The Soul of a Doctor

by Gordon Harper

  As it turned out, JM was told his diagnosis during that admission. I was not present for the actual discussion, but when I visited him afterward, he was calmer than I had seen him since he arrived. He was relieved, he said, to finally know for sure what he had long suspected, and as backward as it might seem, the certainty of his terminal illness had dispelled a great deal of his anxiety and depression.

  We as physicians need to be honest with ourselves, as well as with our patients, about what we are thinking. If it is certain enough to write in the chart, it is certain enough to tell the patient about, unless there are serious mitigating circumstances. Imagine if I had, after reading his chart, asked him about his ALS—imagine if that discussion had been forced upon us right then, with neither of us prepared for it. Disastrous! Patients not only can handle the truth but expect and deserve it from us: as physicians, our charge is not to protect people from the realities of their lives, but to help them understand and work within those realities to improve their lives as much as possible. As physicians we have to come to terms with our own discomfiture and make ourselves responsible for treating our patients with honesty and respect.

  Of Doors and Locks

  Matt Lewis

  MY HOUSE KEY, a car key, keys to various buildings and rooms whose purpose and origin I had long since forgotten, all confused the key chain and made the hospital key hard to find. I struggled to locate it, and after two unsuccessful attempts (it is amazing how similar some keys look), I found the right one. With a twist of the wrist, I opened the door and entered the Faulkner inpatient psychiatric floor. It was only my second day, and I was far from accustomed to feeling trapped behind a steel wall. I could only imagine how the patients felt, stuck inside a wing of a building until a team of people they had never met decided it was OK for them to go. Freedom, it seemed to me, was far too valuable to leave in the hands of another person—regardless of the degrees on the wall.

  As I stepped inside, movement seemed to define who was a care provider and who was a recipient. The caregivers moved like busy ants. With a speed born of dwindling time and countless demands, they dodged patients and colleagues, swiftly locking and unlocking doors, scrawling on dry-erase boards, dragging their patients, who moved with the ease of broken wheelbarrows, behind them. The patients meandered like impossibly huge cargo, intent only on their immediate destination, or lost inside an internal world distant from any external reality. Some would watch with suspicious eyes or slowly follow a care provider into a previously locked room, their intention driven by the individuals possessing keys. I stood like an auspicious but unimportant bit player among this complex ballet. Thumbing my keys, I picked up the pace and walked in the direction of the patient that I was supposed to see.

  The door to his room was open enough for me to see in. Clothes and food were strewn across his floor. There was nothing to indicate that he possessed any means of trash disposal.

  “Hello,” I said.

  “HELLO,” he responded in a tone I had never heard used before. It was like a flat roar.

  Shocked, I looked to the two nurses sitting outside his room with a plea in my eyes. They just smiled and continued about their business. Couldn’t they see that I was new, that I had never encountered a soul like this? Couldn’t they see that I had no clue what the hell I was doing? In my mind, they were fully aware of this fact, and the notion that they possessed some key to correcting my situation would not leave my conscious mind.

  “Do you mind if I come in?” I asked, slightly unsure.

  Silence.

  “Can I ask you a couple of questions?”

  “I DON’T FEEL LIKE TALKING RIGHT NOW.”

  Still, I was not to be deterred. This was my first interaction of my first clerkship.

  “Can I ask you five questions?”

  “NO. YOU CAN ASK ME THREE.”

  Success. “OK, great,” I said, smiling like a fool. I pushed open the door and sat down. He was staring at me. His gaze would not be diverted, and it was immediately obvious that he was hoping I would leave as soon as possible.

  “Can you tell me why you are here?”

  “I WAS LOST.”

  “Can you tell me more?”

  “I DIDN’T KNOW WHERE I WAS GOING. YOU ONLY HAVE ONE QUESTION LEFT,” he boomed at me.

  Right. Sure. I know, I know, I thought. This was not going as I had planned. Gathering my remaining faculties—not that many remained at this point—I came up with my final question.

  “Why can’t you go home?”

  “I AM LOCKED UP HERE. THAT WAS THREE.”

  Confused and frustrated, I left to find my resident. I walked past the nurses, who grinned at me, then returned to their duties. I grabbed my keys from my pocket and opened the door into the chart room. It was small and cluttered. I went to a table and sat down in a huff. My resident walked up behind me.

  “How was it?”

  “I couldn’t get a thing out of him.”

  “Paranoid schizos are hard to get talking. After some time, he may begin to trust you and open up a bit. What did he say?”

  “He told me he came here because he got lost, and he couldn’t leave because the door was locked.”

  “Yeah. He was wandering in traffic for a couple of hours before the cops picked him up. For the longest time, he wasn’t sure where he was or what to make of us. Hopefully we can get him back up to baseline soon. He is pretty bad off. Such obvious negative symptoms at a young age are never a good sign. The best we can hope for is that he is able to take care of himself for a little while.” She nodded, grabbed her keys, and left to speak with the attending.

  I nodded my head and watched as she walked off. I was left sitting and wondering at the myriad of doors that lock behind us when we are lost. Glancing out at the patients sitting around the unit, I said a silent prayer that the people who possess the keys would always be able to find the right one to let us out again.

