646 Journal of Pain and Symptom Management Vol. 43 No. 3 March 2012

Humanities: Art, Language, and Spirituality in Health CareSeries Editors: Christina M. Puchalski, MD, MS, and Charles G. Sasser, MD

Ready to Listen: Why Welcome MattersMargaret E. Mohrmann, MD, PhD, and Lois Shepherd, JDCenter for Biomedical Ethics and Humanities, School of Medicine, University of Virginia,

Charlottesville, Virginia, USA

Abstract

Welcome is a primary moral obligation of clinicians, essential for appropriate compassionatemedical care. Listening to patients’ stories requires a prior welcoming disposition that enablesthe practitioner to listen well. J Pain Symptom Manage 2012;43:646e650. � 2012U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Key Words

Welcome, stories, narrative medicine, listening, ethics, responsibility

In the pivotal scene in Sophocles’s Philoctetes,Neoptolemus regains his moral compass as hesilently watches Philoctetes, chronically af-flicted with an agonizing wound, crying outin pain, and then stays beside Philoctetesthrough his exhausted sleep. Before he arrivedon Philoctetes’s island of exile, Neoptolemusknew the story of the warrior’s injury and aban-donment but was nevertheless convinced tobetray him, for the sake of the Greek armyat Troy, by preying on his hopes of rescue.Once on the island, he hears that story againfrom Philoctetes himself. Although Neoptole-mus reels in pity for the reality of the situation,he does not waver from his task. It is only whenhe witnesses Philoctetes’s cries and helpless-ness, in the context of the suffering man’s (un-warranted) trust in him, that Neoptolemustries to align himself with Philoctetes againstthose who would use and abandon him again.

In recent years, Bryan Doerries has broughtthis central scene to life before numerous

Address correspondence to: Margaret E. Mohrmann,MD, PhD, P.O. Box 800761, School of Medicine,University of Virginia, Charlottesville, VA 22908-0761, USA. E-mail: mem7e@virginia.edu

Accepted for publication: October 5, 2011.

� 2012 U.S. Cancer Pain Relief CommitteePublished by Elsevier Inc. All rights reserved.

audiences of medical professionals as an edu-cational exercise.1 The actors in this ‘‘reader’stheater’’ bring Sophocles’s ancient timelydrama to the very people likely to be presentfor such suffering, insisting that they learn tohear it as it comes. The actor playing the roleof Philoctetes howls the cries of a once-strongman now stricken with overwhelming pain,laced with the bitterness of betrayal and isola-tion. There are no words that describe it, noth-ing that fits into medicine’s traditional ways ofclassifying episodes of pain. There are only theinarticulate, loud, shattering groans of some-one whose suffering is beyond bearing. Asone of our colleagues tells medical studentsabout to witness the presentation, it is thekind of encounter that makes you want toleave the room.

In an educational film on the barriers tocare experienced by patients with sickle celldisease, patients share their difficulties in ob-taining relief from pain:

When I go to the emergency room, there’ssomething of a stigma, where they don’twant to see, it seems like they don’t wantto see me straight away and I see a doctor

0885-3924/$ - see front matterdoi:10.1016/j.jpainsymman.2011.09.004

Vol. 43 No. 3 March 2012 647Ready to Listen

that’s not willing to give me the typical med-icine, the amount of medicine that will helpme get out of pain.

It’s not even the verbal communication, it’sthe nonverbal communication that reallygets under my skin because you get thislook and you get this tone like ‘‘Okay, you al-ready had enough medicine, so I’m not giv-ing you any more.’’ Or, ‘‘You have to havefelt something’’dthat’s the worst. When Ihear, ‘‘You have to have felt that,’’ I’m like,‘‘If I did, I wouldn’t be calling, I wouldn’tbe bugging you every 10 minutes tellingyou I’m in pain.’’

Patients with sickle cell disease are fre-quently met with professional disbelief aboutthe levels of pain they report and the dosesof medication required to relieve it.2 Theymay be met with suspicions that they aredrug seeking, which, of course, they are (seek-ing drugs to relieve pain) but not in the derog-atory sense in which that term is usually used.In the film, one patient explains that she is re-luctant to tell a new provider the kind andamount of narcotic that has worked for herin the past, afraid of being judged. Despiteher extreme pain, she takes care to dress inprofessional clothing before seeking medicalcare, afraid she will not be taken seriously ifshe shows up in sweatpants and socks.

