This Podcast Will Kill You - Special Episode: Dr. Rageshri Dhairyawan & Unheard

Episode Date: July 16, 2024

Going to the doctor is probably not at the top of anyone’s list of enjoyable activities, but when we do go, we expect and deserve to be heard, to have our concerns listened to and our questions answered. However, most, if not all, of us have at some point felt unheard, dismissed, or even gaslit by our healthcare provider. What is it about the doctor-patient relationship or the way medicine is practiced today that enables this miscommunication or mistreatment, and how can we make things better? In Unheard: The Medical Practice of Silencing, author Dr. Rageshri Dhairyawan draws upon her experience on both sides of the patient-physician relationship to explore these questions in depth. Dr. Dhairyawan, who is a sexual health and HIV doctor with the NHS as well as a health equity researcher and science communicator, demonstrates with clarity and compassion how each dimension of healthcare, from training to research and beyond, can contribute to this pattern of patients going unheard. Tune in to this fascinating discussion today! See omnystudio.com/listener for privacy information.

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Terms and conditions apply. Visit blueapron.com slash terms for more information. I'm Amanda Knox, and in the new podcast, Doubt, the case of Lucy Letby, we unpack the story of an unimaginable tragedy that gripped the UK in 2023. But what if we didn't get the whole story? Evidence has been made to fit. The moment you look at the whole picture, the case collapsed. What if the truth was disguised by a story we chose to book?

Oh, my God, I think she might be innocent. Listen to Doubt, the case of Lucy Letby on the Iheart Radio app, Apple Podcasts, or wherever you get your podcasts. I'm Clayton Eckerd. In 2022, I was the lead of ABC's The Bachelor. But here's the thing. Bachelor fans hated him. If I could press a button and rewind it all I would. That's when his life took a disturbing turn.

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Hi, I'm Aaron Welsh, and this is This Podcast Will Kill You. You are listening to the latest episode in our special series we're calling the TPWKY Book Club. This isn't your typical book club where you spend. and about 10% of the time talking about the actual book selection and the other 90% eating tasty snacks and drinking tasty drinks and talking about a million other things, which I absolutely love, by the way, shout out to my real-life book club. In the TPWKY book club, which I also adore,

we're staying on topic, getting to hear directly from the authors themselves about what inspires them, how writing changed their outlook, what they most want people to take away from their book, and so much more. So far this season, we've explored books on topics ranging across the fields of medicine, science, and history, and there is still so much more to come. If you'd like to check out the full list of books we've covered so far and the ones later to come,

check out our website, This Podcast Will Kill You.com, where under the extras tab, you'll find a link to our bookshop.org affiliate page. There, we have several TPWKY book lists covering everything podcast-related, including a book club list, where you can see. see all of the books featured in these book club episodes. And one last thing before we get into the book of the week, that is to please rate, review, subscribe. It really helps us out so much. And also share your thoughts with us. We always love to hear from you. Think of the last time you spoke with a doctor about a concern that you had. How long did the doctor spend with you? Do you feel like

they were present in the room or did they seem distracted? Checking emails, typing up notes with half a mind on the conversation. Did you get all of your questions answered? Did the doctor give you time to ask questions? How did you feel at the end of the appointment? Did you feel listened to, understood, cared after, reassured? Or did you feel gaslit, condescended to, dismissed, unheard? Hopefully your experience falls into the first category of emotions, but I know that many, if not all of you, have at some point or another been made to feel the latter. Going to, a doctor's appointment, whether for a routine checkup or a specific problem or concern, can be a very vulnerable experience. It's no exaggeration to say that you are putting your

life and health into their hands. And when that trust is broken, the damage can be severe, both in the short as well as the long term. What is it about the physician-patient relationship and the way that medicine is practiced today that lends itself to this pattern of dismissal? That's exactly what Dr. Raghashri Darawan explores in unheard, the medical practice of silencing. Dr. Darwan, who is a sexual health and HIV doctor with the NHS, as well as a health equity researcher and science communicator, draws upon her own experience as both patient and physician to examine this nuanced topic from multiple perspectives. Through her research, she demonstrates that this problem of silencing patients is not a matter of a few doctors acting negligent or being to, exhausted to properly listen, but rather a systemic issue in medicine, where the foundations of

patient dismissal are laid out during medical school training and perpetuated by the medical system. And as minorized groups are disproportionately more likely to be silenced by their health care providers, they are also more likely to suffer the negative health consequences that being unheard carries with it. Compounding this are the knowledge gaps that tend to be wider for conditions primarily impacting minoritized groups, a reflection of research priorities that designate funding and resources to more prestigious diseases. To say this matter is complex is an understatement in the extreme. Fortunately, Dr. Darawan's clear and compassionate approach in unheard expertly guides readers through the factors enabling the continued silencing of patients and, crucially, suggests how

positive change can be made by individuals during training. at an institutional level and at a systemic level. I truly loved this book and this conversation for getting to the heart of this issue, for exploring not just why does it happen, but also providing a roadmap for how it can get better. And I am so excited to share this conversation with you all. So let's get into it. Dr. Darawan, I'd like to just first thank you so much for chatting with me today. Welcome to The This Podcast Will Kill You Book Club. Thank you so much for the invite, and I'm really, really excited to be here. Your book, Unheard, The Medical Practice of Silencing,

was a truly compelling blend of infuriating and enlightening, and I suspect that it will resonate with many, many people. I also think it should probably be required reading for medical practitioners as a part of both initial and continued training. Can you describe your journey to writing this book and how your experience on both sides of the power dynamic, as both physician and patient influenced the approach that you took? So I think it's been coming for a really long time.