  Reclaiming the Lost Art of Listening

  Mike Westerhaus

  SITTING BEFORE ME was a sixty-eight-year-old man. He rested comfortably, demonstrating an unexpected ease with the environment, for a guy known to regularly skip his clinic appointments. He wore an old, felty green baseball cap to cover the few wisps of hair left on his head. A T-shirt and jeans rounded out his informal overall yet well-kept appearance. My preceptor had warned me that “this guy skips office visits quite often and only comes in when he’s really got something on his mind.”

  I started my interview with him like any other. I asked about his former work, how he occupied himself during the day, and where he lived. A hint of strain in his breathing, he replied with intention, carefully choosing words to make sure that he communicated his message clearly. As he articulated answers to my relatively superficial questions, he wove in his story of illness. He confessed that in the last couple of months his appetite had gotten out of control. “I find comfort in food,” he remarked, trying to make sense of his voracious eating habits.

  Comfort was something he hadn’t experienced a whole lot of recently. Loss had consumed much of him over the past half decade. Five years ago he’d lost his daughter to cancer. Only one and a half years ago, his wife had passed away. During her final two months of life, he had worked feverishly at his wife’s bedside in their home, scrupulously monitoring her medications, changing her sheets daily, and holding her hand for hours on end. And one day she was gone. Now his sister lay comatose in a hospital after an exhausting nine-month battle against cancer.

  He went on to describe how for months after his wife’s death, he ate nearly nothing and lost forty pounds. Then, three months ago, he resumed eating, more than ever before. In the past two weeks, he had started urinating frequently. Could it be, he wondered, the return of his diabetes, a disease that he had reined in years ago? He felt guilty, helpless, and broken. He expressed a laundry list of other hopes for the office visit: a referral to an eye doctor, a refill of his blood pressure medication, treatment of his receding
gums, and a prescription for a navel truss to reverse his “navel rupture.” He spoke, uninterrupted, for nearly forty minutes after my initial trio of questions. He had arrived today as much for a chance to share his story as for a checkup.

  As he unfurled his world of sadness, I found myself thinking about the art of listening. Hearing this patient communicate intimate emotions and concerns was a privilege surpassed by little else. In plain words, this man constructed an eloquent soliloquy of loss and its toll on health. And I was fortunate enough to sit as his private audience. Yet listening did not come easily. The fact that I was thinking about the art of listening while he told his story was enough to indict me for poor listening. In addition, my mind intermittently wandered from speculating about which medical issues my preceptor would quiz me on to what time I could catch the shuttle back into Boston. I offered a periodic “Uh-huh” to conceal my waxing and waning attentiveness. And even as he detailed the final weeks of his wife’s life, I remember feeling anxious about how long our interview had taken.

  Some might identify this patient as “one of those types who rambles on.” And I might be criticized for not gently interrupting the patient and guiding the interview. And some might charge that I compromised the care of other patients by listening to one patient and leaving other patients waiting.

  Yet it seems that physicians are trained to be far too “good” at interrupting patients. Research shows that on average, physicians interrupt patients eighteen seconds after starting the medical interview. I can’t imagine that much careful listening occurs during such a brief episode. Nor can I imagine that patients feel appropriately listened to in such circumstances. In the case of this patient, listening needed to be the crux of the encounter. To deny him the opportunity to share his grief would have been inhumane and irreverent toward his experience of suffering. Not to mention that a failure to listen increases the likelihood that a patient won’t return to the doctor.

  In my third year of medical school, faculty members started emphasizing the necessity of efficiency and rapid patient visits. We were told that we needed to become masters of showing compassion in fifteen-minute spurts. We were taught a script, complete with lines to use, important nonverbal gestures, and the appropriate boundaries for a patient-doctor relationship. On the wards, I was even advised, “The patient’s history is totally worthless.” I feel skeptical of this model of patient care. Will incorporation of this hurried mentality into the way I practice medicine threaten the sacredness of my future patient encounters? Or are we being taught valuable skills that will truly serve as the gateway to empathy and healing?

  Later, as I directed a penlight into this patient’s pupils, he suddenly burst out, “Thank you so much for listening. I haven’t ever had a doctor who has listened so carefully to what I had to say.” Clearly something had been missing in his previous clinical visits. Does this mean that forty minutes are needed for the patient to feel that the doctor listened? And what really does it mean to listen to the patient? I sense that to listen means not only to hear for the sake of scribbling it in a medical record but also to give the patient an opportunity to explain themselves and their illness. Listening asks something far greater of the physician than the ability to rattle off medical facts or rumble through record numbers of clinic patients. Listening demands patience and the willingness to humble oneself before the concerns and complaints of the patient. Can this genuinely happen within the pressured patient-doctor encounters dominating the health care system today? I suspect that the answer is no.

  Physicians are taught to be doers. Directing patient interviews, examining the body, performing procedures, and prescribing medications constitute the bulk of the job description in today’s world of medicine. Listening, perhaps seen as a more passive activity, seems undervalued and tends to get lost in the shuffle. No box exists to check “Listened” on the reimbursement form (not that I would advocate financial valuation of listening). Undoubtedly the “doer” elements form a vital part of both healing and meeting the expectations of patients. But I sense that medicine could mean and be much more for patients if time spent listening to the patient tell his or her story were prized. Might that mean longer patient visits? Possibly.

