boundaries are bad. Boundaries are a good thing 0:16:36.400 --> 0:16:39.920 as well, but sometimes when we have very rigid boundaries, 0:16:39.960 --> 0:16:42.160 we don't listen as well as we can do. And 0:16:42.240 --> 0:16:44.680 it means that we as a doctor, we hold the 0:16:44.720 --> 0:16:47.360 knowledge and the expertise, and it means that we can 0:16:47.400 --> 0:16:51.160 be very paternalistic because we think we know best, we 0:16:51.200 --> 0:16:53.960 know better than the patient themselves about their own bodies. 0:16:54.880 --> 0:16:58.520 And I think the other things about medical school is, certainly, 0:16:58.560 --> 0:17:01.680 you know, as medical students, you've come through so much 0:17:01.760 --> 0:17:02.920 to get to where you are. 0:17:02.960 --> 0:17:04.080 You know, you've passed. 0:17:03.840 --> 0:17:07.359 Exams, you are you know, some of the cleverest people 0:17:07.520 --> 0:17:12.000 at university, and you're taught together because you have long hours, 0:17:12.800 --> 0:17:15.840 so you kind of end up really being tight as 0:17:15.840 --> 0:17:18.800 a group. And I think that separation and that feeling 0:17:19.080 --> 0:17:22.800 of being special and separate to other students means that 0:17:23.080 --> 0:17:26.360 we can develop a sense of hubris or excessive pride, 0:17:26.400 --> 0:17:28.520 and again that can make us seem kind of more 0:17:28.640 --> 0:17:31.720 unapproachable and less empathic. And I think the other thing 0:17:31.720 --> 0:17:34.680 about the biomedical approach that I was saying is if 0:17:34.720 --> 0:17:38.600 our job as doctors is to diagnose and fix, that's 0:17:38.720 --> 0:17:40.760 what we think our role is, but we don't think 0:17:40.800 --> 0:17:43.879 about other ways in which we could treat patients. So, 0:17:44.600 --> 0:17:47.440 for example, there is value in more holistic care, and 0:17:47.480 --> 0:17:50.320 sometimes I don't think we think about that, So we 0:17:50.359 --> 0:17:53.760 are less likely to listen, for example, when someone is 0:17:53.760 --> 0:17:56.399 telling us something that we don't know how to fix. 0:17:56.600 --> 0:17:59.280 So if someone, for example, has an issue with chronic 0:17:59.359 --> 0:18:02.960 pain and we don't know what to do about it, 0:18:03.000 --> 0:18:05.800 then we find that uncomfortable because we can't fix them, 0:18:05.920 --> 0:18:08.480 and that makes us really question our role as doctors, 0:18:08.920 --> 0:18:11.080 so we might be more likely to shut them down 0:18:11.320 --> 0:18:13.960 and not listen to them. But I think if we 0:18:13.960 --> 0:18:17.000 were taught to find more value in listening as being 0:18:17.080 --> 0:18:21.080 therapeutic in itself, so being witnessed to somebody who is suffering, 0:18:21.600 --> 0:18:24.040 then I think we would see our role as being 0:18:24.080 --> 0:18:27.000 more healers rather than fixers, and we would be better 0:18:27.040 --> 0:18:29.960 at listening in that way. And there's a couple of 0:18:30.000 --> 0:18:32.760 other things at medical school which I think contribute to 0:18:32.840 --> 0:18:34.119 this not listening as well. 0:18:34.800 --> 0:18:36.280 We learn very early on to. 0:18:36.240 --> 0:18:38.760 Be very focused with our history taking, and you know, 0:18:39.160 --> 0:18:41.560 that is a good thing because you know, we need 0:18:41.600 --> 0:18:44.040 to find out what's going on with the patient, but 0:18:44.160 --> 0:18:46.800 sometimes it means we kind of strip away everything else 0:18:46.840 --> 0:18:49.800 that we don't think is important, and again that makes 0:18:49.880 --> 0:18:54.199 us not as good listeners. I have this concept in 0:18:54.240 --> 0:18:57.879 the book of something called the ideal patient. So you know, 0:18:58.240 --> 0:19:01.240 someone has a heart attack, they present in a specific way, 0:19:01.800 --> 0:19:04.480 we kind of know what we expect them to say, 0:19:04.480 --> 0:19:07.160 but if they present in an atypical way or they 0:19:07.200 --> 0:19:10.480 respond in a way that we don't necessarily expect them 0:19:10.480 --> 0:19:12.840 to that we haven't been taught to that we're more 0:19:12.960 --> 0:19:15.439 likely to be skeptical of them and doubt them and 0:19:15.440 --> 0:19:17.760 not listen to them. So I think there's lots of 0:19:17.760 --> 0:19:19.680 things in medical school in the way that we're taught 0:19:19.720 --> 0:19:22.160 which really makes it less easy for us to learn 0:19:22.200 --> 0:19:23.040 to listen better. 