And kind of this year is my 20th year of being a doctor. So, you know, probably all of my career it's been coming. And my work, my day work is I work in sexual health and HIV. So I work with some really kind of minoritized patients who are people who aren't heard generally in policy, who, you know, who are often very poor. They have HIV, stigmatizing disease. So part of that is my work with them. think, but what really instigated the book were my experiences as being a patient. So I was diagnosed

of endometriosis when I was trying to get pregnant, which was unsuccessful and kind of went on to have fertility treatment. And during one of those fertility cycles, I was on a lot of hormones and I developed really, really bad abdominal pain, like excruciating pain, the worst I'd ever had. So my husband took me to the emergency department. Initially, I was seen, I was given, you know, really strong painkillers, and then I was admitted to the ward. And they were really worried that I had this thing called ovarian torsion, which is when the ovary is so big from the hormonal stimulation

that it twists on itself and you need urgent surgery. But a scan showed I didn't. But I was still in a lot of pain, which they thought was due to kind of a flare-up of the endometriosis from the hormones. And whilst on the ward, I asked for more pain relief, I was refused it. Basically, the medical team didn't seem to believe that I was in so much pain. They treated me like I was just trying to get morphine because I wanted it. And it was a really shocking experience for me. At that point, I'd been a doctor for quite a long time and was quite

senior. And I just thought, you know, if this could happen to me, this experience of being disbelieved when asking for pain relief, what on earth happens to everybody else? And in the end, I needed you know, my partner to advocate for me. I thought, you know, what if you can't speak English? What if you don't have a partner? I know how the healthcare system works. What if you don't know how it works? What happens to everyone else? So that was really what instigated it. And also the fact that at the time I didn't complain and I didn't complain afterwards either. I felt really ashamed and I felt silenced for quite a long time. And it wasn't until kind of maybe six or seven years later that I started to do some writing and I ended up writing about this and really reflecting on why did I feel so silenced.

And this really came together into the book. But also the fact, you know, I'm a patient, but I'm a doctor patients. I'm not just any old patient. And I'm a doctor and I know very well that despite my best intentions, I don't always listen well. And, you know, much as I love to say that every single patient I've seen will say they had the best experience with me, that's probably not true. So I thought the book was a really good opportunity. to look at why we don't listen and who doesn't get listened to. In your book, you use the terms deliberately silenced and preferably unheard to describe those patients who are ignored by medical practitioners. Who are those individuals most likely to be?

And what does being silenced or unheard look like? Because it can be a great many things, sometimes maybe not as obvious as just like thinking about, oh, someone is going, I don't believe you. Like that is not often how it comes out. I think when I started the book, I thought it was just some people who go unheard. But during my research, I actually found out that actually all patients go unheard. I'm sure we'll talk more about why that is. But obviously, some patients go more unheard than others.

And these are often people from minoritized groups. So these are people who when they speak, they seem to be less credible when they speak. So they're less likely to be seen as trustworthy and less likely to be believed. And these, as I said, are people from minoritized groups, so people of colour, women, people who are very old or very young, people who are LGBTQ plus. So they're just less trusted and therefore less listened to. And I realise it's not just patients who go unheard in healthcare, it's also minorised doctors, minorised researchers, and this can happen at a global level as well.

And that kind of thing about when you think about the patient doctor kind of contact thing, people are dismissed, they're not believed, they can feel like they're being gaslit. So, you know, that's that really, that phrase, it's all in your head. They might feel like that. And they just may feel like they've been ignored. So they've gone, you know, at their most vulnerable with their concerns to their doctor. And the doctors kind of said, okay, but then they haven't acted on their concerns. So perhaps, you know, they haven't reassured them or referred them or done a test.

So I think there are different ways in which people can feel unheard. but I think that feeling of being gaslit is a really common one. You also introduce the term epistemic injustice as a framework to understand the ways people feel unheard in medicine. Can you take us through this term and the different types of epistemic injustice? This was a term which comes from philosophy. So the British philosopher Miranda Fricker coined it in 2007. And she basically defined this as being a wrong occurring to someone in their capacity as a knower. So basically, as humans, we like to create knowledge and we like to be able to pass it on.

It's part of what makes us human. And when we can't do this, we experience an injustice. And, you know, this is one injustice amongst many other injustices that people who are minorities might face. And there are a couple of types of epistemic injustice. There's one called hermeneutical injustice and one called testimonial injustice. And I talk about both, but I think I want to concentrate more on testimonial injustice here because I think it's something that people will identify with. With testimonial injustice, it's basically when someone speaks, the listener is less likely to believe what they say or listen to them

because they don't feel they're credible due to aspects of their social identity. So, for example, if you are a woman of colour, you may not be seen as being credible, so you're less likely to be listened to. So it's often minorised people who experience this testimonial injustice and they experience what's called a credibility deficit. so they're not seen as being credible speakers by the listener. And actually, it can happen in the other way as well. So you can experience an injustice if you are taken too seriously.

