Wen: The Doctor Is (Not?) Listening

An Interview With Dr. Leana Wen

Disclosures

October 26, 2015

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Editor's Note:
In part 2 of Medscape editor-in-chief Eric J. Topol's One-on-One interview with Leana Wen, MD, MSc, city health commissioner of Baltimore, Maryland, Dr Wen discusses the book she coauthored, When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests (St. Martin's Press), and the initial backlash she experienced following her 2014 TED Talk "What Your Doctor Won't Disclose."

Dr Wen entered college at age 13 after coming to the United States 5 years earlier from her native China. She initially worked as an emergency medicine physician in Boston before becoming Baltimore's health commissioner in January 2015.

Meet Leana Wen

Eric J. Topol, MD: This is Eric Topol, editor-in-chief of Medscape. I have a terrific guest with me today, Dr Leana Wen from Baltimore, Maryland. Dr Wen is the city's health commissioner. Welcome to Medscape.

Leana Wen, MD, MSc: Thank you. I'm a big fan of your work and am delighted to be able to speak with you and your readers and viewers.

Dr Topol: You are quite a fascinating person. We met at the Aspen Ideas Festival and now we are finally getting a chance to talk about your background, as well as what is going on in Baltimore.

You came to the United States from China at around age 8, and you started college at age 13; is that right?

Dr Wen: I was very lucky early on to have good mentors, but also to have the inspiration of my mother, who always emphasized that education is the most important thing. I didn't speak English when I came to this country; we were immigrants. We lived in some very difficult areas—very economically challenged areas of east and south Los Angeles. My classmates were teen moms. They were the victims and perpetrators of gun violence. I saw what happens with substance addiction and when there is a lack of mental and physical health services. That is what inspired me to enter medicine and, in particular, to focus on public heath—the underlying issues about why we are here today.

Dr Topol: It's extraordinary that you had a jump-start at an early point in your life. You went from Cal State [California State University] to Washington University for medical school; is that right? And then you were a Rhodes Scholar?

Dr Wen: Right. I was fortunate during my medical education to have some tremendous mentors who helped me figure out what I wanted to do. Early in medical training, we are all idealistic. We all want to do the right thing. We all enter medicine for the right reasons. But I didn't know where I should go. I remember being in my second year of medical school, and I was dispirited because I didn't think I entered medicine to study science—I mean, I wanted to be evidence-based and science-focused, but it just wasn't the right fit. I kept on thinking about what I should be doing to help my community. How can I be an advocate for my patients? I'm very lucky to have had people to encourage that path instead of telling me, "Well, that is not for you" or "Forget about doing this in your medical career."

Never Turning a Patient Away

Dr Topol: You decided to become an emergency medicine specialist. What prompted you to go into that discipline?

Dr Wen: I loved the idea of never turning away any patient. I wanted to be able to treat anyone who came through my door, regardless of whether it was a 3-week-old baby or a 98-year-old woman, and to be able to treat traumas and medical emergencies. I wanted to feel that, regardless of whether patients had any ability to pay, I would treat them with the same dignity and respect, and give them the same medical care as a member of Congress who might walk through my door would get.

I wanted to feel that, regardless of whether patients had any ability to pay, I would treat them with the same dignity and respect, and give them the same medical care as a member of Congress who might walk through my door would get.

One of my mentors in emergency medicine would say, "This is the one field where we can treat every single person with the human dignity and respect that they really deserve."

Many of our patients are homeless. They are addicted to drugs. They were recently incarcerated. They don't have people who are kind to them. They are seen as "that guy down the street who we see all the time," "the homeless guy," "the drunk guy," or whatever adjectives that we may use. This is our opportunity to treat every individual the same and to give them that basic human respect.

In the emergency room (ER), we are the front doors of public health in every way. We see what happens with infectious disease outbreaks. We are dealing with a possible case of measles here in the city as we speak. We also see violence as a public health issue. We see how unsatisfying it can be at times, when we know that these patients need more than sleeping off an opioid overdose. They don't need just Narcan®. What they need is attention to their undiagnosed mental illnesses, housing, food, and assistance for their other social needs. It's in the ER that we see all of these problems, and in the ER we can intervene to get to the core of what our patients need.

Why Aren't We Listening?

Dr Topol: You make a terrific case for the ER as the front door of public health. Before we get into your responsibility for Baltimore's public health, let's talk about your blog. You began blogging about the issue of doctors listening and were one of the early members of the medical community to start blogging. Can you tell us why you did it and where that experience led you?

Dr Wen: It was born out of an unfortunate experience, one that is deeply personal to me. When I was a second-year medical student, my mother was misdiagnosed for more than a year before she was finally diagnosed with what turned out to be metastatic breast cancer. The cancer was, by then, widely spread, to her lungs, her bones, and her brain. The course of her illness coincided with my medical training. I saw how much doctors mean to do well. My classmates, professors, attendings, and residents all mean to do the right thing. But it is still separate from what our patients and our family members are experiencing. I saw that side of it, too. I saw the disconnect that occurs.

How can we focus on the fact that 80% of diagnoses can be made by listening?

It's nobody's fault, but there are things that we can do. There is low-hanging fruit, but we can also focus on the bigger picture of how to encourage doctors to listen better to their patients. How can we focus on the fact that 80% of diagnoses can be made by listening? How can we go back to the diagnosis and why it is so central? How can we do patient-centered care and not just check off a box saying, "We have consulted a patient and therefore it's patient-centered," or "We have talked to one community member and that's community participatory research"? There is a tendency for all of us to say, "We have done it. We did this very basic thing and we're done." But how can we focus on what it means? So I started blogging, writing, based on my mother's experience, based on my own experience going through medical training and as a caregiver. That is what led me to write my blog, The Doctor is Listening, and also my book, When Doctors Don't Listen.