0:19:24.359 --> 0:19:27.520 Also, in your book, you present these quotes from the 0:19:27.720 --> 0:19:32.680 thirteenth and seventeenth century discussing how or instructing physicians to 0:19:32.920 --> 0:19:36.240 doubt their patients and question their intentions. So it goes 0:19:36.280 --> 0:19:39.200 back literally like we're fighting hundreds of years of this. 0:19:39.960 --> 0:19:43.480 How is this tendency to doubt still reflected in the 0:19:43.600 --> 0:19:47.320 language used in medicine and enabled by the power dynamic 0:19:47.400 --> 0:19:49.359 of physician patient relationships. 0:19:49.920 --> 0:19:52.800 So I was really shocked when I found how long 0:19:52.840 --> 0:19:54.760 it has been going on for actually, like I didn't 0:19:54.800 --> 0:19:58.040 realize it had gone on for so long. So yeah, 0:19:58.040 --> 0:20:00.959 I think it is ingrained in our profess and ingrained 0:20:00.960 --> 0:20:03.960 in our language. So for example, I think, you know, 0:20:04.080 --> 0:20:06.840 we use language which kind of puts a patient at 0:20:06.880 --> 0:20:10.600 a distance and has kind of innate skepticism in it. So, 0:20:10.800 --> 0:20:13.080 for example, some of the medical language, we may use 0:20:13.160 --> 0:20:16.840 terms like the patient denied or the patient claimed, so 0:20:17.080 --> 0:20:20.480 that's kind of inherently skeptic of the patient, or it 0:20:20.560 --> 0:20:24.159 might be derogatory language. So there's a term that we 0:20:24.320 --> 0:20:26.639 use here in the UK. I'm not sure if you 0:20:26.680 --> 0:20:28.920 guys use it in the US, but what we call 0:20:28.920 --> 0:20:32.000 a heart sink patient, so someone when we see them, 0:20:32.119 --> 0:20:33.600 we know, oh, gosh, this is going to be a 0:20:33.640 --> 0:20:37.199 difficult consultation, and we can sometimes use language that is 0:20:37.280 --> 0:20:41.320 victim blaming and language that is paternalistic. So I work 0:20:41.359 --> 0:20:44.640 in HIV medicine where we really want patients to take 0:20:44.680 --> 0:20:47.600 their tablets every day. It's very important, but we talk 0:20:47.640 --> 0:20:51.320 about patient compliance and you know that sounds like a 0:20:51.400 --> 0:20:54.600 very paternalistic attitude to patients. It's not a very patient 0:20:54.640 --> 0:20:58.280 focused language. So I think it really is inherent in it. 0:20:58.800 --> 0:21:00.760 And the other thing is there is a lot of 0:21:00.880 --> 0:21:04.800 use to humanizing language. So again from my specialty of HIV, 0:21:05.040 --> 0:21:07.240 you know, you can see people saying things like the 0:21:07.440 --> 0:21:10.200 HIV patient, but there's been a real shift to talking 0:21:10.200 --> 0:21:14.399 about people living with HIV, so being person focused first. 0:21:15.600 --> 0:21:20.040 If the problem of silencing patients begins during medical training, 0:21:20.160 --> 0:21:23.040 and also like hundreds of years in the making, it 0:21:23.119 --> 0:21:27.000 is only exacerbated by the way modern medicine is practiced, 0:21:27.160 --> 0:21:31.800 where the emphasis tends to be on maximizing productivity. In 0:21:31.880 --> 0:21:35.760 what ways does the medical system hinder or even discourage 0:21:35.760 --> 0:21:38.840 physicians from adequately listening to their patients. 0:21:39.480 --> 0:21:41.280 So I think you're really right when you talk about 0:21:41.280 --> 0:21:44.760 that emphasis on productivity. So it's you know, numbers of patiency, 0:21:45.080 --> 0:21:49.040 number of tests done, number of diagnoses, number of treatments. 0:21:49.080 --> 0:21:50.639 You know, we get paid on that. 0:21:51.280 --> 0:21:55.720 And really what isn't valued are those consultations where listening 0:21:55.760 --> 0:21:58.480 in itself is therapeutic. So you know, we're not going 0:21:58.520 --> 0:22:01.199 to get paid for just you know, listening to a 0:22:01.280 --> 0:22:04.359 patient who is having a hard time and at the 0:22:04.440 --> 0:22:07.720 end of the consultation leaves feeling better because they feel 0:22:07.720 --> 0:22:10.560 like someone has hurt them. So that just isn't valued 0:22:10.600 --> 0:22:13.040 by our medical systems. You don't get money for that. 0:22:13.800 --> 0:22:17.480 And because there is an emphasis on productivity, it means 0:22:17.480 --> 0:22:20.359 that we are often short of time, so we often 0:22:20.840 --> 0:22:23.320 too busy to listen. Well, we're looking at our watches, 0:22:23.400 --> 0:22:26.080 were needing to go on to the next patient. We 0:22:26.200 --> 0:22:29.119 work in environments that aren't very good for listening, so 0:22:29.600 --> 0:22:33.520