So you can have a credibility excess. So, you know, quite commonly, it's white men who speak on something actually they don't know that much about. I don't know if you've seen this anywhere. No, never. I've never experienced that. So they say something and people are like, yes, they're probably right, so I'll believe them. So they actually also experience an injustice, but perhaps one that doesn't. doesn't cause them harm so much. When a medical provider does not listen to or ignores their patient's concerns, that can impact both whether that person receives care at all, as well as

the quality of care received. What are some of the immediate and long-term health impacts of being unheard? So I think the most kind of immediate thing is that you just, you don't get treated or diagnosed. So you're telling, you know, your doctor, your symptoms, and then nothing is done. So you may not be referred for tests. So you may have like a delayed diagnosis or you may have the wrong diagnosis, misdiagnosis, or you may get the wrong treatment or no treatment at all. And I think in its extreme sense, it can be very dangerous. It can be very harmful. I think we see all the time in kind of patient safety reports. So for example, there's been a lot about maternal mortality both here in the UK and in the US. And a lot of the reports say that women and their relatives say that

they are not listened to or believed when they're experiencing care. So kind of at its worst, it can even cause death. In terms of kind of the more other long-term things, I think if you are routinely not listened to by your healthcare provider, routinely not heard, it means that you're kind of less likely to go back to them. So you don't trust them. It increases mistrust. And you might think, you know, I actually don't want to tell them what's going on. So you may avoid healthcare or you may self-censor. So if your doctor says, you know, what's happening with your treatment, how is it going for you? And you've told them time and time again that you're getting side effects. You might just give up and say, oh, no, they're fine.

But in your own time, just stop taking the tablets, for example. So I think it can have, you know, a real effect of silencing, mistrust, and kind of healthcare avoidance. Let's take a quick break here. And when we get back, there's still so much to discuss. Dinner shows up every night, whether you're prepared for it or not. And with Blue Apron, you won't need to panic order takeout again. Blue Apron meals are designed by chefs and arrive with pre-portioned ingredients so there's no meal planning and no extra grocery trip.

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Order now at blueapron.com. Get 50% off your first two orders plus free shipping with code this podcast 50. Terms and conditions apply. Visit blueapron.com slash terms for more information. Anyone who works long hours knows the routine. sanitize repeat. By the end of the day, your hands feel like they've been through something. That's why O'Keefe's working hands hand cream is such a relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands caused by constant hand

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15% off their first order of O'Keefs. Just visit. at O'Keefscompan.com slash this podcast and code this podcast at checkout. In 2023, a story gripped the UK, evoking horror and disbelief. The nurse who should have been in charge of caring for tiny babies is now the most prolific child killer in modern British history. Everyone thought they knew how it ended. A verdict, a villain, a nurse named Lucy Leppie. Lucy Letby has been found guilty.

But what if we didn't? get the whole story. The moment you look at the whole picture, the case collapses. I'm Amanda Knox, and in the new podcast, Doubt, the case of Lucy Letby, we follow the evidence and hear from the people that lived in, to ask what really happened when the world decided who Lucy Lettby was. No voicing of any skepticism or doubt. It'll cause so much harm at every single level of the British establishment of this is wrong.

Listen to Doubt, the case of Lucy Letby, on the eye-heartedly. Radio app, Apple Podcasts, or wherever you get your podcasts. Welcome back, everyone. I've been chatting with Dr. Raghashri Darawan about her book Unheard, The Medical Practice of Silencing. Let's get back into things. The dismissal of patients by health care providers is not something that happens spontaneously. As you point out, it is an explicit and implicit part of training, where the foundations

are laid out for their hierarchical relationship between physician and patient. Can you talk about what that training is like and why it's viewed as an essential part of patient care? Yeah, so I talk quite a bit about medical school in one of the chapters, because I think that's really where we start to develop this almost skepticism of the patient already coming from a thought that we don't believe patients right from the beginning. So one of the ways in which we taught about medicine, particularly in the West, is the biomedical approach. So this is where we think of the disease being separate to the patient. So it's not part of them as a whole. It's a separate thing and our job as doctors is essentially to find the diagnosis and then treat the patient.

So we don't really think of a patient as a whole and it means that we don't necessarily provide holistic care. So it really teaches us to keep a distance from the patient and it means that we're more likely to have boundaries. And I'm not saying boundaries are bad. Boundaries are a good thing as well. But sometimes when we have very rigid boundaries, we don't listen. as well as we can do. And it means that we as a doctor, we hold the knowledge and the expertise, and it means that we can be very paternalistic

because we think we know best, we know better than the patient themselves about their own bodies. And I think the other things about medical school is certainly, you know, as medical students, you've come through so much to get to where you are. You know, you've passed exams. You are, you know, some of the cleverest people at university.

And you're taught together, because you have long hours. So you kind of end up really being tight as a group. And I think that separation and that feeling of being special and separate to other students means that we can develop a sense of hubris or excessive pride. And again, that can make us seem kind of more unapproachable and less empathic. And I think the other thing about the biomedical approach that I was saying is, if our job as doctors is to diagnose and fix, that's what we think our role is.

but we don't think about other ways in which we could treat patients. So, for example, there is value in more holistic care, and sometimes I don't think we think about that. So we are less likely to listen, for example, when someone is telling us something that we don't know how to fix. So if someone, for example, has an issue with chronic pain and we don't know what to do about it, then we find that uncomfortable because we can't fix them.

And that makes us really question our role as doctors. so we might be more likely to shut them down and not listen to them. But I think if we were taught to find more value in listening as being therapeutic in itself, so being witness to somebody who is suffering, then I think we would see our role as being more healers rather than fixes, and we would be better at listening in that way. And there's a couple of other things at medical school, which I think contribute to this not listening as well.