Getting Away From Unnecessary Tests, Misdiagnoses

Dr Topol: In your book, you discuss not just the power and importance of listening, but also the propensity for misdiagnoses and unnecessary tests, and you have waged a strong campaign on that. How do we get rid of all of these unnecessary tests and get the misdiagnoses on track? Approximately 12 million serious misdiagnoses are made in the United States every year. Besides better listening and connecting with patients, do you have any other thoughts about how we can progress?

If we could invent a test that would give us the right diagnosis 80% of the time ... We would be investing millions, if not billions, of dollars in it. Instead, as a result of technology and pressure on a doctor's time, we are spending less and less time listening.

Dr Wen: I have three quick suggestions. Better listening is critical. I find the 80% figure for "diagnosis from listening" astounding. If we could invent a test that would give us the right diagnosis 80% of the time, we would consider it a miraculous test. We would be investing millions, if not billions, of dollars in it. Instead, as a result of technology and pressure on a doctor's time, we are spending less and less time listening. A lot of what I did in academic medicine was to teach, "If we can listen in the extremely busy and chaotic setting of the ER, and if we can focus on our patient, not only will it save time, but it will also present misdiagnoses." Teaching about listening, and then modeling that behavior, is really important.

The second suggestion is to focus on not just what the patient doesn't have but on what they do have. A patient comes in with chest pain and leaves with a diagnosis of chest pain. What does that really mean? We say, "We have ruled out pulmonary embolism, myocardial infarction, and broken ribs," but what is causing this patient's chest pain? Why are we so hesitant to say, "This is musculoskeletal chest pain" or to say, "This is gastroesophageal reflux disease" or "This is cholecystitis"? Whatever that hesitation is, we need to get away from it as clinicians, and we also have to encourage our patients to actively be involved in this process.

Rather, for patient environment, I would encourage patients to really understand themselves, to tell a better story, and not be afraid to advocate for themselves, but in a way that is collaborative with their physician.

The third tip is patient empowerment. People might think of patient empowerment as when a patient brings a stack of papers and asks for five MRIs and three medications. I would say that this is not the right approach, because it implies that you don't trust your doctor and that you know what is best. Rather, for patient environment, I would encourage patients to really understand themselves, to tell a better story, and not be afraid to advocate for themselves, but in a way that is collaborative with their physician.

A Request for Transparency, Followed by a Backlash

Dr Topol: More than 1 million people have watched your TED talk. You are kind of a rebel. You get the docs going by saying that they need to be transparent—the Who's My Doctor? thing had some backlash. Can you tell us about that movement? That has been in parallel to listening and connecting better with patients. It's about establishing transparency, and some doctors didn't like that, right?

Dr Wen: When I was a medical student, I didn't think about taking lunch from drug companies or about all of our orientation materials. That was just what was done. We never thought that there might be something wrong with this. The time that it came to my consciousness was when I was dealing with my mother, and she had found an oncologist who she really liked and trusted. One day she lost his phone number and tried to look him up on the Internet. She found his phone number, but she also found—because he had a fairly distinctive name—that he was a highly paid consultant for a drug company and often spoke on behalf of the same chemotherapy regimen that he had prescribed for her. It made me wonder. It created a barrier between her and her doctor. She wasn't sure why he was recommending something for her—whether it was in her best interest or his. I began thinking that I never wanted to be that doctor and have a patient who was afraid to come to me because they didn't know why I was prescribing a particular medication, whether it benefited me in some way. The "Who's My Doctor?" campaign is our attempt to say, "We have a responsibility to our patients to be totally transparent. Our patients are coming to us at a time of extreme vulnerability." Very few patients, if any, are going to ask me, "Do you take money from drug companies?" or "Are you affiliated with a medical device company?" I don't think I have ever been asked that. It's my responsibility to monitor my own conflicts but also to disclose them to my patients.

Dr Topol: With it being voluntary, why do you think so many doctors revolted against this concept?

Dr Wen: It's the "you but not me," concept, right? Going back to my book, When Doctors Don't Listen, when I first wrote it, I thought doctors were going to hate me. The main thing that I am saying is that doctors aren't listening and that we should be doing better. Doctors would say, "I totally agree. This is a big problem in the medical profession. I am the doctor who listens; these other doctors, they are the ones who don't listen." We see the same thing, in which studies have been done about whether doctors perceive conflicts of interest with drug companies. They will say that other doctors are influenced, but that they themselves are not. By disclosing, I assume that these doctors are saying, "Look, somehow this is implying that I am influenced, and I should be immune from that." Dozens of studies show that we are influenced by drug company advertising and marketing, or else why would they bother doing it?

Dr Topol: You are definitely taking on some tough initiatives that will not necessarily make you popular in all medical circles, and you should be given a lot of credit for that. It's not easy to do. Readers can watch your TED talk and find out about what you had to confront.

It has been great to have a chance to visit with you and for a lot of the Medscape community—physicians and health professionals—to get to know you. We are going to be watching your career. You have many more decades ahead, and you have already had an extraordinary impact at a very young age.

Dr Wen: That's extremely kind of you, Dr Topol. I have the best job in the world.

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