Where can the familiar exhortation to listento the patient’s story get us in situations likethese? Philoctetes’s story is absorbed by hishearers as a part of recent Greek history thatNeoptolemus and his mentor in deviousness,Odysseus, attempt to manipulate on behalf oftheir army laying siege to Troy. As for his suffer-ing, there is finally no story as such, only word-less cries and a plummet into unconsciousnessto be witnessed, or not. Persons with sickle celldisease and recurrent pain crises learn quicklythat telling their story, the narrative of theirpain and of their accumulated experience inhow best to relieve it, is likely to earn themdisrespect and, paradoxically, significantly sub-optimal treatment or no treatment at all. Thebest story listener on the medical staff willfind it difficult to obtain an uncalculated,purely representative story from a patientwho has learneddthe hard waydto craft the

tale that has the best chance of getting herwhat she knows she needs.

Make no mistake: the practice of listeningto patients’ storiesdattentively, empathically,mindfullydis an excellent discipline, one thatshould be taught and promoted at every oppor-tunity in medical education at all levels. But sit-uations like the ones described reveal that it isoften not enough or misses the mark, some-times by a wide margin. In this essay, we presentthe concept of welcome as the essential prior ori-entation that renders this practice meaningful,capacious, useful, and not yet another imposi-tion of the doctor’s educated narratives onthe patient’s expression of experience.

To welcome (etymologically, ‘‘will-come’’)someone is to affirm that their coming is in ac-cord with the welcomer’s will: It is good that youhave come; I want you to be here, as you are.Welcome means that one is invited to comeor, if already present, to stay in the companyof someone who is glad of one’s presence.Undertheorized and underappreciated, wel-come is a primary obligation of health careprofessionals. In fact, we claim that it is the pri-mary obligation.3,4 Without the orientation ofwelcome, other obligations cannot be reliablyrecognized or carried out well, whether we un-derstand those responsibilities to arise fromthe principles of biomedical ethics espousedby Beauchamp and Childress5 or from otherethical approaches that instead emphasizecare, community, solidarity, or professionalism.

Without welcome, we cannot see, under-stand, or appreciate the needs and desires ofthe people in front of us or anticipate howour actions could be perceived by them as dis-respectful, harmful, or unjust. Without wel-come, we are not prepared and willing to staywith and learn from the cries of all the modernavatars of Philoctetesdhurt, alone, fearful, sus-picious, hopelessdwho appear in clinical prac-tice. Without welcome, we may think drugseeking first, hurting person second, if at all.How we, at the most basic level, respond tothe presence of another person determinesall that follows. It is necessary to be welcomingto act responsibly and identify the fitting re-sponsedincluding, but not limited to, the ap-propriate diagnosis and treatmentdto theperson and situation in front of us.6 For healthcare providers, welcome is essential to good pa-tient care.

648 Vol. 43 No. 3 March 2012Mohrmann and Shepherd

The obligation of welcome that we advance isthus broad and demanding, exceeding the re-sponsibility to see one’s patients, to give compe-tent care, and even to be nice while doing so. Asa basic obligation of human relationships, it isa mutual one, owed by each to each and all toall, meaning that no one gets a passdnot sur-geons, housekeepers, security guards, adminis-trators designing and implementing systemsfor patient care, or even patients. As to sub-stance, it goes far beyond a polite greeting. Itsignifies an orientation toward the other thatinvolves an utter and complete willingness tolet another persondwho may be, and in thecontext of medical care often is, a strangerdinto our consciousness, our gaze, our care,our lives, even if only temporarily. Just as criti-cally, it means a willingness to enter into theirlives, to indeed listen to their stories, such asthey are, and to allow them to uncover a ‘‘worldof meaning’’7 that is unfamiliar to us.

Welcome calls on us to appreciate eachother person as a unique human being, ratherthan as a generic instance of a type of humanbeing, as in ‘‘people like that’’ or ‘‘sicklers.’’For there to be true welcome, the presenceof this particular individual, with his or herstories, past, habits, and beliefs, is wanted. Heor she may come with HIV, as transgendered,at 4:30 PM on a Friday afternoon, as a prisoner,as an Internet-trained diagnostician, as onewho has become chronically ill through per-sonal neglect, as an abusive spouse or parent.Not all the behaviors of the person need bewelcome or even tolerated, but the person her-self is invited to be present as she is. No matterhow different you are from me and no matterwhat characteristics you beardeven character-istics I may tend to judge negativelydwelcomesays that you are a person of value to me, and Idesire to understand, know, and be with you.

A responsibility to welcome asks us to look atpractices, such as the skeptical approach to pa-tients who know what they need to relieve theirpain, and at familiar teaching tools borrowedfrom the humanities, such as thinking of pa-tient histories as stories, in a different light.At the first point of contact and every pointfollowing, it matters whether our responsesto patients are grounded in a welcoming orien-tation, a willing receptiveness to this personand his or her particular experiences that ledto the decision to seek medical care.