We learn very early on to be very focused with our history-taking and, you know, that is a good thing because, you know, we need to find out what's going on with a patient. But sometimes it means we kind of strip away everything else that we don't think is important. And again, that makes us not as good listeners. I have this concept in the book of something called the ideal patient. So, you know, someone has a heart attack. They present in a specific way. We kind of know what we expect them to say.

But if they present in an atypical way or they respond in a way, that we don't necessarily expect them to, that we haven't been taught to, then we're more likely to be skeptical of them and doubt them and not listen to them. So I think there's lots of things in medical school and the way that we're taught, which really makes it less easy for us to learn to listen better. Also in your book, you present these quotes from the 13th and 17th century discussing how or instructing physicians to doubt their patients and question their intention. So it goes back literally like we're fighting hundreds of years of this.

How is this tendency to doubt still reflected in the language used in medicine and enabled by the power dynamic of physician-patient relationships? So I was really shocked when I found, you know, how long it had been going on for, actually. Like I didn't realize it had gone on for so long. So, yeah, I think it is ingrained in our profession and ingrained in our language. So, for example, I think, you know, we use language, which kind of. kind of puts the patient at a distance and has kind of innate skepticism in it. So, for example, some of the medical language, we may use terms like the patient denied or the patient claimed. So

that's kind of inherently skeptic of the patient. Or it might be derogatory language. So there's a term that we use here in the UK. I'm not sure if you guys use it in the US, but what we call a heart sink patient. So someone when we see them, we know, oh gosh, this is going to be a difficult consultation. And we can sometimes use language that is victim blaming and language that is paternalistic. So I work in HIV medicine where we really want patients to take their tablets every day. It's very important. But we talk about patient compliance. And, you know, that sounds like a very paternalistic attitude to patients. It's not a very patient-focused language. So I think it really is inherent in it. And the other thing is there is a lot of use of dehumanizing

language. So again, from my specialty of HIV, you know, you can see people saying things like the HIV patient, but there's been a real shift to talking about people living with HIV, so being person-focused first. If the problem of silencing patients begins during medical training and also like hundreds of years in the making, it is only exacerbated by the way modern medicine is practiced, where the emphasis tends to be on maximizing productivity. In what, What ways does the medical system hinder or even discourage physicians from adequately listening to their patients? So I think you're really right when you talk about that emphasis on productivity. So it's, you know, numbers of patients see, number of tests done, number of diagnoses, number of treatments.

You know, we get paid on that. And really what isn't valued are those consultations where listening in itself is therapeutic. So, you know, we're not going to get paid for just, you know, listening to a patient who is, is having a hard time and at the end of the consultation leaves feeling better because they feel like someone has heard them. So that just isn't valued by our medical systems. You know, you don't get money for that. And because there is an emphasis on productivity, it means that we are often short of time. So we often, you know, too busy to listen well. We're looking at our watches, we're needing to go on to the next patient. We work in an environments that aren't very good for

listening. So for example, we work with very clinical rooms. So it may not feel like a welcoming or comforting space or there may not be privacy where people feel that they can talk. And I think with the emphasis on being more productive, and I think particularly since the pandemic, I think healthcare workers are increasingly tired, stressed, burnt out. And those are all conditions which mean that we listen not as well as we could do. And I really loved, like I said, how you provided this perspective from the physicians as well. And so in these scenarios in your book, you describe someone who is seeking medical care, and then you kind of give the perspectives from both different health care providers associated

with the patient and the patient themselves, what might be going through their head, what might they be feeling. And I think that these scenarios help to illustrate the nuance in these interactions, where sometimes there might be doubt, sometimes disbelief, sometimes neglect, and sometimes simple just miscommunication or just like forgetfulness. But all of these things tend to end up with more or less the same result in terms of harm or in terms of lack of care. Do you feel that the distinction between an unwillingness to listen and not having the capacity to listen due to things like you mentioned compassion fatigue, do you think making that distinction is important? Like is one more easily addressed than the other?

I think that's a really good question and you're right, they all lead to the same thing. I think that most healthcare providers, most doctors do want to listen. I think we kind of go into the field because we're, you know, people who are, we're caring people. We want to make people feel better. So I think generally for most people, there is a willingness to listen and often it is our training or the environments that we're working in, which means that it's harder for us to do so. But I do think there is an unwillingness to listen sometimes. So as I've said, you know, when we're uncomfortable hearing what the patient is saying,

because we don't know what to do or when things are uncertain. So again, we're not entirely sure what is the next step to take. I think that's when we shut patients down. So I think there is that unwillingness to listen. But again, I think that comes from how we're trained to be someone who is a fixer rather than someone who is a healer and can just listen. So I think whether it's unwillingness or not. not having the capacity to listen, I think both involves system change and they're both really

important. Let's take another quick break. We'll be back before you know it. Anyone who works long hours knows the routine. Wash, sanitize, repeat. By the end of the day, your hands feel like they've been through something. That's why O'Keefe's working hands hand cream is such a relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands caused by constant hand washing and harsh conditions. Working hands creates a protective layer on the skin that locks in moisture. It's non-greasy, unscented, and absorbs quickly. A little goes a long way. Moisturization that lasts up to 48 hours. It's made for people whose hands take a beating at work, from health care and food service to salon, lab, and caregiving