  Others will write this off as the ravings of a naive, optimistic medical student; the advocates of efficient health care will be quick to argue that longer patient visits are not “cost effective.” While that may be, we cannot forget medicine’s fundamental premise that patients matter most. Complaints about the frantic pace and lack of human compassion in medicine commonly fill the general public’s conversation about health care. The patients who sue their doctors for medical mistakes are the same ones who feel ignored and disregarded by their physicians.

  In fact I would argue that in the long run, a reinvigorated emphasis on listening to the patient would be cost effective. I suspect that greater emphasis on hearing the patient’s perspective could lead to improved diagnosis, patient understanding of their illness, and patient compliance with medications and preventive practices. All of which would likely lead to a patient population with improved health and fewer patient visits, thus alleviating overcrowded clinics and reducing health care costs.

  I fear medicine is moving in the wrong direction. Excuses of pressure from insurance companies and overwhelming patient loads can’t make up for the lost stories and health of patients who feel they have not been heard. Thinking back to my patient in the clinic, I still wonder whether I did the right thing. Was listening to his grief therapeutic? Did I compromise the care of other patients because of the time I spent with this individual? These are questions with which I will continue to wrestle, but in the end, I sense that I did something right.

  II.

  Empathy

  A doctor’s first duty is to ask for forgiveness.

  INGMAR BERGMAN

  Inshallah

  Yetsa Kehinde Tuakli-Wosornu

  WOMEN OF THE AFRICAN ark are distinct. There is something enchanting in the way they walk, talk, sit, stand. A quiet regality to their movements, a twinkling depth to their eyes—it is in my Nigerian mother, Ghanaian tailor, Ethiopian “aunt,” and Guinean braider, a thread that weaves throughout Africa, traversing country borders to enclose, like a purse string, the entirety of the continent. It is unmistakable—indeed, unforgettable.

  At times, it can even be unexpected.

  On the second day my of obstetrics and gynecology clerkship, I saw it. Having finished my morning operating-room duties late, I hurriedly made my way from the depths of the hospital basement (day surgery) to the ground floor (lobby) and followed the directions given me: elevator to first floor, left to Center for Women, elevator to fourth floor, left to ob clinic, second door on right. I entered, made a breathless introduction to the attendant secretary, and was suddenly, almost violently, brought to pause as I noticed the waiting room. Before me sat ten women of the diverse African ark—some cloaked in the ebony abayas of Islam, charcoal-lined eyes glowing against the backdrop of silken darkness; others adorned with the vibrant head ties of West Africa, swirling patterns of peaches, reds, golds, and greens sitting atop heads like crowns; some with pale complexions, others with deep complexions; some with husbands, all with child. Beholding this collage of culture and color, my heart grew quiet. I stood up straight, relaxed my shoulders, exhaled. A sweet calm settled upon me, recalling the sights and sounds, smells and tastes, of time spent with Father in Saudi Arabia, Mother in Nigeria. Looking around the waiting room, I saw Africa—my Africa—and in the middle of a Boston hospital, at a clinic for refugee women, I was at home.

  My first patient was a twenty-seven-year-old woman from Saudi Arabia who came in for a routine prenatal visit. From her chart, I saw that she had lived in Angola and was currently a doctoral student at Harvard. In the usual medical-student-as-first-line offense, I entered the exam room first to conduct the history and physical. I found a quiet, abaya-clad woman, who on my approach smiled warmly and asked immediately, “Where
are you from?” I said Nigeria, and she nodded. “My father lives in Saudi Arabia,” I added, and we were off.

  Our conversation wandered from Saudi Arabian shopping malls to African cuisine to the strength of the Harvard name in Africa. We talked and laughed about immigration and its difficulties, about African presidents and African roads. As we talked, I examined. Quite seamlessly, standard questions of the obstetric clinic wove their way through our conversation: Any complaints? Bleeding? Leakage of fluid? They were standard questions, but this interaction felt different: somehow, the surrounding sterility of the hospital and the typical barrier between patient and doctor had silently fallen away.

  As I turned to exit the room, my patient stopped me.

  “So your father is a Muslim, right?” she asked.

  “No.” I shrugged. “He just lives and works in Saudi.”

  She frowned. “So you are not Muslim …” She trailed off.

  “No,” I said, “I’m Christian.” A silence descended on the room.

  My patient explained that in Saudi Arabia, unfortunately, she might not be as quick to accept my services, that her family would disapprove of her interacting with a non-Muslim physician. How odd to realize that were the context different, were we in Africa—a land that both she and I hold dear to our hearts—our connection might be threatened. In Africa, where everyone is African, lines of division are often dictated by religion—the socially constructed line that a declaration of faith draws around its declarer. In America, religious distinctions are overridden by ethnic divisions—the artificial and socially constructed noose that ethnoracial identity ties around its bearer. In either context, that division can be felt both in society and (sadly) in the exam room.