Sometimes we blame the system, whetherformal rules or entrenched practices, for ourunwelcoming behaviors. Who has time to sitand listen to patients’ groans? There reallyare patients who are addicted and seek nar-cotics for the high alone (in saying so, ofcourse, we choose to set aside the sufferingthat such craving represents and the realitythat our concern about being played for foolsby addicts is both out of proportion to the fre-quency of its occurrence and out of alignmentwith our professional commitments). Never-theless, the way things are done is not theway they have to be done. Systems are designedand carried out by people and can be changed.Welcome is a deliberate choice. We can chooseto adopt an orientation of welcome, and wecan choose to engage in welcoming practices.Although essential to all aspects of health

care, the imperative nature of welcome is par-ticularly evident in practices related to thepain and symptom management integral topalliative care. Doctors and other clinicianslearn early in their education the distinctionbetween symptoms and signs, symptoms beingthe patient’s subjective report of illness as ex-perienced bodily and psychologically and signsbeing illness manifestations that can be seen,heard, smelled, or touched by the examiningprofessional. Some symptoms, like jaundice,also are signs, but the symptoms often mostat issue in the care of seriously ill or dying pa-tients are purely symptoms, not on direct dis-play to the clinician. Pain, nausea, anxiety,fear, humiliation, and despair are not, in the fi-nal analysis, objectively detectable or measur-able, despite medicine’s many attempts to dojust that. The signs of such sufferingdtears,groans, grimaces, a white-knuckled fist, eventachycardiadare nonspecific and their mean-ing easily misread, thus requiring interpreta-tion, or at least confirmation of our guesses,by the sufferer herself. There is nothing togo on with any certainty in the diagnosis andassessment of pain or suffering other thanthe patient’s subjective report. And that re-port, the story, cannot be elicited well, assistedinto articulation and true representation, norcomprehended fully without the clinician’swelcoming orientation.Why must the report be assisted, and why

does that process require that the listener bewelcoming? Many persons, regardless of their

Vol. 43 No. 3 March 2012 649Ready to Listen

educational level or illness history, find them-selves grasping for adequate, honest languageto express the uncomfortable and fearful sen-sations that accompany their disease or theirdying. As young children, when we show thatwe are experiencingdiscomfort of any sortdsay,grabbing at one ear and whiningdwe are mostlikely to be asked, ‘‘Does it hurt?’’ Althoughthe particular sensation may be one of fullnessand pressure in the middle ear, the child isthus taught to think of and express that andmost other uncomfortable sensations with thelimited vocabulary of hurting. It is no wonderthat an adult patient may find himself scarcelyable to put into words the garbled and inconsis-tent sensations coming from his arthritic joints,only some of which seem to hurt, much less thenuanced mix of searing jolts, ominous rum-blings, taut distention, deep aching, constantdread, and general malaise that is what his ad-vancing colon cancer feels like. Most of us, atsome point, become Philoctetes in our pain.

Alexithymia, a term coined in the latter halfof the 20th century to describe patients, partic-ularly those with certain mental illnesses whoseem unable to describe their symptoms,8 maybe a more widespread problem than commonlythoughtdand may be at least partly iatrogenicin origin. A patient’s attempts to render hisexperience intelligible to a clinician may bequicklymet with categorizing questionsdaboutlocation, intensity (on a scale of one to 10), an-alogues (stabbing, burning), and so forthdinstructing the patient that his experience hasto be packaged in certain ways if it is to be com-prehended and, as a result, treated appropri-ately. The patient may well be left feeling shehas failed and has not truly represented whatshe is feelingdeven that she is too stupid tosay it right and is wasting the busy doctor’stimedand, therefore, that whatever is pre-scribed or recommended will be addressednot to her actual condition but to her false de-piction of it.

What difference might a welcoming orien-tation on the part of the clinician make tothis troubling situation? The obligation of wel-come requires and enables the medical profes-sional to be fully aware of and open to thepatient before her, to mentally embrace thatperson in his entirety, as he is. Such opennessis predicated on the fixed belief that character-izes welcome: It is good that this patient,

whoever he is, is here; he is someone worthknowing and is knowable only through hisself-revelation. The welcoming clinician, there-fore, invites, encourages, and awaits that reve-lation, using statements or questions that areexpansively open ended and attuned to the pa-tient: ‘‘Tellmewhat this is like for you;’’ ‘‘Tellmeabout your pain.’’ Although doctors and nursesare taught to ask these sorts of questions, theyoften do so only as an introductory move; theirwelcoming stance lasts about as long as theopening handshake.9 As soon as the patient’sdifficulty expressing himself becomes evident,the cliniciandin a well-intentioned effort tohelp and a differently intentioned effort tomove things alongdbegins asking the specify-ing questions referred to above, signalingclearly the sorts of information that matterand will be heard and those that do not andwill not. Countless patients, attempting to cutthrough the prescribed categories to get theirstory right, have noticed their doctor’s subtlesigns of irritation or waning interest and havegrown silent and acquiescent.