environments. It's been relied on for decades by people who wash their hands constantly or work in harsh conditions because it actually works. O'Keefs is my hand cream of choice in these dry Colorado winters when it feels like my skin is always on the verge of cracking. It keeps them soft and smooth no matter how harsh it is outside. We're offering our listeners 15% off their first order of O'Keef's. Just visit O'Keef's company.com slash this podcast and code this podcast at checkout. In 2023, a story gripped the UK, evoking horror and disbelief. nurse who should have been in charge of caring for tiny babies is now the most prolific child killer in modern British history. Everyone thought they knew how it ended. A verdict, a villain,

a nurse named Lucy Letby. Lucy Letby has been found guilty. But what if we didn't get the whole story? The moment you look at the whole picture, the case collapses. I'm Amanda Knox, and in the new podcast, doubt the case of Lucy Lettby, we follow the evidence and hear from the people. that lived it, to ask what really happened when the world decided who Lucy Lettby was. No voicing of any skepticism or doubt. It'll cause so much harm at every single level of the British establishment of this is wrong. Listen to Doubt, the case of Lucy Letby on the Iheart Radio app, Apple Podcasts, or wherever you get your podcasts. China's Ministry of State Security is one of the most mysterious and powerful spy agencies in the world. But

But in 2017, the FBI got inside. This is Special Agent Regal, Special Agent Bradley Hall. This MSS officer has no idea the U.S. government is on to him. But the FBI has his chats, texts, emails, even his personal diary. Hear how they got it on the Sixth Bureau podcast. I now have several terabytes of an MSS officer, no doubt, no question, of his life. And that's the unicorn. No one had ever seen anything like that.

It was unbelievable. This is a story of the inner workings of the MSS and how one man's ambition and mistakes opened its fault of secrets. Listen to the Sixth Bureau on the IHeart Radio app, Apple Podcasts, or wherever you get your podcasts. Welcome back, everyone. I'm here chatting with Dr. Raghashri Darawan

about her book Unheard. Let's jump back into some questions. Getting into some of those changes that we could make, I loved how in your book you had at the end of chapters, here are ways that we can change things at different levels of organization at an individual level, training, and so on. And I was wondering if you could speak to that a little bit more when it comes to medical training. How can we fix this from the ground up or how can individual providers sort of reassess their own listening skills or maybe where they could improve? improve? So I think there's things for individuals to do and I think there's things for system change which starts from medical training and education all the way to kind of how institutions are run and kind of post-qualification training. So I think as individuals I think it's really important that we learn to reflect on our listening and certainly since writing the book,

that's something I've been doing a lot more of thinking, you know, why was that consultation difficult, like what happened in it that might have made it difficult for me to really listen to what the person was saying. Being aware, obviously, that, you know, we all hold bias and thinking about when that's most likely to come up. So, you know, we're more likely to rely on stereotypes and what I call heuristics, so mental shortcuts when we're tired or stressed. So, you know, for example, you may not be so good at listening or you may be more biased when it's three o'clock in the morning. You're in the emergency department. and it's really busy.

So I think individual reflection is important, but I think listening should be taught at university, right, from medical school, so how we can be better listeners, and also really taking that emphasis away from thinking all patients present in a certain way. Patients may not present in a way that we necessarily expect them to, and not using that as kind of excuse not to believe them or to feel that we're sceptical of them, understanding that people present diversity, people are diverse. I think there's also something

there around being taught about the value of listening and that listening in itself can be therapeutic, so really taking us away from that kind of fixer model of being doctors to being healers again. And I think also really important in medical school is learning more about the social determinants of health, so understanding why people don't present as we expect them to, why they don't behave as we expect them to, and understanding more about the history of medicine, so, you know, understanding about bias, the history of medical experimentation, etc. And then when we get into kind of clinical practice, I think there needs to be room for more reflection in the workforce generally. So I've talked about how, you know, there should be

planned reflection time, so having team supervision. So in clinical practice, often if something bad happens, then the team might reflect. But building that into kind of everyday practice, So teams together can talk about their experiences about what went well and what didn't. I think would be really good for everyone and would help prevent some of that compassion fatigue and burnout. And I guess the other things are about making better listening environments. So, you know, making those private spaces more available, making sure that we have regular break so that we can then feel rejuvenated again, more likely to listen and thinking, what does productivity mean? Maybe it does mean just listening. being a therapeutic tool. Getting a bit more into what that reflection looks like, you discuss in your

book how you as a physician sometimes don't always listen as well as you could. Can you talk about what those moments are like? Is it something that you realize at the time where you're not being a good listener or does it just like feel like you said like this was, this consultation didn't feel great or didn't something was not right about it? Or was it in retrospect that you're seeing this? Or is it a combination of both? I think it's a combination of both. So sometimes you know when you're, you know, for example, in a busy clinic and you're rushing and you're trying, you're on the computer trying to order tests while also listen to the patient. You're trying to make notes. Or, you know, someone pops in to tell you something or an email pops up on your computer. You know

that you are distracted and you know that you're perhaps not listening or focusing as well as you can be. And, you know, obviously doctors are human. You may have not had a good night's sleep before. You might be tired and know that you're not at your best or, you know, something's happening in your personal life. So I think you can be aware of that at the time. But sometimes you're not so aware. So it may be kind of towards the end of the consultation when you're just like,

