Entering a career in medicine comes with many challenges: navigating your way through a practice or specialty that's new to you, learning how to interact with patients as a newbie provider, and having confidence in your (somewhat untested) ability.
However, one of the most significant difficulties we face in practicing medicine is learning how to be quiet.
Being quiet may seem like a simple charge, but in practice, it's quite tough to do—especially if you're new to it.
As a brand new PA, you'll want to prove yourself. You'll want your patients to feel like they're in good hands and your colleagues to think you are capable.
To accomplish this, we talk. And talk. When a patient asks a question, we are quick to respond, happy to know and share the right answer.
I remember the early days of my PA career very distinctly. I remember the relief I would feel when a patient presented with a complaint I thought I could solve. The pride of providing an answer I was sure of to a patient's question. The gratitude for making it through an entire visit able to answer every question they had.
As a new PA, I always had a lingering feeling of "I hope I'm gonna be able to handle this one" right before I entered a patient's room. Often, to prove I was capable, I spent a lot of time covering details of the diagnosis and treatment plan, essentially trying to show patients I knew what I was doing.
But, I didn't quite see how much I might be missing with that approach until over a year into practice when I moved across the country to start a new position.
I moved from one oncology position to another, so the specialty was the same, and I kinda knew what I was doing. But I wanted to learn the practice style of my new collaborating physician in those first few weeks, so after seeing patients solo, I'd go back into rooms with him to see how he did things.
He was quiet. When he'd ask the patient a question, he'd wait patiently for an answer. Then, he'd wait for an extra beat or two after they answered before responding. If you timed it, it was probably 4 seconds or less. But, it felt like all the time in the world.
In those moments, patients moved past questioning the technical details of their treatment and asked the profound, life-altering questions.
Those extra few seconds of silence changed how patients perceived him. They were willing to share more, be more vulnerable, and came to trust him more quickly.
Why it works
I've never seen another tactic work so well or so consistently as being quiet with patients. It utilizes none of your medical training, but it makes you a better provider.
You won't be showing patients how much you know, but you'll gain their trust faster.
To a provider, it is just a moment. But, to a patient, it is an invitation.
As a newish PA, that invitation can be a bit scary. Encouraging patients to ask more questions can feel like dangerous territory.
What if you don't know the answer?
Aren't you risking looking foolish and losing their trust?
But, a curious thing happens when you give patients this space. Often, they don't ask questions right away. They tell you more about themselves. They explain that they are worried about how being sick might affect their work or their children.
When they do ask extra questions, they are generally grateful for the opportunity to ask, regardless of whether you have the answers.
Often, the patients who "don't want to waste your time" are the ones that need it the most. When you give patients the room they need to share, they won't feel like you're rushed or too busy to spend time with them.
How to do it
There are a few ways to give patients the space to ask questions. Certainly, you can ask if they have questions. But, there are other better ways to invite them to talk.
When you merely ask if they have questions, they may feel like it is a burden to you if they do. Instead, you can invite them to share their thoughts in a way that feels more like you have the time to listen.
So, if a patient doesn't pose questions right away, you might ask them;
"What are your thoughts on the information I've shared so far?"
"What are your concerns with the treatment?"
"What questions do you have for me?" (This is different than "do you have any questions?" and invites an answer that is more than a yes/no response.)
When your patient shares information, wait for a few beats before chiming in with your response. In that time, you might get a more detailed question, or you might get to the "real" questions faster.
Once patients share their questions or thoughts, keep it going. Ask, "And what else?" Keep asking this question until they're out of material.
Their "real" questions, the ones that they're afraid or embarrassed to ask, will be buried under a few introductory issues. You have to keep going if you want most patients to share their most essential questions.
If you practice having quiet moments with patients, you'll see immediate positive effects.
Patients will trust you more readily. When you give them the opportunity to talk, they will feel more comfortable sharing information. When you don't seem to be rushing off to the next patient, they're more likely to believe you care about treating them. You won't have to show off any fancy knowledge to earn their trust; you only have to listen to them.
Patients will also often open up to you more quickly, and you'll be able to get at the heart of their concerns faster.
Visits will be more relaxed for both you and your patients. By focusing on their concerns, you can be assured that you are providing exactly the care they were seeking when they sought out your help. You won't have to probe deeply to get answers; the patient will bring them to you.
Things I learned in the void
While it took me over a year to adopt this approach into my practice, I've now spent over a decade using it. I can attest to the strength of silence and the information it uncovers.
There are too many things to count that I've learned about patients by taking a few moments to be quiet.
But there are some that stand out.
A long-term patient of ours had a 5-year history of cancer, but she had a period of being cancer free for a couple of years in that stretch until it had come back three months earlier. Three months into her latest chemotherapy, which she came for every two weeks, she told me that hadn't yet told her family about the recurrence because she didn't want to disappoint them. (She shared the news of her diagnosis with her family the following week, they were incredibly supportive, and they started coming with her to appointments.)
A gentleman who was super reliable when it came to making his follow up appointments in the past had a streak of not showing for visits. Given a few extra moments of silence in a visit, he explained that he was worried about missing work and losing his job and, consequently, health insurance for his kids. (We connected him with a social worker and created backup plans for health care for both him and his children, so he was able to receive the care he needed.)
I was on a call with a terminally ill patient in her forties who resided out of state when I learned, during an intentionally long pause, that she was a victim of domestic abuse and was fearful of what would happen to her young child in the future if she left her husband. (We connected her with resources in her area. She was able to make arrangements for her daughter to be safe long before her passing.)
One patient was with us for 11 years with stage 4 colorectal cancer. If you don't know, that's an insanely long survival for a diagnosis with an average prognosis of 2-3 years. In his last few months, he shared with me that he was leaving his business to his employees because they had been there to support him through so many years of treatment. I knew before they did, and I got to chat about him at each visit and share in his excitement over breaking the news. (Non-healthcare stuff is important too. Patients want to be known as people, and it creates a patient-provider connection that is unparalleled.)
My examples are always rooted in cancer because I've practiced in cancer medicine since the beginning of my career. You might be tempted to think that I believe in giving patients more space to talk because they are facing something severe, and the same doesn't apply to other practices.
But, the importance of silence is not limited to areas of medicine with the scariest diagnoses.
While giving patients enough opportunity to "have the floor" is important in any specialty, it's especially relevant to those who practice in areas that are "gateways" to medical care - like emergency medicine, family practice, urgent care, and women's health.
These areas of medicine are often the starting point for patients, whether they are seeking routine care or assessment of particular symptoms. Allowing patients the window to share any concerns can provide you with the opportunity to treat them more holistically and equip them with education on preventative care.
Along with the immediate impact, taking time for silence with your patients also has positive, long-term effects.
Being quiet helps to build strong patient-provider relationships. When patients know they can easily talk to you, they will more readily discuss concerns that they'd be embarrassed to tell another provider. They will ask you to weigh in on a symptom their sister is having, hoping you can give some guidance.
When patients grow to trust you, they will more easily forgive you for accidentally sending their prescription to the wrong pharmacy, or forgetting to send it at all. They won't question your ability with you don't have an immediate answer to what caused the rash on their back. They'll be cool when the clinic is running late and they still haven't been seen an hour after their scheduled appointment.
In the long run, you'll grow more comfortable with the moments of silence. The fear of being asked a question you don't know the answer to will wash away. Your confidence in your ability to serve patients will increase.
And, when you see returning patients who you've developed this flow with over time, the visits will go a little faster. Once they know they can get straight to the "good stuff" with you, they will be more comfortable asking tough questions from the start.