The deeply welcoming clinician continues towait for the patient’s self-revelation, allowingthe time needed for the words to take shapeand for the patient to be satisfied that he hasindeed conveyed the truth as he knows it.There may be points at which the clinicianshould interject brief reassurances that let thepatient know she is paying attention and notbecoming impatient with his halting nonmedi-cal vocabulary. Acknowledgment that descrip-tions of suffering are hard to compose andharder to deliver, empathic recognition ofa point made, asking ‘‘Is there more?’’ can allbe ways of continuing to welcome this personand his very own burden of pain and dis-ease.

The practice of hearing the patient’s storydthe narrative of the situation as understoodand framed by the patientdis obviously a vitalcomponent of the welcoming orientation.Both the obligation to welcome and the exhor-tation to listen to the story require the nurse ordoctor to attend to the patient’s unique expe-rience of suffering and distress without forcingit into premature diagnostic formulations.However, in the hands of medical profes-sionals, an emphasis on narrative risks reifica-tion into another clinical tool, one that seeksto capture the story, as though what is heardwill include all that need be known. (For

650 Vol. 43 No. 3 March 2012Mohrmann and Shepherd

example, despite all there is to be learned andsavored in Arthur Frank’s excellent work, TheWounded Storyteller,10 there are risks involvedin offering any sort of typology to a professionalways ready for another checklist.) That is, anunnuanced focus on getting the story can bereductionistic, allowing the patient only oneway to communicate the experience of his orher illnessdthrough a storydand only oneway to be knowndthrough a story of illness.It also can be presumptuous: Not everyone un-derstands experience in the form of a story,with a beginning, middle, and end; not every-one is inclined to perceive or encompass theirexperience in the classic narrative format of‘‘this happened, and then this happened.’’11

Narrative categoriesdplot, character, voice,and the likedrisk being as procrustean asthe maligned structure of the traditional med-ical history. For patients struggling with seriouspain and other forms of suffering, there maybe no story to tell, only a fragmented litanyof inadequate descriptors or an inarticulatelament.

The obligation of welcome, both more openand less preordered, insists that it is the personhimself or herself who is to be welcomed andthat there is always more there than narrativesreveal. Each story may give an importantglimpse into the whole, but there will still re-main the mysterious unrevealed core of theperson and the person’s experience of illness,which also must be welcomed and held as it is,untold and real.

To return to the summary of Philoctetes withwhich we began, note that we do not claimthat Neoptolemus was welcoming. He seemsmore to have been shocked into awarenessdhis basic sense of courtesy, followed by conster-nation, keeping him riveted to the scenedandthereby earned the new way of seeing that hisname suggests. A welcoming orientation, incontrast, means that we come to such situa-tions with our eyes already open. We are readyfor the revelation of who this patient is andof what he or she is experiencing and mayneed from us. We no longer require surpriseor epiphany to wake us up to our responsibili-ties. We can hear the truth of the matter frompatients in pain, including those, such as the

persons in sickling crises quoted above, whono longer believe they will be heard. We areready, and we trust that our evident willingnessto receive can bring forth what must beexpressed.It is through continuing fulfillment of the

primary obligation to welcome the patientthat the patient’s stories, in all their formsand whatever their coherence, will be knownand honored. No matter how practiced a clini-cian may be at being attentive to patients, it isa welcoming orientation, a consistent attitudeof certainty that it is good that this person ishere now and good that I am here with himor her, which allows the truly capacious atten-tion and openness to the other that is essentialfor appropriate, compassionate medical care.

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2. Haywood C Jr, Beach MC, Lanzkron S, et al.A systematic review of barriers and interventionsto improve appropriate use of therapies for sicklecell disease. J Natl Med Assoc 2009;101:1022e1033.

3. Levinas E. Totality and infinity. Pittsburgh, PA:Duquesne University Press, 1969.

4. Zoloth L. I want you: notes toward a theory ofhospitality. In: Eckenwiler LA, Cohn FG, eds. Theethics of bioethics: Mapping the moral landscape.Baltimore: Johns Hopkins University Press, 2007:205e219.

5. Beauchamp TL, Childress JF. Principles of bio-medical ethics, 6th ed. New York: Oxford UniversityPress, 2009.

6. Niebuhr HR. The responsible self. New York:Harper & Row, 1963. 60ff.

7. Ogletree TW. Hospitality to the stranger. Phila-delphia, PA: Fortress Press, 1985. 3e4.

8. Sifneos PE. Alexithymia: past and present. Am JPsychiatry 1996;153(7 Suppl):137e142.

9. Coulehan J, Block M. The medical interview,5th ed. Philadelphia, PA: F.A. Davis Company, 2006.

10. Frank AW. The wounded storyteller: Body, ill-ness, and ethics. Chicago, IL: University of ChicagoPress, 1997.

11. Gibson EM. Encountering narrative in medi-cine. PhD diss., University of Virginia, 2004.