oh, you know, that didn't feel right, as you said. Or, you know, that was an uncomfortable consultation. I don't feel like, you know, the patient got what they wanted and I got what I wanted from the consultation. but I think sometimes you don't even realize, and I think that can happen to any doctor, but it is, you know, sometimes you think you've done your best, but the patient doesn't agree for you. So I think trying to recognise when you know you're not listening,

trying to reflect on those consultations which are uncomfortable, but then also kind of learning from patient feedback as well. I think feedback is really important from colleagues and patients throughout our career to make sure we, you know, we understand how well we are communicating and listening. Patients who are unheard by their providers are often or sometimes told that they should better advocate for themselves, which, as you point out, is a form of victim blaming because it shifts the responsibility for the silencing of patients to the patients themselves, and it enables the medical

community to just keep things as they are, or it doesn't really drive any sort of change. But until the medical institution takes meaningful steps to ensure better listening, what are some of the ways that people can increase the chances that they will be heard or listened to by their healthcare providers? Yeah, this is exactly why I wrote the book because I wanted the healthcare system to change. But absolutely, I mean, it's not going to change quickly. And I think it's really important that everyone has the agency to try and get what they need from the healthcare service. So I do provide some tips. So if you are going in for a consultation with a doctor, I think it's really important to be prepared. If you're prepared, perhaps if you know a little bit of

about your condition or you know what questions you want to ask. So for example, I always love it when my patients write a list. So they come in with their list already thought about and then we sit and go through each point. Like, I think that's great. You know, you feel like you've asked everything that you want to. But importantly, it makes a doctor feel that you care about what's going on. It makes you seem more credible. So I'd definitely recommend planning for your consultation. you can always write things down while you're there as well. And I think if you're writing things down that you don't understand, then ask the doctor what it means.

I think sometimes with this innate power imbalance between doctors and patients, it can feel scary to ask things. So I always say if you want to, you should take someone with you, like a friend or a relative who can advocate for you. And if you do, again, prepare them so they know what you want answers to. So if you don't, you know, get a chance to ask the questions yourself, then they can ask it for you. And they can stick up for you as well. I think if you can, if you would find it helpful to see the same doctor, then ask. I think seeing someone who knows you and, you know, you've already had a good consultation with would be really helpful. So continuity of care, I think, it's important and you can ask for it often. And if it doesn't go well, I think it's really important to know your rights.

so kind of know who's in charge of your care, where you can complain to, and that you can get a second opinion and that you can ask for it. I think that's really important. And also, I think another thing about being prepared is just letting before your appointment, letting them know if you have any special communication needs. So if you need an interpreter or something like that, then that's really helpful to the doctor as well. Other things, please bring any medications you're on. It's really helpful to know exactly what you're taking. If you're seeing, other doctors and you have results and things, bring all of that with you. It's really nice for us to see it. And I do write in the book, but sadly, I think lots of studies show that doctors find patients more credible if they are, you know, if they can be, if they can appear more well dressed. And I think that's a terrible thing, but it does improve credibility. And, you know, I talk in the book about my mother who is a, who's a retired family doctor. But she's also, you know, an older Indian woman and stereotypes about them is that, you know, that they often complain about things that are all in their head. And she actually gets dressed up to go to her doctor appointments. And

I, you know, I don't think that should happen at all. But there are lots of studies to show that people do it. And it can help them come across as more credible. So I'm not really saying that as a tip, but I think people should be aware of it. And obviously there's times when you can't be. So, you know, if it's an emergency, you know, that's not going to happen. So I kind of give all these tips with a huge caveat that it is not down to the patients who have to kind of speak up to be heard. We should be listening more. But in an imperfect healthcare system, these are things that you can do. And of course, as you discuss, it's not just patients that face issues with being unheard.

Can you talk about testimonial injustice and credibility deficit and how this affects minoritized doctors as well? Yeah. So we've talked about testimonial injustice with regards to patients. But yeah, minoritized doctors and researchers go unheard. So there is a good example of how it can happen. I write it in the book. So imagine you're in like a work meeting and you're having a discussion in a group and you say something and you, you know, you think you've made this amazing point and you say it and you're kind of waiting for everyone to go, yeah, that's a great point. But no one says anything and the discussion kind of moves on. And then like a few. minutes later, someone else makes exactly the same point as you and they get praised for it. And, you know, that's definitely happened to me in meetings. It may have happened to you as well.

So what you have experienced there is testimonial injustice. And I think that can happen to anybody. But I think if it happens repeatedly to people, then you're just more likely to not speak up because you think no one's really listening to me. So why bother? And what this can do in terms of career prospects for minoritized doctors mean that they lose their self-confidence. You know, they feel less likely to speak up because they won't be heard. That means they won't apply for, you know, promotions or posts on boards. And this can have a real impact in terms of their career progression. And it can make them feel kind of excluded from the workforce. And I think it's really important that minoritized doctors get listened to, one, to have a diverse workforce, but it's good

for patients as well. So yeah, I have a whole chapter about how minoritized doctors go on herd and the effect it can have on patients. I know that you have a whole chapter on it, but can you dive into that a little bit and give us some examples of how a more diverse medical workforce can improve patient health. So there's actually quite a lot of research to show this. And if you're listening, you know, it may be something that you've experienced yourself. So, you know, it may be easier to talk to a doctor, perhaps who looks like you or comes from a similar social background to you. You may feel kind of more comfortable with them. But in terms of research, there's lots to show that a more diverse workforce is better for

diverse patients. So there is a study that I quote, for example, which is from the US in 23, which showed that in counties with more black primary care doctors, black people had longer life expectancy and lower mortality rates. And that is absolutely huge, isn't it, to show that having more black doctors means that black patients do better. So there's lots of different research studies which show this. So it can have a real impact on patient care. And if you think, you know, minoritise doctors who aren't heard, they're not able to stick up for their patients.

So their patients then suffer. So it's really important that we keep the workforce diverse and also acknowledge that some patients also may not want doctors that look like them. And I think about this in sexual health a lot where perhaps, you know, some of our patients don't want to see someone who looks like they're from their community because they're worried about confidentiality. So if you've got a diverse workforce, you can give patient choice as well. And I think, you know, patients have the experience of seeing lots of different doctors, some of who may suit them, some who may not. As you kind of alluded to research or knowledge gaps, especially when it comes to conditions

that predominantly affect minoritized groups take a long time to fill in. What are some of the factors contributing to these research gaps from funding to structural barriers and how do these gaps impact care? A really good example of this is endometriosis in that this is a condition which until quite recently we didn't know that much about despite affecting one in ten cisgender women around the world. So this is, you know, women have complained. of symptoms of endometriosis for centuries, but because doctors have been male, their symptoms

are not been taken seriously. And because of that, the research hasn't been done, leaving us with this big research gap, which means that we still don't know what causes endometriosis, what are the best ways to treat it, how we can help someone get pregnant if they have endometriosis. Even though there's been a lot of push to change this in recent years, and I think that's probably because we have more more female doctors and researchers. When we look at funding levels, we still see that funding, for example, for menstrual conditions, is much lower compared to conditions that affect mostly men. So we still see these real kind of disparities in funding for patient groups who are less heard. I talked about kind of, you know, testimonial injustice with regards to minoritized doctors,

but we see it in research as well. So minoritized researchers are more likely to to study conditions that affect minoritised patients. And when they're not heard, you know, they may not get jobs, they may not get promotions, grants, they may not get their research published or cited, all those things affect their career progression and mean that their research is less likely to be done,

which means that the conditions that affect minoritized patient groups are less likely to be researched and studied. So, you know, we have that gap. And if you think of that on a really, wider scale, if we think kind of when we look at global health, we know that global North researchers are much more likely to be seen as credible researchers. And they get all the grants and all the funding, leaving global South researchers going unheard as well as the communities that they serve when it comes to research. Yeah, I'm so glad that you brought up global health

because I wanted to ask about sort of the imperialist and colonialist roots of global health and how those have left traces in the way that this field is practiced today or the topics and approaches that are prioritized in research. So I was wondering if you could just talk a little bit more about that. So I think there's been lots of discussion in global health recently about how its origins kind of come from disease control during colonial times. And the approaches used then still exist to this day. So there is this kind of feeling of, you know, knowledge that comes from the global north, so the countries that colonised other countries is superior. So, you know, when it came to colonisation, it wasn't just about taking land. It was also about erasing

local knowledge and culture. So, and that included medicine. So Western medicine was part of colonialism. So replacing local health knowledge with Western medicine. And I think global health has continued to do this. So I think there is a critique at the moment saying that we do need to, to decolonize global health. We need to value the local knowledge of researchers in the global South and understand that they are just as credible as researchers in the global North and if not more credible when it comes to conditions that affect their communities. So there needs to be more power sharing. So power needs to go from researchers in the global north to the south. And one of the critiques of kind of the history of global health has been around how

organizations in the global north have kind of enacted policies on communities in the global south that have been colonised without really collaborating with them and without understanding that perhaps their already is knowledge of how to treat some diseases, but that has been devalued and sometimes erased. I pulled a quote from in my notes from your book where you state that global health continues to see local people as being part of the problem, not the solution. And I feel like that was like, yes, that is exactly what is always happening. And really is, I think, a challenge, like, just like with medical training, just like anything where the change has to start from like the beginning, it's like going to just take so much time

and effort to correct and to fix things and to progress in a better way than we are currently doing. Yeah, and I think throughout the book, I think one of the main themes is it's about power and people who hold the power, be that doctors, be that researchers in the global north, are going to have to give up some of that power. And that, I think, is, I think that's going to be the issue, but they need to, we need to understand that it means that it's better for everyone overall if power sharing occurs. going back to the physician-patient relationship, I want to talk a bit about the problem of objectivity and the divide between symptoms and signs. How is evidence ranked in medicine? And where does patient voice or experience fit in among those ranks? So I think we talk about the hierarchy of evidence quite early on in our medical careers because we had kind of taught how to read research papers and to understand them and critique them.

So at the top of the hierarchy are things like meta-analyses, systematic reviews. And then we see randomised control trials and then things like case control studies, cohort studies. And then lower down are things like case series and expert opinion and animal studies. And essentially what the hierarchy is doing is the ones at the top are those that are study designs, which have less bias and are seen to be more objective. And essentially, when it comes to research evidence, we value quantitative evidence much more highly. So, you know, we value numbers and statistics because we think they are more objective. So obviously, that kind of research has been really important and has improved patient care.

So I'm not arguing against it. Evidence-based care is a really, really important thing, which has improved patient care massively. but sometimes research questions aren't best answered by quantitative study design. So, you know, they're very good for asking how many or how much or is there a relationship between two things. But sometimes we need to understand how or why something happens. So other forms of evidence, like, for example, qualitative evidence may be useful, but it's really not as valued as highly as quantitative evidence.

And I think what's really interesting about the hierarchy of medicine is that there no patient voice in any of that. It's all thinking really about numbers and qualitative evidence isn't valued and that does include some patient voice. So I think it's really striking to me how we value evidence which doesn't come from patients because we see it as being too subjective. So I think that has again an impact on how well we listen to patients. Maybe this is going a bit back to like the research gap discussion that we were having but I wanted to ask you about the table that you created for the most and least prestigious diseases. I found that really fascinating and truly eye-opening. So could you just take me briefly through the characteristics of prestigious

diseases and patients and not prestigious diseases and patients? Yeah, so this concept and this table came from research papers by Norwegian researchers. So yeah, I've just compiled it into a table to make easier to read. But essentially, it looks at how doctors look at diseases and value them and in turn value the patients who have those diseases. So things that might be more prestigious, for example, are conditions that have objective features. So, you know, easy to see clinical signs or symptoms or test results. So for example, if you have HIV, you'll have a positive HIV antibody test, so that is easy to test for. Other things that make a disease seem more prestigious or valuable, for example, is if it's sudden or life-threatening, if it affects patients who are young,

for example, if the treatment is kind of active, a bit risky, but means that you can cure somebody. And also, I think really interestingly, the researchers say here, in terms of patients, if the patient is more likely to listen to the doctor and accept what they think, say those diseases in which the patient is more likely to do that are more prestigious. So when they they asked Norwegian doctors over 25 years to rank diseases by their prestige and kind of consistently over that time they found conditions like leukemia, heart attacks and brain tumours to be the most prestigious diseases. So you can see those are ones of objective features that are life threatening and you need quite intensive treatment for it. Whereas the disease,

that are seen as less prestigious are those are kind of the opposite. So there are, you know, fewer objective signs and symptoms. So you may have to rely, for example, more on patient testimony. There may be things in which there isn't an obvious cure or treatment. And there may be things in which the patient may have more to say, you know, they may be more likely to contest what the doctor says. And consistently over the 25 years in this study, in this Norwegian study, fibromyalgia was found to be kind of the least prestigious disease. And I think we also see that with other conditions, such as, for example, long COVID or MECFS. So these are, again, conditions which we can't just fix, which is not so easy to diagnose without patient testimony. So these are the conditions that doctors

value less, find less prestigious. And I think that really affects the patients who have them. I'm very curious to know sort of what reception or what sort of reactions that you have gotten from other physicians. Like, do you think that most people in the medical field are receptive to the idea that medical practitioners aren't always good listeners and that they don't always provide adequate care or has there been any defensiveness or, I don't know, like, just denial outright? Or is it mostly like, yes, I understand and I can see that in myself? So I think actually people have been very receptive, which has been really encouraging. And it's really interesting. I mean, it does tend to be the people who have been patients themselves

and have it been at kind of that end of being a patient and not being listened to. And I think particularly for doctors, when that happens to you, kind of makes you question everything. So people have been very receptive. And the other thing is, you know, all doctors at some point will probably be patients as they get older. So knowing that we'll be on the other side ourselves at some point

means that, you know, we'll be more receptive to it. And the other thing is there's so much evidence to show that patients say they go unheard. I don't think, you know, we can deny that data at all. So people have been really receptive and many of them have experienced themselves as patients. But I think what is going to be interesting about the reaction to this book is the fact that I believe it is ingrained in our profession.

I think many doctors will say, yes, we're not very good at listening because we work in environments that make it very hard to listen. But I think it'll be interesting to see what they think when I say I think it's actually ingrained in our profession right from the beginning. You mentioned earlier in our discussion that working on this book has changed the way that you approach medicine. Can you describe a little bit about what you mean by that?

How has your approach changed? So when I was writing kind of the book proposal and the first few chapters, I was very lucky because I had taken time away from clinical medicine. I took a year out after COVID, off the second COVID wave and did a master's full-time. so I had a year out to study, which was wonderful, and I also had time to write the book proposal. So when I came back to clinical practice, I was still writing the book, and I thought, do you know what, I need to be better at listening, so I'm going to try really hard. And after a few months, I realized it's really, really hard. Listening is really hard. But I think what has really changed

is that I'm so much more reflective than I used to be. I also now don't feel as uncomfortable as I used to. like I understand that if a patient wants to tell me about something which I can't actually help them with, it's okay for me just to listen because they come out of the consultation feeling better. So, you know, it's not a futile consultation. I am still doing something therapeutic. So I think it's really made me reflect on every consultation and it's really made me value just the benefits of just listening and how that can help patients. Dr. Darawan, thank you so very much for taking the time to. to chat with me and for writing this incredible book that, I'll say it again, I really think

should be required reading for anyone going into medicine and everyone already in medicine, and anyone who has an interest in medicine. Basically, everyone should go read this book. So go check out our website, this podcast will kill you.com. We'll post a link to where you can find unheard, the medical practice of silencing, as well as a link to Dr. Darawan's author page. And don't forget, you can check out our website for all sorts of other cool things. things, including, but not limited, to transcripts, quarantini and placebo-rida recipes, show notes and references for all of our episodes, links to merch, our bookshop.org affiliate account, or Goodreads list, a firsthand account form, and music by Bloodmobile. Speaking of which, thank you to Bloodmobile for

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